How Accurate Cost Estimates Could Save $2.8 Million in Staffing Hours and Tripled Patient Assistance in Long-Term Care
Background
Guardian Pharmacy Services, headquartered in Atlanta, is one of the largest long-term care pharmacy companies in the United States. Serving over 325,000 people annually (with more then 160,000 active residents) and filling 22 million prescriptions annually, Guardian excels in providing comprehensive, hands-on medication management and consultative services. A unique business model combines the personal service of a local pharmacy with the extensive technology and resources of a large national support team, ensuring safety, healthier outcomes, and cost reduction for residents in long-term care communities across 35 states.
With a workforce of 3,000 employees, including 313 full-time equivalent pharmacists, Guardian operates 48 locations serving over 6,000 communities. Their clientele spans assisted living communities, skilled nursing, group homes, behavioral health, and organizations focused on individuals with intellectual and developmental disabilities.
Unlike a skilled nursing facility, assisted living communities typically don’t have a medical director or healthcare professionals on site. As a result, the Guardian Pharmacy team is at the center of each patient’s care, and offers additional support for billing and insurance concerns.
Challenges
Hours Spent in Addressing Medication Cost Complaints
Patients or their responsible caregivers often have questions or complaints regarding the costs of their medications. Because the locations Guardian serves rely so heavily on the pharmacy, the billing team is deeply involved in helping patients and their responsible parties understand their benefits, find new plans, and save money. Done with care, these interactions can take as much as an hour for each patient. With 160,000 active residents, this is an impossible task, and only a few patients were receiving this service.
Inaccurate Data on Drug Costs
Current sources of information, such as Medicare.gov, are tailored to a retail pharmacy experience. Regulations and costs regarding long-term care are different. Long-term care facilities are not generally part of preferred retail networks, and Medicare requirements add additional costs. Without access to an accurate data source, estimated out-of-pocket expenses were significantly less than the real costs. This was eroding patient trust and causing headaches for the staff.
Patient and Caregiver Education
Long-term care patients are the most frail, highest utilizers, and most expensive to serve and insure. Caregivers often lack the knowledge needed to navigate these complexities and require significant support. Since residents do not pick up their medications, billing is more complicated. At Guardian Pharmacy, their billing teams prioritize core services to ensure the highest level of care. As a result, additional services, such as educational support for patients and caregivers, may not always be delivered as promptly as desired. Ensuring they understand medication and billing processes is critical for better outcomes and reduced frustration.
Ensuring Trust and Proper Plan Selection
Long-term care patients often face additional challenges in managing their healthcare plans. Many may never reevaluate their plan, and end up overpaying for services as their situation changes. Additionally, patients may receive unsolicited calls, emails, and mailers, leading to confusion and mistrust. These communications are often disconnected and uncoordinated.
“With the changes in Medicare from the Inflation Reduction Act taking effect in 2025, it will be more important than ever for patients to understand their plans, their costs, and their options. They need help to navigate the complex insurance landscape. EnlivenHealth is helping us evolve so that we know our patients are covered and our community is thriving.”
Chris Crisafulli, VP PBM Network Operations, Guardian Pharmacy Services
Solution: EnlivenHealth Medicare Match
Guardian implemented EnlivenHealth’s Medicare Match to provide precise cost estimates for patient out-of-pocket expenses, reduce the staffing needed to provide accurate service, give patients and caregivers more autonomy over their data, and build trust between patients and staff. The implementation of EnlivenHealth was straightforward, with comprehensive training sessions, user-friendly tools, and tutorial modes, ensuring a smooth transition and enhancing the overall process efficiency.
Enhanced Software with Proprietary Algorithm
Since available data catered to the retail audience, EnlivenHealth developed a customized algorithm that integrates Guardian’s historical data, providing more accurate out-of-pocket cost estimations for long-term care patients. This algorithm factors in the standard copay versus the preferred retail copay, aligning patient expectations with actual costs, with a reduced administrative burden.
Improved Communication Tools and Licensed Agents
EnlivenHealth introduced features to enhance patient communication, ensuring transparent and accessible cost comparisons. Residents and their families can view these comparisons and even enroll directly through the platform. Additionally, the EnlivenHealth platform can connect patients directly with HP1 licensed agents. These agents provide expert assistance, supporting caregivers and enhancing their understanding of their options.
Building Trust Through Accuracy
With EnlivenHealth’s more accurate cost estimates, patients no longer risk receiving unpleasant news with their billing cycle. By providing precise information and offering opportunities to save money, Guardian builds trust with patients and shows dedication to their financial well-being. Every bill that matches the original estimate adds to this good will. Enhanced transparency gives patients more confidence in their plan selection and fosters a more trusting relationship with Guardian Pharmacy.
“If we aren’t looking for better ways to serve residents, and be as efficient in that service as possible, the changes and struggles that all long-time pharmacies are facing are only going to get worse. The instant, accurate data EnlivenHealth provides saves our staff time and our patients money. It’s a service that allows everyone to win.”
Daks Hamner, Director, Network Finance, Guardian Pharmacy Services
Results
From 2021 to 2023, Guardian Pharmacy Services saw substantial improvements across various areas due to the implementation of EnlivenHealth’s Medicare Plan Finder:
More Accurate Data = Increased Efficiency and Trust
- Improved Accuracy: Because it is based on real historical data specific to the long-term care population, EnlivenHealth’s custom algorithm gives Guardian a much clearer picture of what out-of-pocket drug costs will be.
- Community and Staff Trust: The enhanced accuracy of EnlivenHealth tools built greater trust and adoption across all locations. By demonstrating a commitment to more accurate cost estimates and patient savings, Guardian established stronger credibility with residents and caregivers.
- High Adoption Rate: Print comparison runs for patients increased by 744%. More Guardian employees adopted the tools as they were able to provide detailed and accurate cost comparisons.
- Widespread Adoption: As a result of the improved data accuracy, more employees within the Guardian network adopted the tool, and nearly 3.5 times more patients were assisted.
Enhanced Patient and Caregiver Support
- Adoption and Training: EnlivenHealth successfully rolled out comprehensive training sessions for Guardian staff, ensuring proficiency with the new processes.
- Regional Pilot Success: A pilot program in North Carolina and Virginia led to a 483% increase in usage in 2023, setting a precedent for future expansions. The new, accurate information provided led 60% of patients to choose a new plan that saved them money.
Cost Savings and Efficiency
- Copay and Premium Reductions: EnlivenHealth’s accurate cost estimates enabled significant savings. For example, one patient on Tricare was guided through the process and chose to add a Medicare plan based on the information. With the new plan, they saved $1,343.28 on copays in just one year.
- Efficiency Gains: If every employee in the Guardian system used the EnlivenHealth process, and if every active resident opted in to the tool, the automation and improved processes would save over 141,000 man-hours (estimate valued at $2.8 million in staffing hours). These saved hours can be redirected to focus on higher-value tasks, enhancing the overall service quality and efficiency.
“I love the fact that we’re able to share the information with our customers—they can physically see their information and choices in realtime by logging in with their internal patient ID. They also have the option to enroll right there within the EnlivenHealth platform and start saving money. It’s been a game changer for us.”
Walt Rowland, Senior Manager – Medicare Benefits and Patient Services, Guardian Pharmacy Services
Conclusion
Guardian Pharmacy Services has demonstrated a commitment to excellence and innovation in long-term care pharmacy management. Their partnership with EnlivenHealth has not only addressed current challenges but has also laid the groundwork for future growth and success. By embracing technology, collaboration, and a forward-thinking mindset, Guardian is poised to continue making a meaningful impact on patient care and satisfaction in the years to come.
“Without the seamless connection and daily updates of the EnlivenHealth software, we wouldn’t be able to be as successful as we are. And we’re just scratching the surface.”
Chris Crisafulli, VP PBM Network Operations, Guardian Pharmacy Services
Need Help Navigating Medicare with Your Patients?
At EnlivenHealth, we’re committed to helping pharmacists and their patients navigate the often complex task of comparing Medicare plans. Our comprehensive Medicare plan comparison tool, Medicare Match, empowers pharmacists to help their patients compares the costs and benefits of different plans available and make the best selection for their needs.
For more information about Medicare Match and how it can help your pharmacy have a successful Annual Enrollment Period, click the button below.