PBM programs typically function in two ways. They are either “carved in”, provided by the health insurance company or “carved out”, provided independent of insurance. Whether the pharmacy benefit plan is self-funded or fully insured, any employer with more than one hundred active employees should consider and investigate a carve-out strategy for their pharmacy benefits. Simply put, a PBM carve-out gives employers more control and flexibility which leads to efficiency in managing pharmacy benefits. A carved-out program provides better cost control, transparency, information, and reporting. In a carve-in arrangement, health insurers may bundle the two programs and subsidize some of the pricing from one service with that of another. If service levels are equal or better yet costs are lower with more transparency, why choose a carve-in arrangement? For companies with a carved-in program, there may be concerns about changing to a carved-out program due to a perception that additional time and resources will be needed, but I have seen that on a day-to-day basis, there is slight difference in having a separate PBM program. The functions are similar along with the type and quantity of calls into HR. Over the course of a year, there are separate review meetings for companies with carved out programs, but overall, the time spent should be roughly the same as meetings taking place with carved in providers. From the employees point of view there is virtually no change besides possibly another card in their wallet. They will have continued access to the full range of services offered by a pharmacy benefit manager (PBM). In fact, many carved in programs use third party PBM companies to provide pharmacy services. Learn more at PBIA What are the Benefits of a Pharmacy Carve-out? 1.  Better Contract Terms – Carved-in plans are based on a single, pre-determined contract that does not allow a plan sponsor or its advisor to negotiate non-pricing terms critical to managing cost trends. For example, carved-in Rx plans seldom have audit rights and, if they do, they are frequently toothless. Detailed clinical programs are also usually missing. Conversely, a carved-out PBM contract, if correctly negotiated by the plan sponsor or an advisor specializing in pharmacy benefit contracting, will clearly outline important non-pricing terms. 2.  Carved-out Specialty Rx – A carved-out PBM also permits the plan sponsor to install a carved-out specialty pharmacy benefit. Because specialty pharmacy is the fastest growing and most expensive portion of any pharmacy benefit plan, carving-out specialty drugs provides all the advantages listed above including lower cost and more transparency. 3.  Customized Clinical Programs – Better data management and detailed analytics enable clinical licensed pharmacists, whether at the PBM or within a specialized advisory firm, to recommend, implement, and manage customized clinical programs based on the plan sponsors unique population. Examples of this include opioid management, diabetes management, and oncology programs. 4.  Lower Pharmacy Costs – A carved-out PBM contract allows for aggressive price negotiations and more competitive Request for Proposals (RFPs). Separating the medical and prescription drug benefits enables a plan sponsor…

Report: Specialty drugs are by far the most expensive, but classification seems arbitrary and other notes from around the interweb: Report: "Specialty" drugs are by far the most expensive, but classification seems arbitrary. The prescriptions with the most astonishing price tags — like cancer meds that can cost more than $20,000 a month — are usually classified as “specialty” drugs. You’d think that since they’re so costly, there would be clear criteria for putting drugs in the specialty category. But, according to a new report, you’d be wrong. The issue might seem arcane, but it’s hugely important. Specialty drugs account for only about 2% of the volume of drugs dispensed in the United States, according toq industry estimates, but they also account for more than 50% of overall drug spending. The report, by data analysis firm 46Brooklyn Research, found that the three largest drug middlemen in the United States often don’t classify the same medicines as specialty. It also said that a substantial portion of the ones they do put into that category are generics — drugs that are usually no longer under patent and thus are supposed to be cheaper because multiple drugmakers can supply them. Learn More at CPBS Now! How Payers Can Cut Through the Noise and Optimize Their PBM Partnerships. Some payers and PBMs are owned by the same parent companies, and in fact, they make up a large share of the market — something that has attracted scrutiny. The complicated relationships between these large, combined entities make it important to build a working partnership that aligns with the goals of cost-effective, high quality and accessible care. As payers work to optimize their PBM partnerships, the complexity of their agreements makes it important to increase understanding and apply best practices to ensure transparency and value. The thought of switching PBMs can be overwhelming and often immobilizes payers instead of evaluating opportunities that would drive a more sustainable sound partnership. Payers need PBMs as partners to provide core critical functions. To optimize their relationship, payers can take several key steps. What employers want to see as Congress aims to reform PBMs. A key Senate committee last week advanced a bill that includes several significant reforms to pharmacy benefit managers, including a ban on spread pricing. However, one provision that was left on the cutting room floor is a change that many employers are still hopeful to see, Alan Gilbert, vice president of policy at the Purchaser Business Group on Health (PBGH), told Fierce Healthcare. And that's establishing PBMs as fiduciaries. While the Senate Health, Education, Labor, Pensions (HELP) committee considered a similar policy change, what made the final cut was instead a directive to the Department of Labor to study the issue to enable legislation in the future. Gilbert said that making PBMs fiduciaries in the pharmacy benefits process would hold them as accountable as health plans and plan sponsors. Pushing these companies to have more skin in the game would be key to curbing the worst…

Pharmacy benefit costs have become increasingly unsustainable, according to professionals in HR, finance, and procurement. Attempts to curb these costs, such as raising employee cost share and limiting access, have had limited success. Unsurprisingly, many pharmacy benefit managers (PBMs) are profiting significantly, often surpassing the actual cost of prescription drugs. Uncovering overcharges in pharmacy benefit management requires a unique skill set and values. CLICK TO LEARN MORE In this article, we present three key indicators to determine if your PBM is overcharging you, empowering you to improve your company's pharmacy benefit management results. Contract Definition for Brand, Generic, and Specialty Drugs: The contract definition for brand, generic, and specialty drugs serve as an essential starting point. If your definition resembles the following example: "Brand Drug means a prescription product identified as a 'brand' by Acme PBM or its designee using indicators from reporting services such as First Databank or other third-party reporting sources," it's likely that you are being overcharged. A vague or convoluted definition can be exploited to inflate costs. A report, by data analysis firm 46Brooklyn Research, found PBMs charged employers $16,000 for a 180-supply of the generic multiple sclerosis drug Tecfidera. Meanwhile the cash price (no insurance) is $162 for the same prescription. The investigation also discovered that 42% to 54% of the medications on the specialty lists were generics, which is a high percentage. They were therefore on expensive specialty preferred lists even though they are often off-patent and ought to be less expensive because of competition.Contract Definition for Rebates: Examining the definition of rebates in your contract is crucial. Ensure that there are no unreasonable exclusions or limitations such as DAW codes, for instance. Remove any phrases resembling "Rebates do not include administrative fees paid by Pharmaceutical Manufacturers" or "Rebates do not include purchase discounts paid by Pharmaceutical Manufacturers or directly attributable to the utilization." Such exclusions permit the PBM to retain discounts that otherwise should be passed through to the self-funded health plan.Low or No Administrative Fee: An excessively low administrative fee should raise suspicion as it often indicates overpayment. If the administrative fee is artificially too low, how then does the PBM earn its management fee? PBMs want their clients to accept an artificially low administrative fee. It gives non-fiduciary PBMs a blank check of sorts to keep discounts they've negotiated with pharmacies, drug wholesalers and manufacturers. This becomes particularly concerning when the plan sponsor lacks audit rights on pharmacy reimbursements, cannot determine net costs through NDC claim level detail for rebates, or has limited input on benefit design beyond member cost share. These conditions limit transparency and will lead to overcharges. Effectively managing pharmacy benefits is a complex task, demanding considerable time, effort, and expertise. While anyone can assess profitability from a P&L statement, understanding the underlying story behind pharmacy benefit cost drivers requires specialized skills, such as those provided by a Certified Pharmacy Benefits Specialist (CPBS). Similarly, uncovering overcharges in pharmacy benefit management to achieve lowest net cost necessitates a unique skill…

Major Trends in the 2023 Specialty Therapy Pipeline and other notes from around the interweb: Major Trends in the 2023 Specialty Therapy Pipeline. Specialty pharmacies grew by 315% between 2015 and 2021, with hospital or health system-owned specialty pharmacies accounting for about a third of this total growth—and that the specialty drug pipeline is projected to grow by another 8% each year through 2025. Specialty pharmacy continues to carry the FDA pipeline year over year with 39 more drugs that could potentially be approved by the end of 2023, and of those 39, 28 of them could be considered specialty. Listed first are 8 major recent specialty drug approvals that have the potential to change the standard of care in a given disease and/or have a large economic impact to the payer. Looking to the rest of 2023, there are several more specialty drugs anticipated to receive FDA approval. Here is a wrapped-up version of these anticipated approvals. Learn More at CPBS Now! Self-Funded Health Plans: Breaking the Myths to Find Cost Savings. Employees generally know healthcare is expensive, but they often don’t know just how expensive it is until they’re on COBRA and are shocked at the cost. Companies pay around $23,000 per year for family and $8,000 per year for single coverage medical insurance. For even a small, 100-person company, that’s a $1.6 million budget. While 3–5% savings doesn’t sound like much, it is a lot when you consider the high starting costs. But how do you achieve cost-savings on an employee benefit plan? Self-funding may be the answer, providing average savings of up to 10% per year. Misconceptions about self-funded health plans are a big inhibitor to adoption. We’ll tell you right now—the idea that companies must take on more risk isn’t true. Read on for more myths about self-insurance and what the real story is behind this cost-saving approach. Pharma-PBM Battle Escalates on Capitol Hill. As the legislators have advanced reforms related to PBMs and other drug pricing issues, manufacturers, insurers, and PBMs have escalated their attacks on each other. The Pharmaceutical Research and Manufacturers of America (PhRMA) recently launched a wave of anti-PBM TV ads highlighting how the middlemen limit patient access to needed medicines and fail to pass on discounts to consumers. Conversely, America’s Health Insurance Plans (AHIP) has financed a million-dollar campaign blaming pharma companies for high drug costs. And the PBMs’ Pharmaceutical Care Management Association (PCMA) is airing ads to highlight the benefits of their operations and the need for drug patent reform. The Price of the PBM. One crucial element of the US drug supply chain is the wholesaler, who purchases drugs from manufacturers using purchasing power to gain discounts that average around 16 percent, according to IQVIA data. About 92 percent of prescription drugs are distributed through the three largest pharmaceutical wholesalers, McKesson, AmerisourceBergen, and Cardinal. Wholesalers earn revenue through "forward-buying," purchasing extra inventory at current prices to sell them in future at a revised higher price.

The debate on whether the Big 3 Pharmacy Benefit Managers (PBMs) offer better price savings just because of their size is a myth. The notion is largely perpetuated by the old guard who has benefited from overpayments received from opaque PBM business practices. However, the truth is that the Big 3 have more purchasing power, but their clients often don't realize the full benefit. Does size really matter when it comes to pharmacy benefit managers and cost savings? PBMs generate revenue from rebates following each eligible drug claim. Therefore, a PBM's interest typically rests in raising prescription drug prices rather than decreasing them to get larger rebates. Pharmaceutical firms' priorities have been fundamentally altered by this method; rather than competing to provide patients with high-quality, reasonably priced medications, they are now more interested in gaining the PBMs' support for the top spot on formularies by providing generous incentives thus driving up costs. Furthermore, there is a high concentration of purchasing power due to the vertical integration of the major PBMs, specialty pharmacies, and insurers. As a result, the three largest PBMs control 80% of the market for prescription volume. The following diagram shows the vertical business connections between retail chains, PBMs, and insurers: Source: The Medicine Maker For instance, while a rebate aggregator may pay a $3000 rebate for drug "A" and return every penny back to the client with an audit trail, the Big 3 may earn $4000 on the same drug but retain $1200 in-house, resulting in the plan sponsor pocketing an additional $200 when working with a radically transparent, albeit smaller, PBM. Additionally, non-fiduciary PBMs use estimates in their price quotes, which can lead to discrepancies between projected and actual costs. As a result, the plan sponsor's PBM contract is the most valuable tool to address the actual level of drug spending, not cost projections. However, non-fiduciary PBMs often use opaque contract language to eat away at the proposed savings, such as discount and rebate guarantees as soon as your plan goes live. It's essential to consider the PBM management fee in how you procure pharmacy benefit management services. The PBM management fee is largely an undisclosed fee that non-fiduciary PBMs charge for providing their services to plan sponsors, and the bulk of this fee is buried in the final plan pharmacy cost. Therefore, the contract is king. Check out this free webinar if you've never considered the PBM management fee in PBM procurement. With transparency in PBM practices, smaller PBMs can offer more significant cost savings, as illustrated in the webinar below: https://youtu.be/bnEtinkxYfU How PBMs Make Money Remember that the size of a PBM does not always guarantee better price savings. Look for transparency in PBM practices to ensure that you're getting the most value out of your pharmacy benefit management services. Having a trained eye enables a person to quickly and accurately identify details, patterns, and anomalies that may not be immediately apparent to an untrained observer. This can lead to better decision-making, problem-solving, and…

2023 Trends in Specialty Drug Benefits Report Released by PSG and other notes from around the interweb: 2023 Trends in Specialty Drug Benefits Report. Specialty drug costs have continued to push the boundaries in terms of complexity and affordability. The complicated landscape must consider many variables, such as multiple dispensing channels, dual payment methods, and site of care. This report takes a detailed look into what plan sponsors are facing as they make decisions relative to specialty drug benefit plan design. Additional topics covered in the report include increasing usage of new-to-market formulary blocks, interest in site of care programs, prior authorization tracking and reporting, and use of strategies related to biosimilars. Expert: Targeted Approach of Specialty Drugs Drives Rising Prices. In an interview with Pharmacy Times at the 2023 Asembia Specialty Pharmacy Summit, Naveen Mansukhani, BPharm, director of Operations and Account Management for Retail Pharmacy Services at Cardinal Health, discussed skyrocketing prices for specialty drugs and what is driving those increases. Q: Despite being just about 2% of overall prescription volume, specialty medications are now more than half of total annual pharmacy spending. Are there specific drug classes or disease states that are driving this issue? Naveen Mansukhani, BPharm: Specialty drugs are very targeted drugs to targeted disease states. Inflammatory disorders, oncology, multiple sclerosis, those are just some of the drug classes that are currently driving the specialty spend. Learn More at CPBS Now! Data and Collaboration Provide a Way Forward for Value-Based Care. In the 13 years since the passage of the Affordable Care Act, healthcare organizations and other stakeholders have recognized that tracking key performance indicators such as readmission rates, average length of stay and patient satisfaction are insufficient to realize the full potential of a patient-centered care experience. As value-based care models mature, measurements have expanded to include the social determinants of health and other issues that providers and payers must consider if they are to treat patients holistically. This includes the availability of transportation, family assistive services, affordable housing and other factors that provide a foundation for population health. This progress is encouraging, but the industry still has a long way to go. Clinical and financial metrics are just one lens to assess the success in delivering value-based care, and even medical, demographic, and economic data is insufficient. More granular, incisive data on the healthcare industry itself is required to fully assess how much progress the industry is making in delivering value-based care. What is transparency? Six things to look for in a PBM contract. If you don’t know the answer, they’re not transparent. PBMs aren’t incentivized to be transparent because they make money on drugs in many creative ways. So long as this remains true, their interests are not aligned with those of the employer or employees, and being transparent puts their business model at risk. For example, it’s an open secret that many PBMs make huge profits by negotiating “rebates” with drug manufacturers in the name of lowering the price of drugs. The…

The current pharmacy benefit management industry developed from transparent third-party prescription claims adjudication in less than two decades to become incredibly lucrative and opaque. Most value choices that plan sponsors cannot or do not want to make are made by PBMs. Self-insured employer strategies for optimizing pharmacy benefit plan design includes six critical pillars. However, the majority of PBMs are non-fiduciary, which implies that their interests are not congruent with those of their customers. Without this, there wouldn't be an issue. Even worse, non-fiduciary PBMs take advantage of the inexperienced plan sponsors' purchasing power by haggling with drug companies and pharmacies for their own financial gain. Prior to realizing they might utilize the inexperienced consumers' purchasing power for their own financial advantage, non-fiduciary PBMs concentrated on cost-efficiency, or achieving the greatest results at the lowest possible price. In many instances, the emphasis has turned to promoting the services that would bring in the greatest money for the PBM. Click to Learn More Fiduciary PBMs are required to act in their clients best interest. Bad actors use pharmacy benefit plan design for bad things. Hence, smart purchasers of PBM services want more control over their plan design not less. If this is you, here are self-insured employer strategies for optimizing pharmacy benefit plan design that will lower your pharmacy benefit costs and improve outcomes. I. Evaluate your internal resources and pharmacy expertise If you're reading this and work for a self-funded employer never retain the services of a PBM or a PBM consultant who benefits when your pharmacy costs increase. Should you do so, never leave them completely to their own accord. Do you have the expertise within your company to design the pharmacy benefit plan? Or do you need pharmacy benefits education or the services of a pharmacy benefits consultant?How do you want to be involved in the management of the plan design after it is set up?Do you have the expertise and resources to manage the plan design or do you need to build in the incentives for the PBM to manage your program? In other words, hire consultants not because you lack the requisite knowledge to design or manage the pharmacy benefit plan in-house, but because you lack the time or human capital to go it alone. Plan sponsors might be surprised to learn that many so called advisers know little more than they do when it comes to pharmacy benefits. Who is watching the watcher? Employ digital innovations to continuously monitor your PBMs performance. II. Access A formulary is a list of medications for which a plan will provide reimbursement. When considering a formulary, access defines the basic aspects of a pharmacy benefit design which includes but is not limited to: The products that will be coveredThe products that will not be coveredThe products that need prior approvalPlan cap or maximum dollar amount a plan will pay for outpatient drug benefitsMail service benefits including specialty pharmacy, if anyPharmacy network makeup  Managing a formulary and improving its efficiency involves an ongoing assessment…

Study Reveals Factors That Dissuade Commercial Plans From Covering Biosimilars and other notes from around the interweb: Study Reveals Factors That Dissuade Commercial Plans From Covering Biosimilars. A recent study found factors that influence a commercial plan's likelihood of placing coverage restrictions on biosimilars, including how many competitors are on the market, the prevalence of the drug indications, and the plan’s relationship with pharmacy benefit managers (PBMs). The study, published in BioDrugs, is the first to examine the characteristics associated with US commercial health plan biosimilar coverage. It also expanded on previous literature that found that biosimilars were preferred over their reference products in only 14% of coverage decisions and were less preferred in 33% of cases. The researchers used data on coverage decisions from the Tufts Medical Center Specialty Drug Evidence and Coverage database, cost-effectiveness evidence from the Tufts Medical Center Cost-Effectiveness Analysis Registry, and list prices from the Merative Micromedex RED BOOK. They identified 1181 coverage decisions through August 2021 regarding 19 commercially available biosimilars for 7 reference products and 28 indications. AHF Confronts Cigna CEO over PBM’s ‘Rapacious’ Greed. AIDS Healthcare Foundation (AHF), the world’s largest HIV/AIDS healthcare provider, sharply criticized health care behemoth Cigna today over its management of Express Scripts, the nation’s second largest Pharmacy Benefit Manager (PBM), which Cigna acquired in a 2018 merger. AHF’s criticism comes on the heels of a so-called “transparency” campaign Cigna and Express Scripts recently launched. In a letter to Cigna CEO David Cordani, AHF President Michael Weinstein details how Cigna, through its Express Scripts PBM, “…is ripping apart the healthcare system through its rapacious, self-serving, member-unfriendly practices…” Issues concerning AHF and hundreds of independent and mom-and-pop pharmacies nationwide include the following: Express Scripts (ESI) actively drives pharmacies out of its networks through reimbursements that don’t even cover a pharmacy’s drug costs, let alone the costs associated with dispensing the drugs and consulting with patients. This predatory practice is contributing to the bankruptcy of independent pharmacies and to the creation of pharmacy deserts, leaving members stranded. Learn More at CPBS Now! Florida is still battling the federal government over imported drugs. Gov. Ron DeSantis and then-Florida House Speaker Jose Oliva, R-Miami Lakes, made the drug-importation issue a priority in 2019, with lawmakers approving a plan to make imported drugs available in government programs such as Medicaid, the prison system and facilities run by the Department of Children and Families. At least initially, the state wants to import drugs to treat conditions such as HIV and AIDS, hepatitis C, diabetes, and mental illness, according to court documents. The state submitted a proposal in November 2020 to the Food and Drug Administration, which would need to approve the importation program. The proposal falls under what is known as the federal Section 804 Importation Program, or SIP What is transparency? Six things to look for in a PBM contract. If you don’t know the answer, they’re not transparent. PBMs aren’t incentivized to be transparent because they make money on drugs in many creative…

Choosing a fiduciary PBM could revolutionize your healthcare benefits. Importantly, ERISA now codifies key elements that must exist for a PBM-Plan arrangement to be judged reasonable, expanding on the reasonableness standard. For instance, a PBM-Plan contract cannot be deemed reasonable unless the PBM makes the following written disclosures: A description of the services that will be rendered to the Plan in accordance with the agreement;A declaration that the PBM, an affiliate, or a subcontractor will, or reasonably anticipates providing, services in accordance with the agreement directly to the Plan in its capacity as fiduciary;A breakdown of each direct payment that the PBM, an affiliate, or subcontractor anticipates receiving in relation to the services rendered, whether in total or by service;A description of all indirect payments that the payer expects to make to the PBM, an affiliate, or a subcontractor in connection with the services mentioned; this description should also include information about the contract between the payer and the relevant PBM, affiliate, or subcontractor that governs the payment of indirect payments;If compensation is determined based on transactions (such as commissions, finder fees, or other similar incentive compensation based on business placed or retained), a description of any compensation that will be paid among the PBM, an affiliate, or a subcontractor in connection with the services, including identification of the services for which such compensation will be paid and identification of the payers and recipients of such compensation (including the status of the pay)An explanation of any remuneration that the PBM, an affiliate, or a subcontractor could be expecting to get in connection with the contract or arrangement's termination, as well as how any pre-paid money will be computed and reimbursed after that [1]. Watch the on-demand webinar below to learn how choosing a Fiduciary PBM could revolutionize your healthcare benefits. If you are short on time, increase the playback speed to 1.25x or 1.5x. CLICK TO WATCH! Additionally, PBMs are obligated by ERISA to provide any additional information on compensation received by the PBM in connection with the contract that is necessary for the Plan to meet its reporting obligations under the CAA. This information must be provided upon written request from the Plan [2]. Click here to learn more about TransparentRx, America's first fiduciary model PBM. [1] See 29 U.S.C. § 1108(b)(2)(B)(i) and (iii). [2] See 29 U.S.C. § 1108(b)(2)(B)(vi).

3 Digital Health Strategies to Improve Health Plan Member Experience and other notes from around the interweb: 3 Digital Health Strategies to Improve Health Plan Member Experience. Health plans have innumerable reasons to focus on improving member experience right now. The Centers for Medicare and Medicaid Services (CMS) are heavily weighting member experience in STARS ratings and HEDIS scores. And healthcare consumers want more accessible care and support. Digital member engagement tools give health plans the opportunity to deliver a better member experience by making healthcare more convenient—which, in turn, drives satisfaction and retention. Members are also looking to get the best value for the soaring prices they’re paying for health insurance coverage. But adopting a new digital health solution can be challenging, especially when it comes to aligning goals with staff and member expectations. Building a digital engagement strategy requires buy-in from individuals across an organization. Here, we’re highlighting three strategies health plans can use to improve digital adoption and enhance the member experience. 15 biggest pharmacies by prescription revenue. Pharmacies earned a record $548 billion from prescription dispensing revenues in 2022, and 15 pharmacies account for 75 percent of that figure, according to Drug Channels. The market share from the top fifteen dipped from 2020 to 2021 and again from 2021 to 2022, according to past reports. They accounted for 78.6 percent of the market in 2020, 76.9 percent in 2021 and 75.6 percent in 2022, according to the site's past reports. The decrease from 2021 to 2022 is because of Walgreens' losses after the Prime Therapeutics deal, the report said. Five of the largest pharmaceutical companies are owned by companies that also have a pharmacy benefit manager, including CVS with Caremark, Cigna with Express Scripts, Centene with Envolve Health, Humana with CenterWell and UnitedHealth Group with Optum. Click here to see the Top 15 ranked by prescription revenue. Learn More at CPBS Now! Survey: More than Half of Payers Use Outcomes-based Contracts. About 58% of payers had at least one outcomes-based contract with a pharmacy benefit manager for prescription drugs in 2022, according to a survey published last week. In an outcomes-based contract, prescription drug reimbursement is based on the outcomes achieved for the patient. These contracts represent a shift to value-based care. Avalere Health, a healthcare business consulting firm, published the survey. The company conducted it online from February 14 to February 20 and received responses from forty-six health plans. This is the fifth year the company has conducted the survey. Of the payers that had at least one outcomes-based contract, more than 35% had more than ten outcomes-based contracts in 2022. Another 10% of payers had five to ten contracts, and a little over 10% had two to five contracts. About 15% had no contracts but were in negotiations for one or more. Less than 10% had no contracts and were not planning to take any on. In addition, the survey found that of the respondents who had at least one outcomes-based contract in 2022, the…