Annual Report on Specialty Spend and Trends and other notes from around the interweb:

• Annual Report on Specialty Spend and Trends (2023). The seventh annual State of Specialty Spend and Trend Report uses integrated pharmacy and medical claims data to provide a holistic view of specialty drug spend and trends. First published in 2017, this report is the sole comprehensive analysis of specialty drug spending, powered by the industry’s leading integrated dataset through Artemetrx. Key takeaways include the percentage of members taking at least one specialty drug continues to rise (4%), while the average number of claims per person remains steady at 5 claims per year. Another key takeaway, specialty spend continues to shift from the medical benefit to the pharmacy benefit, the latter of which now accounts for 56.3% of spend.

• How Self-Funded Employers Can Use Point Solutions to Manage Pharmaceutical Costs. Point solutions are specialized tools or platforms designed to address specific issues or challenges faced by organizations. In the context of pharmaceutical cost management, point solutions provide targeted assistance in identifying cost-saving opportunities, improving medication adherence, streamlining prescription processes, and enhancing overall health outcomes. Before delving into the benefits of point solutions, it is essential for self-funded employers to gain a comprehensive understanding of their pharmaceutical costs. This entails assessing the utilization patterns, identifying high-cost drugs, analyzing prescription data, and exploring trends in pharmacy benefit claims. By closely examining these factors, employers can identify areas of potential savings and develop tailored strategies to optimize their pharmacy benefit plans.

• Playbook for Employers – Addressing PBM Misalignment. The guide, released by the National Alliance of Healthcare Purchaser Coalitions, identifies several key strategic recommendations that employers can adopt when looking to better navigate their relationship with PBMs. For one, the playbook recommends that employers find advisers that are genuinely putting in the work for them. Advisers should be independent and transparent, according to the guidebook, and contracts should be designed to ensure that PBMs act in the employer’s best interest. “As we uncover these increasingly apparent anomalies, I think we’ve got to challenge ourselves to do better and most importantly require that our advisers, our middlemen and our intermediaries do better on our behalf,” Mike Thompson, CEO of the alliance, told Fierce Healthcare.

• STAT News investigation takes deep dive into PBM broker conflicts of interest. Employers across the country — from big names like Boeing and UPS to local school systems — pay consulting firms to handle a straightforward task with their prescription drug coverage: Get the best deals possible, and make sure the industry’s middlemen, known as pharmacy benefit managers, aren’t ripping them off with unfair contracts. But a largely hidden flow of money between major consulting conglomerates and PBMs compromises that relationship, a STAT investigation shows. Some consulting firms often are getting paid more — a lot more — by the PBMs and health insurance carriers that they are supposed to scrutinize than by companies they are supposed to be looking out for.

PBM data analytics platform solutions provide specialized tools and services that analyze and interpret healthcare-related data to derive valuable insights. These insights can help employers make informed decisions, optimize their benefit programs, and improve employee health outcomes. In some cases, the right platform solution can help employee benefit brokers and consultants increase win rates. Here’s how PBM data analytics platforms enhance medical and pharmacy benefit programs while simultaneously serving as a valuable point solution:

• Benefit Program Optimization: Data analytics vendors can analyze healthcare utilization patterns, prescription drug data, and medical claims to identify trends and areas for improvement within the benefit program. Employers can use this information to make data-driven adjustments and tailor the program to better meet the needs of their workforce.
• Cost Containment: By analyzing claims data and pharmacy benefit usage, data analytics vendors can identify cost drivers and recommend strategies to contain healthcare spending without compromising the quality of care.
• Identifying High-Risk Individuals: Data analytics can be used to identify employees at risk for chronic conditions or those who may benefit from targeted wellness programs. Early identification allows employers to provide appropriate interventions and support, potentially reducing future healthcare costs.
• Predictive Modeling: Leveraging historical data and trends, data analytics vendors can build predictive models to estimate future healthcare costs and utilization. This helps employers plan and budget more effectively for their benefit programs.
• Pharmacy Benefit Management: Data analytics can help employers understand prescription drug usage patterns and identify opportunities for cost-saving measures, such as promoting the use of generic medications or negotiating better contracts with pharmacy benefit managers.
• Performance Measurement: Data analytics vendors can track the effectiveness of wellness programs, disease management initiatives, and other interventions. Employers can use this information to assess the program’s impact on employee health and make necessary adjustments.
• Compliance and Fraud Detection: Data analytics can be used to monitor healthcare claims for compliance with regulations and identify potential instances of fraud or abuse, safeguarding the integrity of the benefit program.
• Personalized Health Recommendations: By analyzing individual health data (while maintaining privacy), data analytics can provide personalized health recommendations to employees, encouraging healthier lifestyle choices and preventive care.

Integrating a PBM data analytics platform solution, as part of a medical and pharmacy benefit program, should be so easy that a ninth grader could do it after a 20-minute demo. PBM data analytics platform solutions can significantly enhance an employer’s ability to understand, manage, and improve the health outcomes of their workforce while optimizing the overall cost of healthcare benefits. However, it’s important to measure ROI and that appropriate data privacy and security measures are in place to protect employees’ sensitive health information.

How Self-Funded Employers Can Use Point Solutions to Manage Pharmaceutical Costs and other notes from around the interweb:

• How Self-Funded Employers Can Use Point Solutions to Manage Pharmaceutical Costs. Point solutions are specialized tools or platforms designed to address specific issues or challenges faced by organizations. In the context of pharmaceutical cost management, point solutions provide targeted assistance in identifying cost-saving opportunities, improving medication adherence, streamlining prescription processes, and enhancing overall health outcomes. Before delving into the benefits of point solutions, it is essential for self-funded employers to gain a comprehensive understanding of their pharmaceutical costs. This entails assessing the utilization patterns, identifying high-cost drugs, analyzing prescription data, and exploring trends in pharmacy benefit claims. By closely examining these factors, employers can identify areas of potential savings and develop tailored strategies to optimize their pharmacy benefit plans.

• Employers are suing their health plan for claims data in increasing numbers. Lawsuits from large companies and employers are increasingly being filed against third-party health plan administrators to access complete employee medical claims data. Through lawsuits recently filed against Aetna, Elevance Health and BCBS Massachusetts, employers claim payers have breached their fiduciary duties by not allowing complete access to claims data and how claims are processed. In a June 30 complaint, Kraft Heinz alleged Aetna has used its role as its TPA “to enrich itself to Kraft Heinz’s detriment” through undisclosed fees and processing medical and dental claims without human review. In December, bricklayer and metal worker unions filed a lawsuit against Elevance Health, alleging the payer does not allow self-insured plans to access their own claims data and charges the plans higher rates than it had negotiated with hospitals. A labor union in Massachusetts sued BCBS Massachusetts in April over similar allegations. These lawsuits are largely being driven by the Consolidated Appropriations Act and the hospital price transparency rule that took effect in 2021, according to a July 6 Bloomberg Law report.

• Playbook for Employers – Addressing PBM Misalignment. The guide, released by the National Alliance of Healthcare Purchaser Coalitions, identifies several key strategic recommendations that employers can adopt when looking to better navigate their relationship with PBMs. For one, the playbook recommends that employers find advisers that are genuinely putting in the work for them. Advisers should be independent and transparent, according to the guidebook, and contracts should be designed to ensure that PBMs act in the employer’s best interest. “As we uncover these increasingly apparent anomalies, I think we’ve got to challenge ourselves to do better and most importantly require that our advisers, our middlemen and our intermediaries do better on our behalf,” Mike Thompson, CEO of the alliance, told Fierce Healthcare.

• STAT News investigation takes deep dive into PBM broker conflicts of interest. Employers across the country — from big names like Boeing and UPS to local school systems — pay consulting firms to handle a straightforward task with their prescription drug coverage: Get the best deals possible, and make sure the industry’s middlemen, known as pharmacy benefit managers, aren’t ripping them off with unfair contracts. But a largely hidden flow of money between major consulting conglomerates and PBMs compromises that relationship, a STAT investigation shows. Some consulting firms often are getting paid more — a lot more — by the PBMs and health insurance carriers that they are supposed to scrutinize than by companies they are supposed to be looking out for.

The Federal Trade Commission votes to issue a cautionary statement against reliance on prior advocacy statements and studies related to pharmacy benefit managers (PBMs) due to several compelling reasons:

• Outdated Information: The advocacy letters and studies in question were published or issued between 2004 and 2014. With the rapidly evolving healthcare landscape and significant changes in the PBM industry since then, these materials no longer accurately represent the current market realities and practices of PBMs.
• Evolving PBM Industry: The PBM industry has undergone substantial transformations over the years, including changes in regulations, business models, and market dynamics. The Commission recognizes that relying on outdated materials could lead to misguided decisions and policies that do not align with the current state of the industry.
• Ongoing FTC Study: The Commission is actively engaged in an ongoing study of the PBM industry to update its understanding of the sector and its practices. This study is essential for gaining a comprehensive and up-to-date perspective on the challenges and opportunities within the industry. As such, relying on old advocacy statements and studies may hinder the progress of this critical investigation.
• Opposition to Transparency and Disclosure Requirements: The cautionary statement highlights that PBMs have been using older FTC advocacy materials to oppose mandatory transparency and disclosure requirements. This indicates a potential bias towards preserving a lack of transparency in their operations, which could adversely impact consumers and other stakeholders.
• Ensuring Accurate Decision-Making: The Commission’s primary role is to promote competition, protect consumers, and make informed policy decisions. By issuing this cautionary statement, the FTC aims to encourage stakeholders to base their decisions and arguments on the most current and reliable data available to ensure fair and effective regulation within the PBM industry.
• Fairness and Consumer Protection: The cautionary statement is part of the Commission’s commitment to fair competition and consumer protection. Relying on outdated materials may result in policies that do not adequately address present challenges or adequately safeguard consumers’ interests.

By providing these reasons, the Federal Trade Commission seeks to promote a more informed and accurate discussion surrounding PBMs, ensuring that decisions are based on the latest data and understanding of the industry’s dynamics.

FTC Reverses Course on Previous Endorsement of Pharmacy Benefit Intermediaries and other notes from around the interweb:

• FTC Reverses Course on Previous Endorsement of Pharmacy Benefit Intermediaries. The FTC on Thursday plans to walk back years of advocacy in support of the entities that manage prescription drug coverage—support that analysts say has helped fuel the growth and market integration the agency is now investigating. The agenda for the Democratic-controlled Federal Trade Commission’s open meeting includes voting on a statement that would withdraw prior advocacy statements against state legislation aimed at boosting transparency, as well as studies related to pharmacy benefit managers that the FTC said, “no longer reflect current market realities.” The agency declined to provide specifics on the statement ahead of the meeting but said the vote is a direct response “to PBMs’ continued reliance on older FTC advocacy materials that opposed mandatory PBM transparency and disclosure requirements.” A former top FTC policy official and other antitrust analysts said this includes several statements the FTC issued primarily in the early 2000s against state legislation that would have required PBMs to disclose certain information about their business practices and finances to state governments. The entities manage drug coverage on behalf of health plans and others.

• Employers are suing their health plan for claims data in increasing numbers. Lawsuits from large companies and employers are increasingly being filed against third-party health plan administrators to access complete employee medical claims data. Through lawsuits recently filed against Aetna, Elevance Health and BCBS Massachusetts, employers claim payers have breached their fiduciary duties by not allowing complete access to claims data and how claims are processed. In a June 30 complaint, Kraft Heinz alleged Aetna has used its role as its TPA “to enrich itself to Kraft Heinz’s detriment” through undisclosed fees and processing medical and dental claims without human review. In December, bricklayer and metal worker unions filed a lawsuit against Elevance Health, alleging the payer does not allow self-insured plans to access their own claims data and charges the plans higher rates than it had negotiated with hospitals. A labor union in Massachusetts sued BCBS Massachusetts in April over similar allegations. These lawsuits are largely being driven by the Consolidated Appropriations Act and the hospital price transparency rule that took effect in 2021, according to a July 6 Bloomberg Law report.

• Playbook for Employers – Addressing PBM Misalignment. The guide, released by the National Alliance of Healthcare Purchaser Coalitions, identifies several key strategic recommendations that employers can adopt when looking to better navigate their relationship with PBMs. For one, the playbook recommends that employers find advisers that are genuinely putting in the work for them. Advisers should be independent and transparent, according to the guidebook, and contracts should be designed to ensure that PBMs act in the employer’s best interest. “As we uncover these increasingly apparent anomalies, I think we’ve got to challenge ourselves to do better and most importantly require that our advisers, our middlemen and our intermediaries do better on our behalf,” Mike Thompson, CEO of the alliance, told Fierce Healthcare.

• STAT News investigation takes deep dive into PBM broker conflicts of interest. Employers across the country — from big names like Boeing and UPS to local school systems — pay consulting firms to handle a straightforward task with their prescription drug coverage: Get the best deals possible, and make sure the industry’s middlemen, known as pharmacy benefit managers, aren’t ripping them off with unfair contracts. But a largely hidden flow of money between major consulting conglomerates and PBMs compromises that relationship, a STAT investigation shows. Some consulting firms often are getting paid more — a lot more — by the PBMs and health insurance carriers that they are supposed to scrutinize than by companies they are supposed to be looking out for.

The evolving relationship between self-funded employers and their third-party administrators within the US healthcare system is underlined by the Consolidated Appropriations Act of 2021. This act provides employers with enhanced access to claims data. Highlighted within this context are two significant lawsuits. Kraft Heinz and two unions have taken legal action against health insurance providers. A CAA-Compliant Checklist will help self-funded companies avoid similar actions.

Central to these lawsuits are allegations that the providers have not fully adhered to the law’s requirements. It is mandated that employers must have unrestricted access to their de-identified claims data. Accusations levelled at the providers suggest they have supplied selective and edited claims data. Consequently, employers find it challenging to assess the integrity of payment associated with the management of their plans’ funds.

Additional allegations against Aetna include wrongful retention of millions in undisclosed fees, payment of millions of dollars in provider claims that should not have been paid, and misconduct related to claims processing. These actions have been to the detriment of Kraft Heinz.

CAA-Compliant Checklist for HR Leadership Teams

These lawsuits could potentially mark the beginning of a wave of similar legal actions. Stakeholders in the healthcare industry and employers who do not undertake proper reviews of their health plans could face significant implications.

Advice to employers includes conducting an in-depth review of their advisors. This includes consultants, brokers, third-party administrators, and pharmacy benefit managers (PBMs). The aim is to understand if there are any conflicts of interest. It is suggested that employers establish fiduciary committees to review contracts and the spending of health plans.

Employers are warned of the risk of being sued by their own employees if they fail to meet their fiduciary responsibilities. In summary, this discussion raises serious concerns about transparency and fiduciary duties in the management of healthcare plans. It also highlights potential legal repercussions for employers and third-party administrators.

Understanding PBM Key Performance Indicators (KPIs) is crucial for HR and finance leaders. KPIs provide measurable and actionable insights into PBM performance, progress, and success. Furthermore, KPIs serve as quantifiable metrics that help assess the effectiveness and efficiency of PBM pricing and clinical programs. Mastering pharmacy benefit management (PBM) KPIs is crucial for the following reasons:

Performance Evaluation: KPIs provide a standardized and objective way to evaluate PBM performance at member, departmental, or organizational levels. By setting clear KPIs, HR and their consultants can monitor progress, identify strengths and weaknesses, and make data-driven decisions to improve performance.

Goal Setting and Alignment: KPIs play a crucial role in establishing SMART goals—specific, measurable, achievable, relevant, and time-bound. By offering a clear sense of direction, KPIs effectively channel efforts towards desired outcomes. When HR fully understands the KPIs, they can concentrate their actions and allocate resources to the areas of utmost importance, thereby facilitating the accomplishment of strategic objectives.

Decision Making: KPIs provide valuable insights that assist in making informed decisions. By tracking relevant KPIs, employee benefit brokers, consultants, and self-funded organizations gain visibility into what is working and what needs improvement. KPIs enable data-driven decision-making, helping to prioritize initiatives, allocate resources effectively, and adjust when required.

Continuous Performance Monitoring: KPIs serve as monitoring tools that allow individuals and organizations to track progress over time. Regularly reviewing KPIs helps identify trends, patterns, and areas of concern. By analyzing KPI data, organizations can identify bottlenecks, inefficiencies, or underperforming areas and take proactive measures to address them, leading to continuous improvement. Continuous performance monitoring is best done with software automation that doesn’t rely on PBM self-reporting.

Accountability and Transparency: KPIs promote accountability by clearly defining expectations and responsibilities. When KPIs are well-defined and understood, PBM and HR teams know what is expected of them. This fosters a sense of ownership and responsibility, leading to improved performance. Furthermore, transparently sharing KPI data within an organization promotes a culture of transparency, enhances communication, and enables collaboration.

Benchmarking and Performance Comparison: KPIs facilitate benchmarking by allowing organizations to compare their performance against industry standards, competitors, or their own historical data. Benchmarking helps identify areas where an organization is lagging or excelling, providing insights for improvement or potential areas of competitive advantage.

Communication and Stakeholder Management: KPIs provide a common language for communicating performance to stakeholders, whether they are employees, management, investors, or customers. Clear and well-defined PBM KPIs help stakeholders understand the progress, achievements, and challenges faced by an organization, fostering trust, and facilitating effective communication.

To ensure a successful relationship with their Pharmacy Benefit Manager (PBM), the self-insured organization and their advisors must possess a comprehensive understanding of their objectives and the competitive landscape. Additionally, they should be capable of compelling the PBM to provide pertinent information about essential services. Evaluating PBM transparency is best accomplished by a trained individual who possesses intimate knowledge of the buyer’s desired benefits and disclosure objectives. Pharmacy Benefit Managers will offer openness and disclosure to the extent that the competitive market requires them to do so, and they often depend on demands for information from potential customers when negotiating their contracts.

In summary, understanding PBM Key Performance Indicators (KPIs) is essential for individuals and organizations to monitor performance, set goals, make informed decisions, foster accountability, and drive continuous improvement. By leveraging KPIs effectively, self-insured organizations can enhance their competitiveness, achieve their objectives, and adapt to the ever-changing pharmacy benefit management landscape.