Samuel is a 68-year-old Medicare beneficiary living on a fixed income. After retiring, he faced the harsh reality of managing his healthcare on a limited budget. Samuel has been living with type 2 diabetes for several years and was prescribed Metformin by his primary care physician. Despite being aware of his condition and the importance of taking his medication, Samuel found himself skipping doses to make the prescription last longer. Even with his Medicare coverage, he struggled to afford the cost of all the necessary medications to manage his chronic conditions.
Samuel also harbored deep distrust towards the healthcare system. He often felt like just another number rather than a human being, leaving him frustrated. His past experiences led him to believe no one really cared about his well-being. This skepticism further deterred Samuel from seeking alternative treatments or discussing his financial concerns with his care team.
Samuel was referred by his primary care provider to CHESS Health Solutions for help with his medication nonadherence. Once the CHESS pharmacist reviewed his chart, they saw multiple prior authorizations had been sent in and denied. When digging further, they found that the provider had sent in the wrong formulation. This more expensive formulation, reserved for patients unable to tolerate the generic version, was not covered by insurance. This error went unnoticed for months.
The CHESS team collaborated with Samuel’s doctor to prescribe the correct, covered formulation and helped him apply to a financial assistance program. With the correct medication and financial assistance, Samuel resumed his treatment. He began to feel more hopeful about his health. He felt cared for and supported by a team that truly understood his situation and needs.
Pharmacists and pharmacy technicians play a crucial role in ensuring access to medications, supporting adherence, and optimizing care. In 2023, the CHESS pharmacy team helped over 10,000 Medicare beneficiaries navigate and manage their medication challenges. These 40,000+ interactions were key in reaching the quintuple aim of value-based care: lowering the per capita cost of care, enhancing the patient experience, improving the provider experience, increasing population health, and establishing health equity.