Author: Tyrone Squires, MBA, CPBS

This author has written 1326 articles

Bureau of Securities Releases Rule to Impose Fiduciary Duty on Brokers

New Jersey Bureau of Securities is proposing new N.J.A.C. 13:47A-6.4 to establish, by regulation, the common law fiduciary duty and apply it to broker-dealers and agents, and to codify it for investment advisers and investment adviser representatives.

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The Bureau believes that the proposed new rule is necessary to ensure that persons involved in the securities markets are uniformly held to a high standard in their dealings with the general public and is necessary to ensure the welfare of New Jersey investors.

Under the New Jersey regulation, brokers would have to make recommendations about securities and provide investment advice “without regard to the financial or any other interest of the broker-dealer, agent, adviser, any affiliated or related entity … or any other third party.”
Brokers also must recommend the “best of the reasonably available options” when opening or transferring assets to a specific type of account or suggesting that clients purchase securities or other investments.
Tyrone’s Commentary:
 
While no such rule exists [yet] for health insurance brokers or PBMs, it would likely deliver these protections to pharmacies, patients and self-insured employers alike:
 
Fiduciary responsibility: The model requires PBMs to have a fiduciary duty to its health plan clients. This means PBMs have a legal responsibility to protect the financial interests of their health plan clients.
 
Patient OOP costs: This section prevents a health plan or its PBM from setting patient copays or coinsurance at a higher level than the actual cost of the drug to the health plan (or its PBM).
 
Conflict of interest: Requires a PBM to notify health plan clients if the PBM has a conflict of interest. For example, when a PBM owns its own pharmacy operations, it may want to drive business there, instead of focusing on the most cost-effective drug distribution for its health plan client.
 
Rebate transparency: The act requires a PBM to report rebates and fees in a variety of ways including compensation or remuneration of any kind received or recovered from a pharmaceuticalmanufacturer attributable to the purchase or utilization of covered drugs by eligible persons. 
 
Limiting PBM requirements on pharmacies: Some PBM contracts limit which drug wholesaler or distributor a pharmacy can buy from. Those PBM-specified distributors may serve the PBM’s financial interests more than a pharmacy’s.
 
The good news is purchasers of PBM services don’t have to wait for legislation to benefit from fiduciary standards. All you have to do is require it from the PBM you choose to do business. The benefit is almost always lower costs and better patient healthcare outcomes.

Reference Pricing: “Gross” Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 264)

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.

 

How to Determine if Your Company [or Client] is Overpaying

Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.
 

Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list.

Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement. It’s impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions.

Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our acquisition costs then determine if a problem exists. When there is more than a 5% price differential for brand drugs or 25% (paid versus actual cost) for generic drugs we consider this a potential problem thus further investigation is warranted.

Multiple price differential discoveries mean that your organization or client is likely overpaying. REPEAT these steps once per month.

— Tip —

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.

“Don’t Miss” Webinar: How to Slash PBM Service Costs, up to 50%, Without Changing Vendors or Benefit Levels

How many businesses do you know want to cut their revenues in half? That’s why traditional pharmacy benefit managers don’t offer radical transparency and instead opt for hidden cash flow opportunities such as rebate masking. Want to learn more?


Here is what some participants have said about the webinar.

“Thank you Tyrone. Nice job, good information.” David Stoots, AVP


“Thank you! Awesome presentation.” Mallory Nelson, PharmD
 
“Thank you Tyrone for this informative meeting.” David Wachtel, VP

“…Great presentation! I had our two partners on the presentation as well. Very informative.” Nolan Waterfall, Agent/Benefits Specialist


A snapshot of what you will learn during this 30 minute webinar:

  • Hidden cash flows in the PBM Industry such as formulary steering, rebate masking and differential pricing 
  • How to calculate cost of pharmacy benefit manager services or CPBMS
  • Specialty pharmacy cost-containment strategies
  • The financial impact of actual acquisition cost (AAC) vs. maximum allowable cost (MAC)
  • Why mail-order and preferred pharmacy networks may not be the great deal you were sold
 
Sincerely,
TransparentRx
Tyrone D. Squires, MBA  
3960 Howard Hughes Pkwy., Suite 500  
Las Vegas, NV 89169  
866-499-1940 Ext. 201


P.S.  Yes, it’s recorded. I know you’re busy … so register now and we’ll send you the link to the session recording as soon as it’s ready.

Electronic Prior Authorizations (ePA) Save Plan Sponsors Time and Money

Certain drugs on a formulary may require prior authorization (PA) before a patient can receive the medication. Drug Prior Authorization is a utilization management tool that requires the prescriber to provide clinical information (e.g. lab values, chart notes, etc.) in order for the payer to make a determination whether it will pay for the drug. 
 
The country’s first fiduciary-model PBM – Click to learn more

The traditional prior authorization process relies heavily on fax and phone and involves  prescribers, payers, pharmacists, and patients. The National Council on Prescription Drug Programs (NCPDP) noted several problems with the current state of drug prior authorization and the cumbersome flow of information1:

 
·    “Prescribers often are not aware that a PA is needed until the prescription claim is rejected at the pharmacy. This leads to delays in 1) the opportunity to discuss the PA process with the patient 2) the potential to prescribe another medication, and 3) the patient’s treatment beginning as anticipated.“

·    “Pharmacists are often playing middlemen, contacting the prescriber to initiate a PA, and notifying the patient of the coverage restriction. They spend time contacting the prescriber, either by phone, fax or via a secure transaction. They may also contact the payer to determine the status of the PA request and update the patient.”
·    “Patients may learn of the need for a PA when they attempt to obtain their medication. They are then faced with the choice of waiting for the PA process to be completed, paying the full price for their prescription or not obtaining the medication.”
 
·    “For payers the current manual process may result in delays as data received via phone or fax cannot be systematically reviewed. As more processes are handled electronically, reverting to paper, phone, or fax for communication between payers and prescribers may cause delays. “
With electronic Prior Authorization (ePA), the process is automated as the provider initiates the PA electronically at the point of prescribing within the EHR or electronic health record. According to the covermymeds scorecard, payers can expect to receive the most benefit from ePA solutions2:
  •     Time and cost savings due to the reduction in phone calls and faxes
  •     Decrease in time to therapy to improve member satisfaction and outcomes
  •     Increased medication adherence to limit unnecessary hospitalizations
  •     Complete and accurate initial submission of PA requests
  •     Possible real-time determinations based on preset, payer-specific criteria

Understanding the Complexity of DIR Fees

The Centers for Medicare and Medicaid Services (CMS) describe DIR fees as “fees, payments, or payment adjustments made after the point-of-sale that change the cost of Part D covered drugs for Part D sponsors or PBMs must be reported to CMS as Direct or Indirect Remuneration (DIR).”1  

Source: Diplomat Pharmacy

DIR fees originated in Medicare Part D, however, these fees are now utilized for commercial plans. Pharmacies are charged DIR fees by PBMS after the point of sale.  DIR fees may be based on pharmacy performance, ability to participate in a preferred network or as reconciliation between negotiated price and a claim.2  DIR fees have come under scrutiny by pharmacies.  According to the White Paper: DIR Fees Simply Explained, DIR fees “create losses in revenue that, at times, may surpass the acquisition cost of the drug itself.” Moreover, certain pharmacy organizations have advocated for DIR fee reform. 3    

Based on a survey by the National Community Pharmacy Association (NCPA), a large majority of independent community pharmacy owners do not know what their final reimbursement will be at the point of sale and that it takes 4 to 12 months before they know the final reimbursement figure. 4 
For plan sponsors and patients the financial impact of DIR fees are even less transparent. Two big issues surrounding DIR fees for plan sponsors and members, who to a large extent are unaware DIR fees even exist, are:

1) DIR fees hide the true cost of the drug, from the plan sponsor, to the PBMs financial benefit. For example, PBMs might break-even on retail pharamcy network discounts on the front-end only to make up for it on the back-end through DIR fees. PBMs should be negotiating these discounts on behalf of the client then passing these savings onto plan sponsors. At the very least, PBMs should be disclosing their take home on these fees to plan sponsors.

2) Members cost share (i.e. coinsurance) too doesn’t take into account the PBM’s true cost when DIR fees are collected. If these fees were applied at the point-of-sale these plan participants would pay less and in some cases significantly so.

As a first proactive step to manage DIR fees, pharmacies should understand their contract and the various conditions therein. The NCPA DIR Fee FAQ guidance document asserts that pharmacy owners should manage these fees by performing “due diligence when evaluating contracts and make sure you are aware of and understand all of the different terms and conditions contained in your contract including network pharmacy manuals when incorporated by reference into a contract.

Alternately, make sure any contracting entity that might negotiate on your behalf (PSAO) explains to you the parameters of all of your contractual terms.”5

1) https://www.cms.gov/newsroom/fact-sheets/medicare-part-d-direct-and-indirect-remuneration-dir
2) https://www.specialtypharmacytimes.com/news/white-paper-dir-fees-simply-explained/P-1
3) https://www.nacds.org/news/pharmacy-groups-praise-cms-progress-on-dir-fee-reform-to-lower-patients-out-of-pocket-drug-costs/
4) https://www.ncpanet.org/newsroom/news-releases/2018/02/09/ncpa-survey-pharmacy-dir-fees-plague-both-community-pharmacies-and-their-patients
5) http://www.ncpa.co/pdf/dir-faq.pdf

Reference Pricing: “Gross” Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 263)

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.


How to Determine if Your Company [or Client] is Overpaying

Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.
 

Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list.

Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement. It’s impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions.

Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our acquisition costs then determine if a problem exists. When there is more than a 5% price differential for brand drugs or 25% (paid versus actual cost) for generic drugs we consider this a potential problem thus further investigation is warranted.

Multiple price differential discoveries mean that your organization or client is likely overpaying. REPEAT these steps once per month.

— Tip —

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.

Robbing Peter to Pay Paul: Co-Pay Accumulator Programs Could be Doing More Harm Than Good

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Some experts say co-pay accumulators drive down drug prices as patients seek cheaper drugs. But the programs also add value for people who are ill and dealing with health issues.
Co-pay accumulator programs began appearing in 2016 in employer-provided private health plans and in Affordable Care Act marketplace plans. The programs change the way out-of-pocket costs are calculated if members use a manufacturer’s discount card or coupon to reduce prescription costs.

Members can download discount coupons or cards from a drug company’s website or get them from their doctors. They are used with their insurance; in some cases, members pay as little as $5 or $10 for their medication. But the total cost for the medicine counts toward your deductible, substantially lowering your out-of-pocket costs for future refills.

If a plan has a co-pay accumulator adjustment program, members can use a co-pay assistance card or coupon. But the drug’s full cost won’t count against the deductible. And most assistance cards have a dollar limit on how much they will pay.

Tyrone’s Commentary:

A co-pay accumulator program which focuses only on employer cost share without consideration for patient outcomes or satisfaction can be a disaster. Consider these three points:

1) Plan sponsor Rx costs will decrease. As a result, medication adherence will also decline. 
2) Expect higher hospital costs due to lower adherence of critical medications.
3) Members might become disconnected from their employer so look for low moral or higher absenteeism.

I’m not suggesting that these programs are bad. What I am saying is that before implementing a co-pay accumulator program to evaluate the overall impact first or it could turn out to be a case of robbing Peter to pay Paul (see #2 and #3 in this list).

[Read More]

Smaller independent pharmacies consistently offer cheaper options than chain pharmacies

The price of the same prescription drug can vary by hundreds or even thousands of dollars, depending on where you buy it, according to a new report by the U.S. Public Interest Research Group which surveyed hundreds of pharmacies and found large price differences for identical medications.

Adam Garber is the consumer watchdog for the U.S. PIRG. The group surveyed more than 250 pharmacies across the country for the cash prices of common medications, the price someone pays if they don’t have insurance or are under-insured and do not qualify for coupons or savings programs sometimes offered by drug manufacturers.

Tyrone’s Commentary:

While the study looked at only cash transactions, the premise is consistent with insured persons. The difference is that the employer picks up most of the tab. For many employers, there is a huge opportunity to cut costs by nudging members to smaller independent pharmacies. Those limited networks being pitched by large chains can be a trap. It’s a popular tactic in the pharmaceutical supply chain; that is bait and switch.

When I was an operator, a mail-order pharmacy owner, we had a wholesale contract with one of the Big Three wholesalers. You know who they are; Mckesson, Cardinal Health and AmerisourceBergen. Like most independent pharmacies, options were limited in terms of where to buy brand drugs. For generics competition was/is much more fierce. 

But, when entering into an agreement with one of these big wholesalers they can require pharmacies to purchase as much as 80% of their inventory from them to remain compliant. Because secondary wholesalers don’t carry nearly enough inventory, it’s a catch 22. The big three wholesalers overcharge, especially for generics, now that the independent pharmacy can’t shop anywhere else. Sound familiar?

Ex. Employer Cost Savings Analysis

The limited or preferred networks offered by large pharmacy chains, in conjuntion with coalitions and non-fiduciary PBMs alike, often employ similar tactics they’re just not as conspicuous. A PBM or coalition could meet its performance guarantee on the front-end but that performance can be distorted hiding the true cost. 

NDC upcharging, repackaging, DAW rules or DIR fees are just a few of the hidden cash flow tactics which make network performance look much better than it really is. Take my word for it, we run pharmacy switch analyses and aren’t surprised when we find $1 million savings on a $15 million annual Rx spend just by nudging members to lower cost pharmacies. 

The study found consumers could save anywhere from $100 to $5,400 a year just by price shopping. In Ohio, they found the same inhaler being sold for $11.99 at one pharmacy and $1,136 at a different pharmacy. In North Carolina, a generic medicine to lower cholesterol could cost $7 or $393 depending on where it was purchased.

[Read More]

Don’t look now but things are getting even more complicated: Point-of-sale discounts (rebates) to consumers as part of employer-sponsored plan design

Building on the introduction of its point-of-sale (POS) discount program, OptumRx and UnitedHealthcare are expanding their POS prescription drug discount programs to apply to all new employer-sponsored plans. The idea behind the expansion is to make medications more affordable and to improve health outcomes.

Tyrone’s Commentary:

Education is the leading market driver of transparency
in the PBM space. Employers click here to learn more.

1) The POS discount program alone doesn’t change the rebate share Optum keeps for itself which is the biggest problem. Optum’s POS rebates may reallocate part of the plan sponsor’s share to another participant (patient) in the US Pharmacy Reimbursement and Distribution System, for example.

2) Patients should be able to benefit from lower costs so I agree with the premise. However, how is the POS rebate calculated and is it consistent? A patient with a 20% coinsurance should receive a larger rebate than a patient with a lower flat copay especially when that flat copay is significantly lower than the OOP for coinsurance. POS discounts or rebates can make the process of getting to true cost or eliminating overpayments challenging to say the least.

3) Reporting. This adds another layer which OptumRx or any non-fiduciary PBM could make it difficult for the plan sponsor to ascertain the patient’s financial benefit, at the POS, which can lead to an increase of opacity.

Bottom line plan sponsors now more than ever need to win radical transparency from their PBM. Now that one additional beneficiary [patient] has been added to the financial flow of money, from rebates, the US Pharmacy Reimbursement and Distribution System is even more complicated.

[Read More]

Reference Pricing: “Gross” Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 262)

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.


How to Determine if Your Company [or Client] is Overpaying

Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.
 

Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list.

Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement. It’s impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions.

Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our acquisition costs then determine if a problem exists. When there is more than a 5% price differential for brand drugs or 25% (paid versus actual cost) for generic drugs we consider this a potential problem thus further investigation is warranted.

Multiple price differential discoveries mean that your organization or client is likely overpaying. REPEAT these steps once per month.

— Tip —

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.