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Over the entrance of what looks like a regular, aging CVS drugstore outside Houston, a billowing blue banner announces “HealthHUB Come Inside!”The HealthHUB section at the far end goes far beyond what you’d find at a typical walk-in clinic. They offer testing and treatment for chronic conditions, and boast four consultation rooms equipped with exam chairs and retinal cameras for diabetes screening. Video screens display prices for popular services: Today’s rates are $100 for diabetic retinopathy imaging and $89 for a cholesterol screening.

Tyrone’s Commentary:

I wrote about this back in December. Non-fiduciary PBMs hidden cash flows aren’t so hidden any longer so how will they continue to grow revenues? One answer, shift lost retail prescription drug revenue to the medical Rx spend. When you see inflated AWP discounts over 20% for retail brand and 25% for mail brand then something stinks (if not on a cost plus model). If these discounts are accurate then costs likely have been shifted elsewhere. Pharmacies simply don’t make any money at these price points. But, take a look at prescription drug costs on the medical spend, for example, and you might discover the non-fiduciary PBMs who either own or are owned by an insurance carrier are printing money. They have taken a loss on the retail side only to double-up on the medical Rx spend. Buyer beware. 

Employees from the Texas Department of Transportation get full physicals here. At the pharmacy adjacent to the HealthHUB, pharmacist Alex Ybarra counsels patients in a private office as part of the new high-touch approach; the previous day, she spent an hour advising a senior who needed help measuring the effect of his six diabetes medications on his blood sugar.

The HealthHUB is Jacqueline Haynes’s destination for wellness. She was given a blood test for hypertension by a nurse practitioner, who wrote a prescription for beta-blocker Bystolic that Haynes filled at the pharmacy, steps away. She credits the full-time dietitian with helping her shed 72 pounds since January. “That brings my weight to 167.7,” says Haynes, who frequents a CVS “gentle yoga” class on Tuesdays. “I was addicted to avocados and chocolate. He got me eating healthy by doing things like substituting low-cal cacao nibs when I craved candy bars.”

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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 a prescription drug is dispensed at the pharmacy counter, patients pay cost sharing to the pharmacy, which usually consists of a fixed payment (copayment) or percentage of the drug’s list price (coinsurance), with the cost-sharing varying by the drug’s formulary tier placement). Employers, through their contracted insurance carriers, pay the pharmacy the amounts determined to them by their PBMs.

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Many employers do not pay administrative services fees to PBMs, but simply pay prescription drug claims and receive monthly manufacturer rebates passed through by PBMs. The contracts between employers and PBMs usually specify certain savings guarantees (based on list prices) but often limit the employers’ right to audit. At the end of each fiscal period, PBMs send reports to employers showing that the contractually specified savings guarantees have been honored, and sometimes that additional savings (again based on list prices) have been achieved.

Tyrone’s Commentary:

This is a great article which was originally written on healthaffairs.org. It is factually accurate and offers some good tips for self-insured employers. One thing (well two things but more on that later) in the article really bugs me. The article touches on it but doesn’t go into a deep dive. That is holding employers and consultants more accountable when it comes to being a more sophisticated purchaser of pharmacy benefits. Non-fiduciary PBMs won’t willingly forgo profits that are driven largely by hidden cash flows. You must demand they do it and that starts with education. With education comes more confidence then, eventually, an unwillingness to accept the status quo. Oh before I forget…the other thing which bugged me about the article is I wish they would have at least sited this blog in the article. Some of the strategies discussed in the original article can be found right here in this blog and no where else. Bummer! 

This seemingly convenient and advantageous contractual arrangement (from the employers’ perspective) deprives employers of the ability to completely understand the drug benefit design, evaluate the efficiency of their drug utilization, and assess the PBM’s performance. For example, employers may not know that reclassifying some drugs as generic (or branded) can have important implications for their costs or that their employees may have been steered to utilize expensive drugs when cheaper generics are available. This inefficient contractual arrangement leads to overutilization of expensive drugs, higher patient cost sharing, and higher employer spending on drugs.

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A long-awaited state report appears to confirm legislators’ suspicions that pharmacy benefit managers or PBMs are reaping big profits from Kentucky Medicaid dollars. Called “Opening the Black Box,” Kentucky’s report released in February shows payments to PBMs grew over the past year, even as lawmakers increased scrutiny and passed legislation demanding more transparency about prescription drug costs.

Spread by Pharmacy Type

Last year, pharmacy benefit managers, or PBMs, took in $123 million through a practice known as “spread pricing,” the difference between what the pharmacy benefit company pays the pharmacist and what it bills the state Medicaid program, according to the report.

Tyrone’s Commentary:

This should sever as a warning to all self-insured employers. Despite Kentucky’s best efforts to reduce PBM service fees, payments to PBMs grew year-over-year. Even as lawmakers increased scrutiny and passed legislation demanding more transparency, non-fiduciary PBMs still increased the amount of revenue they took in! If a state with unlimited resources can’t stem PBM service fees, how does a commercial employer even stand a chance? Here’s the answer. Do business with a fiduciary-model PBM. While the answer may seem self-serving it isn’t. There are just too many loopholes, from which a non-fiduciary PBM can benefit, for even the sharpest consultant, HR Executive or CFO to close. Leave just one loophole open and you will bleed out. 

Kentucky’s Eight (8) Recommendations:

1)  Mandate pass-through contracting for all MCO-PBM contracts for pharmacy.

2)  Remove all DIR fees including transactional fees, in-network fees, GER and BER fees.

3)  Evaluate the implementation of a pricing methodology to managed care Medicaid pharmacy. Using a similar lesser of logic methodology, medications would be reimbursed the same as Kentucky’s fee-for-service population.

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Health benefits brokers would have to reveal the fees and other enticements they’ve received from the insurance industry under bipartisan legislation proposed Thursday in the U.S. Senate. The brokers are supposed to independently help employers select benefits for their workers. Similar proposals have been submitted in the past but this one has legs. Business Value Awareness in the health care industry is at an all time high.

A ProPublica investigation in February found that the insurance industry often uses undisclosed money and gifts to influence which plans the brokers favor. The payments and perks include healthy commissions, six-figure bonuses and exotic island vacations. Critics call the compensation a “classic conflict of interest” that drives up costs.

Tyrone’s Commentary:

Let me start with TransparentRx’s position on brokerage fees. Yes, some PBMs too are willing to pay hefty fees to win business. Any fees we pay to a brokerage must be disclosed (not in the fine print) to the plan sponsor. This is a requirement of the fidudiary standard we offer to every client. I suspect this is part of the reason why we aren’t yet a half billion dollar company but I digress. I’ve personally had conversations with leadership at several health benefits brokerage firms on this very topic. For some of these leaders, their conscience is getting the better of them. This is good news for the industry as a whole. They want more disclosure. They want more transparency for their clients. Ideally, more disclosure leads to lower fees for plan sponsors. I don’t necessarily believe that a brokergage firm has to give up revenue for disclosure. The value proposition, however, must change. As a health benefits brokers value proposition begins to take shape, it is important to compare it against your competitors’ value proposition, or at least your best estimate of what those value propostions are. This is different from and far more challenging than merely comparing service offerings and fees. The same can’t be said for carriers. It was a carrier when an executive at a large brokerage firm shared with me their desire for more disclosure and transparency only for the carrier to push back saying, “why…we are making a lot of money.” Unfortuntately, this is how a large part of business gets done in healthcare – you scratch my back and I’ll scratch yours.

ProPublica’s findings prompted Sen. Lamar Alexander, R-Tenn., chairman of the Health, Education, Labor and Pensions Committee, and Sen. Patty Murray, D-Wash., the committee’s ranking minority member, to include new requirements for brokers in a sweeping health care legislation proposal. The draft bill, known as the Lower Health Care Costs Act, also takes on surprise medical bills, high drug prices and public health problems among other issues.

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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.

The CBS 11 Dallas Fort Worth news team asked local pharmacists to ring up the prices of commonly used medications, first, with a popular insurance plan, then the same drug for someone without insurance. Here are two examples of real cases where insured patients paid more.

1) Valacyclovir is a common anti-viral drug used to treat cold sores, chicken pox and shingles. The copay amount with a popular insurance plan is $50, but if you never told the pharmacist you had insurance, the drug would cost $26.67 out of pocket.

2) Armour-throid, used to treat an under-active thyroid, has a copay cost of $150 with a common insurance plan. Without insurance the price is $39.21, a difference of more than $110.

This billing practice is known as a “clawback” and you may have no idea it’s happening. These clawback monies are a contributing factor to significant overpayment for pharmacy benefits management services.

While pharmacists have known about this price discrepancy for years, in many cases they have been prevented from telling their customers. Gag clauses in contracts made by insurers and pharmacy benefit managers (PBMs) often prevented pharmacists from discussing alternative price options with their customers. However, last year the federal government made these gag clauses illegal.

1.  Uncertainty Over Regulation

Federal and State governments are now keenly aware of the self-dealing which takes place in PBM arrangements. Ohio’s Attorney General, Dave Yost, is continuing to wage war on non-fiduciary PBMs or pharmacy benefit managers. You might remember him from an earlier blog post when he served as Ohio’s State Auditor.

AG Yost just announced a four-part proposal and called for quick action from the state’s legislature to shine a bright light on PBM contracts and cut down on hidden cash flows. Yost’s proposal calls for:

• Drug purchases in the state to be conducted under a master PBM contract that is administered by a single contact point
• Ohio’s Auditor of State to have full power to review all PBM contracts, purchases and payments
• PBMs to operate as fiduciaries, uh-oh!
• The state to prohibit nondisclosure agreements on drug pricing.

Last summer, in his previous role as state auditor, Yost learned PBMs earned nearly $225 million through spread pricing between April 2017 and March 2018 while operating in Ohio Medicaid. As a result, the state canceled all PBM contracts in Medicaid that used spread pricing.

2. Power is Consolidated

One of the important signs that an industry could be disrupted is imbalance, or dominance by one side of the economic equation. Oligopolies, where a few companies have consolidated vast amounts of the market share either on the supply or demand side, are often good candidates. Make no mistake about it ESI, Caremark and Optum is an oligopoly.

3. Business Practices aren’t Changing—Despite Negative Consumer Sentiment

The car rental industry is universally panned. Car Rental has a net promoter score of 23. (Just to give you a benchmark if you’re unfamiliar with the NPS, Apple has a net promoter above 80). Basically less than 1 in 4 rental car customers in the US would recommend these brands to a friend.

Enter Silvercar. They are working to create a simplified experience for renting a car. Something that might not be for everyone. But for the right person—say, a business traveler—it would feel like a godsend.

Despite the sentiments reflected above, car rental companies did very little to improve the overall experience—either because they didn’t want to, or simply couldn’t due to the complexity of their systems and operating models. The same is true for non-fiduciary PBM models and like the rental car industry purchasers have better options.

4. The Research Backs Me Up

I always recommend that people spend a lot of time, and even a lot of money, getting educated and doing research on the PBM industry. Why? Because education and research breeds confidence. Confidence in your procurement, monitoring and evaluation of PBM performance just works.

5. Established PBM Firms are Bogged Down in Their Own Infrastructures

Nimble startups developing alternative approaches to pharmacy benefits management are able to disrupt dominant incumbents in the self-insured market, particularly where the infrastructure of entrenched players hampers their own ability to innovate. Legacy PBMs can’t offer radical transparency and keep the lights on at the same time. So they “recruit” brokers pay them a handsome commission to keep the cash cow producing, for example. What self-insured employers don’t know is that those rebates you forgo for a lower admin fee are costing you millions! Large PBMs are finding it more feasible to partner with or buy out more nimble startups who are educating self-insured employers on these types of facts.

6. Customers Have to Work at Managing Their Costs

Another signal for disruption is that cost models are difficult to understand for customers. This is often the situation when the PBM profits by keeping customers heads in the sand. A good example, TransparentRx educates brokers, HR executives and CFOs to be better stewards of the pharmacy benefit. This greatly improves the results for purchasers of PBM services, most of whom don’t really know if what they are being told is the truth – “head in the sand.”

7. Inertia

Generally, the more established people’s habits, the higher the inertia, meaning they’re less motivated to consider alternative choices. Many PBM customers, for example, say that they dislike their PBM service costs and would be delighted to switch. But, the prospect of disrupting the member experience and attending implementation meetings is so overwhelming that it’s easier to just stay where they are. Wherever customers feel trapped by inertia in a situation they find less than desirable is where I find tension. Opportunities are being created to either break or leverage that inertia with self-insured employers who act out of habit.

Source:  https://www.zdnet.com/article/5-reasons-the-financial-industry-is-ripe-for-disruption/
Source:  https://sloanreview.mit.edu/article/three-signals-your-industry-is-about-to-be-disrupted/

Some say it might be the biggest price-fixing scheme in U.S. business history. More than 40 states filed a 500-page lawsuit accusing generic drug makers of a massive, systematic conspiracy to bilk consumers out of billions of dollars. For example, text messages implicate at least three companies: Heritage, Aurobindo and Teva, the world’s largest generic drug maker. The national accounts manager at Heritage wrote:

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A.S.: “We are raising the price right now — just letting you know, Teva says they will follow”

A.S.: “Aurobindo agrees too”

A corporate account representative from Citron answered:

KA: “…we are def [initely] in to raise pricing … are doing this immediately”

The Heritage executive responded:

AS: “We are raising our customers 200% over current market price.”

Congress established the current generic industry in 1984 to push prices down. The idea was that once patents on brand name drugs expired, generic makers would compete to make drugs more affordable. But 1,215 generics, many of them the most prescribed drugs, jumped on average more than 400 percent in a single year.

Connecticut has been examining the generic drug industry for almost five years. Last night, 60 minutes gave us a peek inside the investigation. Two relentless attorneys built the cases the state attorney general calls the most egregious examples of corporate greed he has ever seen.

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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.