This document is updated weekly, but why is it important? Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs, and MCOs pursuant to health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.

Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.

When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization. In this case, the market check language is effectually meaningless.

I’ve long held the belief that the PBM business model is good for self-funded employers when they [employers] are put first. Even when a non-fiduciary PBM places you second, behind profits and dividends, a sophisticated plan sponsor still realizes a significant ROI. It is the unsophisticated plan sponsor who pays for bloated payrolls and other wasteful spending. 

Things start to get murky when plan sponsors or their stakeholders are unsophisticated in the PBM space and make selection decisions on anything other than transparency first! Transparency (defining it, interpreting it and ultimately winning it) is by far the #1 factor in determing what you pay PBM services. Transparency is also more difficult to see, without a trained-eye, than buyers think. Most plan sponsors don’t know what they don’t know. 

The PBM business is so complicated such that being part of a steering committee, every two to three years for 20 years, will only teach you the basics. PBM education is vital insofar as turning the tables on PBMs. Watch the brief video from Kaiser Health below.

Some of the primary supporters of PCMA have themselves self-admitted to not being responsible for containing their clients’ pharmacy cost. What’s the problem? It is the primary job of a PBM to contain our clients’ cost. 

A radically transparent PBM makes money just one way – the administrative fee. When the administrative fee is artificially low (less than $4 per claim) forget it no way your PBM is transparent. In some form, it is generating huge overpayments or mark ups via hidden cash flow.

The findings in the new study are eye-opening. But, read on with a critical eye. 

Major Findings:

• Pharmacy Benefit Managers (PBMs) help reduce prescription drug costs for 266 million Americans.
• PBMs save payers and patients 40-50% on their annual drug and related medical costs compared to what they would have spent without PBMs.
• PBMs save payers and patients an average of $962 per person per year.
• For every $1 spent on their services, PBMs reduce costs by $10.
• PBMs account for just 6% of the net cost of a prescription, while manufacturers account for 65%.
• Over the next 10 years, PBMs will help prevent 1 billion medication errors.
• PBMs improve drug therapy and prescription adherence in diabetes patients, helping to prevent some 480,000 heart failures, 230,000 incidents of kidney disease, 180,000 strokes, and 8,000 amputations annually.
• Through specialty pharmacy services, PBMs will help extend and improve the quality of life for patients with multiple sclerosis and rheumatoid arthritis by approximately 1 million Quality Adjusted Life Years (QALYs) over 10 years.

Self-funded employers now have the technology available to them to automate large portions of repetitive tasks, streamline operations, and supercharge their pharmacy benefit manager RFPs. Companies that fail to adapt to technology will find themselves losing out to PBMs and competitors who have successfully embraced digital transformation and implemented new solutions to their PBM selection process.

e-Procurement provides excellent leverage for businesses that want the most efficient PBM spend process. RFI, RFQ and RFP software can help self-funded employers and take things to the next level.

First, let’s define what RFI, RFQ and RFP mean:

• RFI – Request for Information is created to retain information from a supplier or vendor with no commitment to engage in a project. Typically RFI include no information about the project and can be issued to suppliers using RFI software.
• RFQ – Request for Quote strictly relates to price. RFQs focus on providing a quote that has a specific validity period. RFQ is typically used when the main terms of a deal are focused on financial metrics.
• RFP – Request for Proposal is an in-depth list of specific goods and/or services to be rendered by the service provider. PBMs typically respond to RFPs with their least transparent offer to provide what is being asked of them.

Reduced Prices. When you implement eRFx software  into your company, you save money through digitizing your PBM procurement process by going paperless. Errors that occur when filling out or evaluating forms with a manual process are eliminated. This means you can avoid costly mistakes that need investigation, resolution and reworking to be fixed.

Faster Business Cycles. e-Procurement software which handles eRFx operations enable transactions to be completed faster than manual processes once allowed for. The software uses an automated process which increases the volume of transactions completed in near real-time. This enhanced efficiency can have a domino effect throughout your entire business and improve go-live timing, as other relevant departments no longer have to wait for manual data entry and manual approvals.

Skyrocket Productivity. To have a successful PBM procurement process, you need to be operating under maximum efficiency and productivity. eRFx software reduces the amount of time required to complete time-consuming business tasks like proposal evaluation and scoring. Through automating tasks that once were completed manually, you free your team members from performing low-value tasks such as data entry, emailing, and paper processing. Instead, team members can cast their efforts on high-quality functions that drive business like contract analysis and scoring.

Take Control of your Pharmacy Spend with e-Procurement Software

A robust PBM e-procurement system breeds transparency and control within your company. This also means you can share better information with relevant stakeholders. Dashboards enhance visibility which provides a full procurement cycle transparency that your competitors cannot offer to clients if they are failing to use e-procurement software.

<<Watch a DEMO>>

Value-based contracts (sometimes referred to as risk-sharing agreements or outcomes-based contracts) are a type of innovative payment model that brings together two key stakeholders—health care payers and biopharmaceutical manufacturers—to deliver medicines to patients. Under value-based contracts, biopharmaceutical manufacturers and payers agree to link coverage and reimbursement levels to a drug’s effectiveness and/or how frequently it is utilized. There are three types of value-based solutions:

There are several potential factors limiting manufacturers’ interest in outcomes-based contracting, including a potential inability to obtain accurate data and outcomes measures, inability to discuss information that is outside the FDA-approved label, and regulatory barriers that prevent disclosing information, according to a recent AMCP membership survey (J Manag Care Spec Pharm 2018;24[5]:410-415).

The same survey found that payors, too, were concerned with identifying simple and easily measurable outcomes, wanted greater risk sharing with manufacturers, and were concerned with meeting a sufficient patient population to make the agreement worthwhile.

Continue Reading>>

1. Improved care coordination and communication

Click to Learn More

Controlling specialty spend is about supporting patients and working with their healthcare team to ensure that treatment is safe and effective. Medications that don’t work as they should translate to poor health outcomes, which drive up overall costs.

PBMs are perfectly positioned to work with all members of a patient’s healthcare team to improve communication. PBM pharmacists have access to all data gathered from prescription claims and, potentially, integrated medical claims data. This allows them to see a comprehensive picture of the patient’s medication history, diagnoses, lab results, indicators of adherence and other applicable medical data. As a result, PBM pharmacists can alert prescribers and retail pharmacists of any issues and facilitate the identification of safer, more effective treatment options.

2. Advanced clinical programs

To be able to provide effective care coordination, PBMs must also offer comprehensive, advanced clinical programs. Prior authorization provides an example of how clinical programs are not created equal. The intention of prior authorization is to make certain medications are used appropriately. But does the analysis review whether the medication is appropriate for a specific individual’s needs? Not all prior authorization programs do. A comprehensive program considers whether there are warnings and contraindications related to factors such as the patient’s age, health conditions, metabolism, lifestyle or other medications they may be taking.

3. Creative contracting and partnerships

Finally, plan sponsors need a PBM that works with them, putting the plan’s and patients’ best interests first while delivering ethical, transparent benefit management. They should consider PBMs that tie performance guarantees directly to their clinical programs. A pay-for-performance arrangement holds the PBM accountable for how well it facilitates responsible, effective drug utilization that reduces the plan’s spending.

Continue Reading >>

This document is updated weekly, but why is it important? Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs, and MCOs pursuant to health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.

Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.

When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization. In this case, the market check language is effectually meaningless.

When you have something someone else wants you have leverage. You may use leverage to compel people to change their behavior, change the shape of time, move forward your position, and make concessions. For this reason, leverage is currency and it must be used as such. It has value and must be exchanged for value.

Although the cost-of-dispensing (COD) incurred by pharmacists in Florida is $10.24 per claim, according to the state’s COD analysis, this required pharmacy reimbursement methodology does not apply to Medicaid managed care organizations (MCOs) that contract with PBMs. The report’s analysis of Florida’s top 7 MCOs found that pharmacies were paid a weighted average of $2.72 per claim in 2018—significantly lower than the $10.24 COD and down from $7.70 in 2014.

The authors noted, however, that not all pharmacies seem to be experiencing this pressure equally. In 2018, the state’s 5 largest specialty pharmacies collected 28% of the available profits paid to all providers in Florida Medicaid managed care, despite dispensing just 0.4% of all managed care claims. Based on these findings, the authors wrote, “MCOs and PBMs appear to be using their control in managed care to incrementally shift dollars to their affiliated companies.”

Tyrone’s Commentary:

A contract rate is the reimbursement level agreed to between a single pharmacy and the PBM. The effective rate, however, is the blended performance rate among a group of pharmacies. It is the difference between these two contract rates which can create spreads and hidden cash flow to non-fiduciary PBMs. That spread can be taken during claim adjudication or after in the form of DIR fees. A spread is the difference between the amount reimbursed to the pharmacy and billed to the plan sponsor. Spreads are often much larger than a plan sponsor believes especially when measured on a pharmacy-by-pharmacy basis.
      
Generic and Branded Drug Spend Analysis

The authors said PBMs set generic prices differently for different pharmacies, which can create a significant advantage for pharmacies affiliated with the PBM. For example, they noted the displacement of Walgreens pharmacies by CVS pharmacies in both Staywell/Wellcare and Sunshine/Centene MCOs during the period when CVS Caremark was providing PBM services to those organizations.1

Furthermore, the report said payments for generic drugs vary greatly across MCOs and between PBMs within the same MCO. As an example, the authors noted that in 2018, Sunshine/Centene (managed partly by CVS Caremark) reported the cost of generic aripiprazole (Abilify, Otsuka America Pharmaceutical) to be $11.18, $0.53, and $0.24 at CVS, Small Pharmacies, and Public, respectively.

Download Full Report >>