Benefits Pro recently published “5 Pharmacy Benefit Trends on Every Employer’s Mind.” The article claims half of employers feel very knowledgeable about pharmacy benefits. From my unique perspective, this figure is exaggerated, and the real percentage is closer to 10%. If you’re skeptical, let’s confirm it together. Embark on this brief quiz to discover the truth. When employers are truly knowledgeable about pharmacy benefits, it often leads to better healthcare decisions for employees and more cost-effective management of benefits. Here are critical pharmacy benefit questions to ask for HR.

Human Resources (HR) professionals can improve their knowledge of pharmacy benefits management (PBM) by following these steps:

1. Education and Training: Enroll in courses or workshops that cover the basics of PBM, including understanding drug pricing, pharmacy networks, formulary management, and the regulatory environment.
2. Industry Research: Stay updated with industry reports and publications from reputable sources to keep track of trends, innovations, and changes in PBM practices and regulations.
3. Networking: Join professional HR and PBM groups and forums to exchange knowledge, experiences, and best practices with peers and experts in the field.
4. Vendor Partnerships: Work closely with PBM vendors to understand the specifics of contracts, cost management strategies, and to receive tailored training on their platforms and services.
5. Employee Feedback: Gather feedback from employees about their experiences and challenges with the current pharmacy benefits to identify areas for improvement.
6. Compliance Understanding: Ensure a deep understanding of compliance requirements, such as those related to the Consolidated Appropriations Act (CAA), Health Insurance Portability and Accountability Act (HIPAA), and the Affordable Care Act (ACA), which can all affect pharmacy benefit managers.
7. Use of Technology: Leverage technology and data analytics to understand usage patterns, cost drivers, and to evaluate the effectiveness of current PBM strategies.

By focusing on these areas, HR professionals can develop a well-rounded expertise in pharmacy benefits management (PBM) that can contribute to better healthcare decisions, more cost-effective and employee-friendly benefits plans.

Copay Accumulators: Implications for PBMs and Health Plans After Court Strikes Down HHS Rule and other notes from around the interweb:

• Copay Accumulators: Implications for PBMs and Health Plans After Court Strikes Down HHS Rule. The striking down of the 2021 HHS rule on copay accumulators represents a significant development that necessitates adaptation from health plans and PBMs, who will need to adjust their operations on not just copay accumulator programs, but also copay maximizers and potentially alternative funding programs (the most recent evolution of these copay adjustment programs), to align with the reinstated federal rule. This may involve revising policies and procedures to ensure compliance and communicating the changes in copay accumulator policies to members to ensure transparency and clear communication so that members understand their cost-sharing responsibilities. Additionally, health plans and PBMs may need to reevaluate their formulary and benefit design to accommodate the new regulatory landscape while continuing to provide cost-effective and quality care to patients.

• Pharmacy Benefit Manager Pricing and Spread Pricing for High Utilization Generic Drugs. The practice by pharmacy benefit managers (PBMs) of spread pricing—charging the client (i.e. insurer) a higher amount than is reimbursed to the pharmacy—has garnered substantial attention from policymakers. The bipartisan proposals in the PBM Transparency Act and PBM Reform Act and numerous state laws prohibit spread pricing. However, others in the pharmaceutical supply chain, such as pharmacies and wholesalers, also rely on spread pricing to earn profits. The gross profit for each entity in the supply chain remains unexplored in the literature. Using Medicare Part D data, this study analyzed entity-level gross profit in the pharmaceutical supply chain for high-utilization generic drugs.

• Employers take tougher measures because of rising health costs. Employers are facing the biggest annual increase in health care costs in a decade, according to Mercer. Two-thirds of the employer health insurance market is in self-insured plans, in which an employer is on the hook for some or all of workers’ health care costs rather than an insurer, according to KFF. However, they work with third parties — often well-known health insurance brands and pharmacy benefit managers — to administer their benefits. Large, self-insured employers over the past year have been able to examine insurers’ negotiated rates with providers, thanks to federal price transparency rules. Congress, meanwhile, is looking at strengthening transparency requirements. These employers are beginning to see that their own arrangements aren’t always working to their benefit, said Rob Andrews, CEO of the Health Transformation Alliance, which includes member companies like Marriott, Coca-Cola and American Express.

• Competition in Commercial PBM Markets and Vertical Integration of Health Insurers with PBMs: 2023 Update. Based on 2020 data and newly acquired 2021 data for people with a commercial drug benefit tied to a medical benefit and the PBMs used by insurers, the updated analysis presents market insight on five PBM services performed for insurers: rebate negotiation, retail network management, claim adjudication, formulary management, and benefit design. Insurers face a make-or-buy decision—they can perform these functions in-house or buy them from a PBM. The AMA Policy Research Perspectives report, “Competition in Commercial PBM Markets and Vertical Integration of Health Insurers with PBMs: 2023 Update”, found that insurers largely use a PBM for three of them—rebate negotiation, retail network management and claims adjudication—and therefore assessed market competition for those three product markets.

In the highly competitive world of healthcare, Pharmacy Benefit Managers (PBMs) play a crucial role in ensuring that patients have access to affordable and high-quality medications. To gauge their performance and customer satisfaction, many PBMs turn to Net Promoter Score (NPS). In this blog, we will explore what NPS is, how it is calculated, strategies to improve a low NPS score, and take a closer look at the Net Promoter Score (NPS) in the PBM industry.

Understanding Net Promoter Score (NPS)

Net Promoter Score, developed by Fred Reichheld in 2003, is a metric used to measure customer loyalty and satisfaction. It provides a straightforward way to assess how likely customers are to recommend your company’s products or services to others.

NPS is based on a single, simple question: “On a scale of 0 to 10, how likely are you to recommend our company/product/service to a friend or colleague?” Based on their responses, customers are categorized into three groups:

1. Promoters (score 9-10): These are enthusiastic and loyal customers who are likely to recommend your company.
2. Passives (score 7-8): These customers are satisfied but not enthusiastic. They are less likely to promote your company.
3. Detractors (score 0-6): These are unhappy customers who may even spread negative feedback about your company.

Calculating NPS

To calculate NPS, you subtract the percentage of Detractors from the percentage of Promoters. The formula looks like this:

NPS = % Promoters – % Detractors

NPS scores can range from -100 (if all respondents are Detractors) to +100 (if all respondents are Promoters). A higher NPS indicates better customer loyalty and satisfaction.

Strategies to Improve a Low NPS

1. Analyze Feedback: Start by collecting and analyzing customer feedback. Understand the reasons behind low scores and identify areas for improvement.
2. Close the Feedback Loop: Reach out to Detractors and Passives to gather more detailed feedback. Show that you value their opinions and are committed to addressing their concerns.
3. Continuous Improvement: Implement changes based on customer feedback. Communicate these improvements to your customers, showing them that their input matters.
4. Employee Training: Ensure that your employees are well-trained and equipped to provide excellent service. Happy employees often lead to satisfied customers.
5. Personalization: Tailor your services to individual customer needs. Personalized experiences can significantly boost customer satisfaction.

PBM Industry NPS Performance:

The PBM industry’s NPS performance can vary widely based on factors such as the size of the PBM, the quality of services provided, and the effectiveness of cost-saving measures. The overall Net Promoter Score (NPS) of PBMs has suffered a dramatic decline from 38 in 2021 to 8 in 2023. Typically, PBMs with a strong focus on customer service and transparency tend to have higher NPS scores.

In recent years, there has been a growing emphasis on transparency and accountability in the PBM industry, which has driven PBMs to improve their customer satisfaction efforts. PBMs that excel in areas like medication access, cost control, and customer support often receive higher NPS scores, reflecting their commitment to enhancing the patient experience. TransparentRx guarantees one-prompt access to a live, USA-based member support representative with hold times under 20 seconds for 90% of calls to its call center, for example. An independent third-party has measured TransparentRx’s NPS, which stands at 86.

In conclusion, Net Promoter Score (NPS) in the PBM industry is a valuable metric for assessing customer loyalty and satisfaction. By understanding NPS, calculating it correctly, and implementing strategies to improve low scores, PBMs can enhance their customer relationships and drive positive outcomes in the ever-evolving healthcare landscape. Continual efforts to improve NPS can lead to increased customer loyalty and success in the competitive world of healthcare management.

Employers take tougher measures because of rising health costs and other notes from around the interweb:

• Employers take tougher measures because of rising health costs. Employers are facing the biggest annual increase in health care costs in a decade, according to Mercer. Two-thirds of the employer health insurance market is in self-insured plans, in which an employer is on the hook for some or all of workers’ health care costs rather than an insurer, according to KFF. However, they work with third parties — often well-known health insurance brands and pharmacy benefit managers — to administer their benefits. Large, self-insured employers over the past year have been able to examine insurers’ negotiated rates with providers, thanks to federal price transparency rules. Congress, meanwhile, is looking at strengthening transparency requirements. These employers are beginning to see that their own arrangements aren’t always working to their benefit, said Rob Andrews, CEO of the Health Transformation Alliance, which includes member companies like Marriott, Coca-Cola and American Express.

• Competition in Commercial PBM Markets and Vertical Integration of Health Insurers with PBMs: 2023 Update. Based on 2020 data and newly acquired 2021 data for people with a commercial drug benefit tied to a medical benefit and the PBMs used by insurers, the updated analysis presents market insight on five PBM services performed for insurers: rebate negotiation, retail network management, claim adjudication, formulary management, and benefit design. Insurers face a make-or-buy decision—they can perform these functions in-house or buy them from a PBM. The AMA Policy Research Perspectives report, “Competition in Commercial PBM Markets and Vertical Integration of Health Insurers with PBMs: 2023 Update”, found that insurers largely use a PBM for three of them—rebate negotiation, retail network management and claims adjudication—and therefore assessed market competition for those three product markets.

• Hawaii Targets PBMs With Suit Alleging Unfair Pricing System. Hawaii has joined the legal fray against the country’s top companies managing prescription drug benefits, alleging the entities are driving up high drug costs for patients they’re supposed to serve. CVS Health’s Caremark, UnitedHealth Group’s OptumRx, and Cigna Group’s Express Scripts have “engineered a business model which distorts the market to their benefit, rather than serving the best interest of their client, the payer, or the end consumer, the patient,” Hawaii Attorney General Anne E. Lopez wrote in the complaint filed Wednesday in Hawaii state court. The lawsuit claims the three pharmacy benefit managers—which together control 80% of the market—violated state laws prohibiting deceptive commercial acts and practices, and unfair methods of competition, among other actions. PBMs manage prescription drug benefits on behalf of health plans and employers, including by negotiating collecting rebates and other fees from drug manufacturers.

• ICER Updates Assessment Framework to Include New Measures of Value. The Institute for Clinical and Economic Review (ICER) has updated the framework it uses to assess the cost-effectiveness and value of prescription drugs. The organization has for 15 years provided information that has assessed the available evidence about a product’s value. Its first formal value assessment framework was published in 2015 with updates in 2017 and 2020. One of the more significant changes will be to include an assessment of a drug’s impact from a societal perspective, for example on patient and caregiver productivity, what ICER calls “non-zero” inputs. Clinical trials often do not gather this information and health economists have been conservative when there is no data, which leads to a “zero” input on measures of societal impact.

In the ever-evolving landscape of healthcare, Pharmacy Benefit Managers (PBMs) play a pivotal role in the drug pricing ecosystem. Historically, their business model was heavily reliant on rebates negotiated with drug manufacturers. However, a recent report by healthcare equity researcher Nephron has shed light on a significant shift in the PBM profit paradigm over the past decade. This shift has seen PBMs pivot from their traditional rebate-centric model to one that emphasizes fees and specialty pharmacies as primary revenue sources. Here is a summary of the report, Trends in Compensation of PBMs and PBM Contracting Entities:

• Over the past decade, PBMs have shifted their profit sources from rebates negotiated with drugmakers to two primary areas: fees and specialty pharmacies.
• Profits derived from fees have increased fourfold since 2012, and those from specialty pharmacy have more than doubled.
• The report, by healthcare equity researcher Nephron, is based on a survey of biopharma companies from 2018 to 2022.
• PBMs are now relying less on commercial rebates and more on opaque fees and directing patients to pharmacies they own.
• Three major PBMs control about 80% of the market and charge fees to various stakeholders, including manufacturers and health insurers.
• In 2023, lawmakers held several hearings to address the lack of transparency in PBM pricing practices. Bipartisan efforts aim to increase clarity around costs.

• Fees charged to pharma companies have doubled over the last five years, reaching $7.6 billion in 2022.
• New types of fees, such as vendor fees and data portal fees, have emerged and grown significantly.
• Rebates negotiated with drugmakers have decreased as a profit source for PBMs, dropping from 46% of estimated profit in 2012 to 13% in 2022.
• Specialty pharmacy is now the largest PBM profit source, accounting for 39% of PBM profits.
• Other profit sources include rebates, pricing protection, spread pricing, and mail order.
• A qualitative survey revealed that PBMs are directing more fee proceeds to subcontractors, potentially reducing transparency.
• PBM fees are often tied to list prices, also known as wholesale acquisition costs. There’s an ongoing debate about delinking these fees from medicine prices.

The Nephron report underscores a transformative period in the PBM industry, highlighting the diversification of profit sources away from the once-dominant rebate model. With specialty pharmacies emerging as the most significant profit pool and the rise of new fee structures, the PBM landscape is undeniably changing. As lawmakers and industry stakeholders grapple with these revelations, the call for transparency and reform becomes even more pressing. The future of PBMs will undoubtedly be shaped by these discussions, with a potential focus on ensuring clarity, fairness, and value for all parties involved.