In the complex and rapidly evolving field of pharmacy benefits management (PBM), expertise is not just valuable; it’s essential. However, the terrain is fraught with self-professed experts whose credentials and experience may not stand up to scrutiny. This poses a significant risk to employers, unions, health plans, and health systems that rely on their guidance for managing pharmacy benefits, which are a critical and costly component of healthcare benefits. The risks of relying on self-professed pharmacy benefit experts and the value of certification can coexist; they are not mutually exclusive.

Fiduciaries, tasked with making decisions in the best interest of their beneficiaries, often turn to external experts for guidance, especially in areas outside their immediate expertise. This practice is not only prudent but expected under certain conditions to ensure well-informed decision-making. However, it’s crucial that fiduciaries do not simply take this external advice at face value. The Court of Appeals for the Third Circuit has highlighted a nuanced stance regarding this reliance. The court acknowledges the value of engaging consultants for their expertise in making informed investment decisions. Nonetheless, it emphasizes that fiduciaries under ERISA (the Employee Retirement Income Security Act) bear the responsibility to actively engage with the information provided by these consultants.

Pitfalls of Self-Professed Pharmacy Benefit Experts

Lack of Accountability

One of the primary risks of engaging with self-professed experts is the lack of accountability. Certified professionals, on the other hand, are accountable to the standards and ethics set forth by the certifying body, ensuring a minimum level of competence and integrity.

Inadequate Knowledge

Pharmacy benefits management is a specialized field that requires a deep understanding of cost management, benefit design, contract review, healthcare policy, and pharmaceutical pricing fundamentals. Self-professed experts may lack the comprehensive knowledge necessary to navigate these complexities effectively, potentially leading to suboptimal outcomes.

Bias and Conflicts of Interest

Without the transparency and ethical obligations required of certified professionals, self-professed experts may have undisclosed biases or conflicts of interest. This can lead to recommendations that serve the expert’s interests rather than those of their clients.

Benefits of Certified Pharmacy Benefits Specialists

For Unions

Unions benefit from certified specialists by ensuring their members and employees have access to the best possible pharmacy benefits at the lowest possible cost. Certified specialists are equipped to negotiate effectively with pharmacy benefits managers, identify cost-saving opportunities, and design benefits plans that meet the needs of diverse populations.

For Health Plans and Health Systems

Health plans and health systems face the dual challenge of managing costs while ensuring patient access to necessary medications. Certified Pharmacy Benefits Specialists (CPBS) bring a level of expertise that can help these organizations balance these objectives, through strategic formulary management, vendor selection, and compliance with regulatory requirements.

For Commercial and Public Sector Employers

Commercial and public sector employers, who often provide health benefits to large numbers of employees, stand to gain significantly from the expertise of certified specialists. These professionals can help employers navigate the complexities of pharmacy benefits management, including specialty drug coverage, benefit design, and wellness integration, leading to improved health outcomes and cost savings.

Conclusion

In an era where healthcare costs continue to rise, and the landscape of pharmacy benefits grows increasingly complex, the value of Certified Pharmacy Benefits Specialists (CPBS) cannot be overstated. By relying on certified professionals, unions, health plans, health systems, and employers can mitigate the risks associated with self-professed experts. Certification ensures that these critical stakeholders have access to knowledgeable, accountable, and ethical experts who are committed to optimizing pharmacy benefits in the best interest of their clients. The Certified Pharmacy Benefits Specialist (CPBS) program stands at the forefront of this effort, providing a benchmark for excellence and integrity in the field of pharmacy benefits management.

ERISA’s Cure for the $1.5 Trillion Health Benefits Market and other notes from around the interweb:

• Hiding in Plain Sight: ERISA’s Cure for the $1.5 Trillion Health Benefits Market. Fiduciaries are expected to consult outside experts to inform their decisions where the circumstances warrant but may not blindly rely on expert advice. As the Court of Appeals for the Third Circuit has explained, “While we would encourage fiduciaries to retain the services of consultants when they need outside assistance to make prudent investments and do not expect fiduciaries to duplicate their advisers’ investigative efforts, we believe that ERISA’s duty to investigate requires fiduciaries to review the data a consultant gathers, to assess its significance and to supplement it where necessary.”

• Best Pharmacy Benefit Consultants for Cost-Effective Drug Plans. In the complex world of healthcare and pharmaceuticals, managing costs while ensuring the best possible care can be a daunting challenge for businesses of all sizes. Pharmacy Benefit Consultants (PBCs) play a crucial role in navigating this landscape, offering expertise that can lead to significant savings and more effective drug plan management. This article delves into the importance of PBCs, what to look for when selecting a consultant, and how they can transform the cost-effectiveness of drug plans.

• 5 ways to improve your PBM procurement process in 2024. Many self-funded plan sponsors struggle to manage the cost of pharmacy benefits and rely on non-transparent contract guarantees to hold PBMs accountable. Meanwhile, drug spending continues to compound at an astonishing rate in defiance of the savings promised during the procurement process. As a former pharmacy program director for a plan covering more than 16,000 lives, I can tell you that it is possible to stop the “games” PBMs play, control costs, and ensure that all contractual guarantees are met, especially in scenarios where a PBM won’t guarantee an all-in per member per month (PMPM) cost for the year. Understanding the problem is a part of the solution, but making meaningful changes to the way plan sponsors and brokers evaluate PBMs is where the real opportunity lies.

• 3 thing to know about specialty pharmacy in 2024. Specialty drugs may be covered by a medical benefit (what patient-members likely think of as “their insurance”) or pharmacy benefits. There’s often a gray area for where specialty falls, but it can relate to whether the drug is being administered in a clinical setting, like a doctor’s office, outpatient clinic, or infusion center. Reimbursement for these drugs can also vary between average wholesale price (AWP) for pharmacy reimbursement and average sales price (ASP) for the medical benefit. It’s complex to compare, and both ASP and AWP are used in the health care industry, but they’re different. ASP is a government-regulated tool that uses manufacturer sales information including discounts, such as rebates. AWP is the average price that wholesalers sell drugs to pharmacies, prescribers, and others. A government report found the median percentage difference between ASP and AWP to be 49%.

In the complex world of pharmaceuticals, drugmakers are often scrutinized for the high prices of their medications. These prices, while reflective of the research and development costs involved in bringing new drugs to market, also highlight the industry’s strategic efforts to protect profit margins. As consumers and healthcare systems worldwide grapple with escalating drug costs, understanding the tactics employed by pharmaceutical companies to maintain their financial edge becomes crucial. From patent protections to direct-to-consumer advertising, these methods reveal a multifaceted approach to sustaining high drug prices. Here are ten strategies pharmaceutical companies use to maximize profits on drugs.

1. Patent Protection: Drugmakers often obtain patents for their new drugs, giving them exclusive rights to sell the drug for a certain period, typically 20 years. This prevents other companies from making generic versions.
2. Evergreening: This involves making slight modifications to existing drugs and re-patenting them. These modifications could be changes in dosage, delivery method, or combination with other drugs. This extends the patent life of the drug.
3. Litigation: Pharmaceutical companies sometimes engage in legal battles to extend their patent exclusivity. This could involve suing generic manufacturers alleging patent infringement.
4. Pay-for-Delay: In some cases, brand-name drug manufacturers pay generic drugmakers to delay the release of generic versions of their drugs. This agreement benefits both parties but can keep drug prices high.
5. Exclusive Contracts: Some drugmakers enter into exclusive contracts with suppliers or distributors to control the drug’s supply chain, making it difficult for competitors to access these channels.
6. Controlled Release of Generics: Companies might release their own generic version of a drug when the patent is about to expire. This allows them to capture a portion of the generic market.
7. Bundling Products: Pharmaceutical companies might bundle a popular drug with a less popular one, forcing buyers to purchase both, thereby sustaining the sales of the less popular drug.
8. Orphan Drug Designation: Companies might seek orphan drug status for drugs intended to treat rare diseases. This provides benefits like tax credits and market exclusivity, even for drugs that might have broader applications.
9. Direct-to-Consumer Advertising: This increases consumer demand for specific drugs, which can help maintain unaffordable prices due to increased demand.
10. Lobbying and Political Contributions: Pharmaceutical companies invest heavily in lobbying efforts and political contributions to influence drug-related policies and regulations in their favor.

The tactics employed by pharmaceutical companies to protect their profit margins encompass a broad spectrum of strategies, from leveraging patent laws to engaging in sophisticated marketing and legal maneuvers. While these practices are integral to recovering the substantial investments made in drug development, they also raise questions about the accessibility and affordability of essential medications. As policymakers, healthcare providers, and consumers navigate the challenges of ensuring drug availability at reasonable costs, the balance between rewarding innovation and preventing monopolistic practices remains a pivotal concern.

In the complex and dynamic realm of Pharmacy Benefit Management (PBM), the strategic use of data analytics stands as a cornerstone for achieving competitive advantage, cost efficiency, and superior patient outcomes. As decision-makers—pharmacy benefit consultants, employee benefit brokers, CFOs, and CHROs—it’s imperative to understand the transformative role of leveraging data analytics in PBM and the critical need for a shift towards digital transformation, moving beyond traditional reliance on spreadsheets.

The Strategic Role of PBM Data Analytics

Data analytics in PBM transcends mere number crunching; it’s about deriving actionable insights that drive strategic decisions. This involves analyzing diverse datasets, including prescription claims, patient demographics, drug pricing, and pharmacy networks, to:

• Enhance Cost Management: Strategically reduce costs while maintaining or improving care quality.
• Improve Fraud Detection: Employ sophisticated analytics to identify and mitigate fraudulent activities effectively.
• Optimize Patient Care: Utilize data to personalize medication management, improving health outcomes.
• Boost Operational Efficiency: Identify and address inefficiencies, streamlining processes for better performance.

Why Digital Transformation is Essential

The reliance on spreadsheets for managing and analyzing PBM data is increasingly becoming a bottleneck in an era defined by big data. Here’s why embracing digital transformation is not just an option but a necessity for industry leaders:

Scalability and Complexity

As organizations grow, the volume and complexity of data escalate, making spreadsheets impractical. Digital analytics platforms are designed to handle large datasets effortlessly, providing the scalability needed to adapt and thrive.

Enhanced Accuracy and Reliability

The manual processes associated with spreadsheets are prone to errors. Digital solutions automate data processing, significantly reducing the risk of inaccuracies and enhancing the reliability of insights.

Advanced Analytical Tools

Digital transformation opens the door to advanced analytics, including predictive modeling, machine learning, and AI, offering deeper insights and foresight that are invaluable for strategic planning and decision-making.

Seamless Data Integration

Integrating data from various sources is crucial for a comprehensive view of PBM operations. Digital platforms facilitate this integration, breaking down silos and enabling a unified analysis.

Regulatory Compliance and Data Security

In the healthcare sector, data security and regulatory compliance are paramount. Digital platforms offer sophisticated security features and compliance capabilities, ensuring data is managed responsibly and securely.

Charting the Path Forward

For decision-makers in the PBM space, the move towards digital analytics is a strategic imperative. Here’s how to navigate this transition:

1. Conduct a Thorough Assessment: Evaluate your current data management and analytics practices to identify gaps and opportunities for improvement.
2. Invest in the Right Technology: Choose data analytics platforms that align with your strategic goals and operational needs.
3. Develop Skills and Knowledge: Ensure your team is equipped to leverage new technologies through training and professional development.
4. Implement Robust Data Governance: Establish clear policies for data management to ensure accuracy, security, and compliance.

Conclusion

For pharmacy benefit consultants, employee benefit brokers, CFOs, and CHROs, the journey towards leveraging data analytics in PBM is not just about adopting new technologies; it’s about strategically positioning your organization for success in a rapidly changing landscape. By embracing advanced data analytics, you can unlock unparalleled opportunities for cost savings, operational excellence, and improved patient care. The future of PBM is data-driven, and the time to act is now.

Copay Adjustment Programs: What’s Next for Manufacturers and other notes from around the interweb:

• Copay Adjustment Programs: What’s Next for Manufacturers? The ongoing battle over controversial copay adjustment programs that shift more of the costs of specialty medications onto patients—otherwise known as accumulators and maximizers—continues to draw significant interest from the healthcare community. As payers and manufacturers clash over cost-shifting strategies while state and federal courts increasingly become involved, patients keep getting caught in the middle. Since these programs are designed to ensure that manufacturer copay assistance payments no longer count toward a patient’s deductible or out-of-pocket costs, the stakes are particularly high for manufacturers. With their assistance coupons restricted from counting toward their annual out-of-pocket maximums, patients are far more likely to stop taking their medications because they can no longer afford them.

• Best Pharmacy Benefit Consultants for Cost-Effective Drug Plans. In the complex world of healthcare and pharmaceuticals, managing costs while ensuring the best possible care can be a daunting challenge for businesses of all sizes. Pharmacy Benefit Consultants (PBCs) play a crucial role in navigating this landscape, offering expertise that can lead to significant savings and more effective drug plan management. This article delves into the importance of PBCs, what to look for when selecting a consultant, and how they can transform the cost-effectiveness of drug plans.

• 5 ways to improve your PBM procurement process in 2024. Many self-funded plan sponsors struggle to manage the cost of pharmacy benefits and rely on non-transparent contract guarantees to hold PBMs accountable. Meanwhile, drug spending continues to compound at an astonishing rate in defiance of the savings promised during the procurement process. As a former pharmacy program director for a plan covering more than 16,000 lives, I can tell you that it is possible to stop the “games” PBMs play, control costs, and ensure that all contractual guarantees are met, especially in scenarios where a PBM won’t guarantee an all-in per member per month (PMPM) cost for the year. Understanding the problem is a part of the solution, but making meaningful changes to the way plan sponsors and brokers evaluate PBMs is where the real opportunity lies.

• 3 thing to know about specialty pharmacy in 2024. Specialty drugs may be covered by a medical benefit (what patient-members likely think of as “their insurance”) or pharmacy benefits. There’s often a gray area for where specialty falls, but it can relate to whether the drug is being administered in a clinical setting, like a doctor’s office, outpatient clinic, or infusion center. Reimbursement for these drugs can also vary between average wholesale price (AWP) for pharmacy reimbursement and average sales price (ASP) for the medical benefit. It’s complex to compare, and both ASP and AWP are used in the health care industry, but they’re different. ASP is a government-regulated tool that uses manufacturer sales information including discounts, such as rebates. AWP is the average price that wholesalers sell drugs to pharmacies, prescribers, and others. A government report found the median percentage difference between ASP and AWP to be 49%.

In the evolving landscape of healthcare benefits, corporations find themselves at a crossroads, especially when it comes to covering weight loss medications like Wegovy. A recent development has seen Novo Nordisk, the pharmaceutical giant behind Wegovy, imposing penalties on employers who limit access to these expensive drugs, have led at least two major employers to discontinue their coverage, unveiling a weight loss drug coverage dilemma:

• Increased Healthcare Costs: Employers face rising expenses in providing health benefits, driven by the excessive cost of weight loss medications.
• Access and Affordability for Employees: Restricting or discontinuing coverage affects employees’ access to potentially life-changing treatments, raising questions about healthcare equity.
• Negotiation Dynamics: The power struggle between pharmaceutical companies, PBMs, and employers over drug pricing and discounts reveals the complex negotiations that underpin healthcare benefits.
• Corporate Responsibility and Employee Well-being: Companies must balance their financial constraints with their responsibility to support employees’ health and well-being.
• Broader Healthcare Debate: This situation contributes to the ongoing debate about drug pricing, insurance coverage, and the right to healthcare, highlighting the need for systemic changes in how medications are priced and covered.

The crux of the matter lies in the negotiation dynamics between employers, Pharmacy Benefit Managers (PBMs), and drug manufacturers. PBMs play a crucial role in negotiating drug prices, but their ability to secure discounts is being challenged by the manufacturer’s aggressive tactics. This situation leaves employers grappling with soaring healthcare costs, putting them in a difficult position: either absorb the excessive costs of these medications or face the manufacturer’s financial penalties.

The standoff has major implications for both companies and their health plans, as well as for employees dependent on these medications for their health. Despite a company’s financial resources, deciding whether to cover weight loss drugs remains a complex issue. Additionally, there’s a significant risk of fraud associated with GLP-1 weight loss medications. This concern arises from the potential for these drugs to be overprescribed, misused, or diverted, leading to unnecessary costs for companies without corresponding health benefits for users.

The bar chart (figure 1) could simplify this decision-making process regarding their inclusion in the formulary. I suggest holding off until prices decrease. Meanwhile, consider exploring other options such as diet and exercise. As corporations navigate this tricky terrain, the broader conversation about drug pricing, healthcare benefits, and corporate responsibility continues to evolve. This scenario underscores the complex interplay of financial, ethical, and healthcare considerations that companies must balance in the modern corporate landscape.

A good pharmacy benefits consultant plays a vital role in guiding organizations through the complexities of pharmacy benefits management, aiming to optimize healthcare outcomes while controlling costs. Here are some key attributes and certifications that define a good pharmacy benefits consultant which are key to unlocking the value of pharmacy benefits:

1. Expertise in Pharmacy Benefits Management (PBM): A deep understanding of how PBMs operate, including drug pricing, rebate management, benefit design, formulary, and utilization management, is crucial. This knowledge helps in negotiating contracts and ensuring that clients receive the best possible terms.
2. Analytical Skills: The ability to analyze data effectively is essential. This includes interpreting drug utilization reports, identifying trends in prescription drug spending, and evaluating the financial impact of different pharmacy benefit strategies.
3. Certifications: Relevant professional certifications can enhance a consultant’s credibility and expertise. Certifications such as the Certified Pharmacy Benefits Specialist (CPBS) or Certified Employee Benefit Specialist (CEBS) with a specialization in healthcare and benefits can demonstrate a consultant’s commitment to their profession and expertise in the field.
4. Regulatory Knowledge: A thorough understanding of healthcare regulations, including the Affordable Care Act (ACA), Medicare, and Medicaid, as well as compliance issues related to pharmacy benefits, is important. This ensures that advice and strategies are compliant with current laws and regulations.
5. Communication Skills: Effective communication and negotiation skills are vital. A good consultant must be able to explain complex pharmacy benefits concepts in understandable terms to clients and negotiate effectively with PBMs and drug manufacturers.
6. Ethical Standards: High ethical standards and transparency are essential, particularly in areas such as rebate management and contract negotiations, to build trust with clients.
7. Continuous Learning: The healthcare landscape, especially pharmacy benefits, is constantly changing. A good consultant stays updated with industry trends, new drugs, technologies, and regulatory changes to provide informed advice.
8. Strategic Thinking: The ability to develop innovative and strategic solutions that align with the client’s healthcare goals and financial constraints is critical. This might involve designing custom formularies, implementing cost-saving measures, or leveraging technology to improve pharmacy benefits management.

In summary, a good pharmacy benefits consultant combines industry-specific knowledge and certifications with analytical, strategic, and communication skills, all underpinned by a commitment to ethical practice and continuous learning. These attributes enable them to play a critical role in unlocking the value of pharmacy benefits and delivering value to their clients, helping them to manage their pharmacy benefits effectively and efficiently.

Best Pharmacy Benefit Consultants for Cost-Effective Drug Plans and other notes from around the interweb:

• Best Pharmacy Benefit Consultants for Cost-Effective Drug Plans. In the complex world of healthcare and pharmaceuticals, managing costs while ensuring the best possible care can be a daunting challenge for businesses of all sizes. Pharmacy Benefit Consultants (PBCs) play a crucial role in navigating this landscape, offering expertise that can lead to significant savings and more effective drug plan management. This article delves into the importance of PBCs, what to look for when selecting a consultant, and how they can transform the cost-effectiveness of drug plans.

• 5 ways to improve your PBM procurement process in 2024. Many self-funded plan sponsors struggle to manage the cost of pharmacy benefits and rely on non-transparent contract guarantees to hold PBMs accountable. Meanwhile, drug spending continues to compound at an astonishing rate in defiance of the savings promised during the procurement process. As a former pharmacy program director for a plan covering more than 16,000 lives, I can tell you that it is possible to stop the “games” PBMs play, control costs, and ensure that all contractual guarantees are met, especially in scenarios where a PBM won’t guarantee an all-in per member per month (PMPM) cost for the year. Understanding the problem is a part of the solution, but making meaningful changes to the way plan sponsors and brokers evaluate PBMs is where the real opportunity lies.

• 3 thing to know about specialty pharmacy in 2024. Specialty drugs may be covered by a medical benefit (what patient-members likely think of as “their insurance”) or pharmacy benefits. There’s often a gray area for where specialty falls, but it can relate to whether the drug is being administered in a clinical setting, like a doctor’s office, outpatient clinic, or infusion center. Reimbursement for these drugs can also vary between average wholesale price (AWP) for pharmacy reimbursement and average sales price (ASP) for the medical benefit. It’s complex to compare, and both ASP and AWP are used in the health care industry, but they’re different. ASP is a government-regulated tool that uses manufacturer sales information including discounts, such as rebates. AWP is the average price that wholesalers sell drugs to pharmacies, prescribers, and others. A government report found the median percentage difference between ASP and AWP to be 49%.

• Lawsuit alleges J&J health plan fiduciaries mismanaged prescription drug benefits. A lawsuit filed on February 5, 2024, against Johnson and Johnson and its health plan fiduciaries is a good reminder that the fiduciary duties that exist under the Employee Retirement Income Security Act of 1974 (ERISA) do not just apply to qualified retirement plans. They apply to ERISA health and welfare plans, too. There is likely a very strong “rest of the story” to the allegations in this lawsuit and the defendants will no doubt vigorously dispute and defend this case, but the allegations in this new class action complaint give employers and their plan fiduciaries much to think about. Among the allegations in the proposed class action complaint, the plaintiff alleges that someone with a 90-pill prescription for one generic drug could fill that prescription without insurance for between $28.40 – $77.41, and yet, it alleges, the defendant fiduciaries contractually agreed to have the plan pay $10,239.69 for the same 90-pill prescription.

In this legal dispute, employees hit Johnson & Johnson with a major lawsuit. Ann Lewandowski and other plaintiffs are suing Johnson & Johnson for allegedly mismanaging their prescription-drug benefits, resulting in significant financial losses for participants in the company’s ERISA plans. The complaint asserts that Johnson & Johnson and its benefits committee failed in their fiduciary duties by allowing the plans to overpay for prescription drugs, notably generic medications, through arrangements with their Pharmacy Benefits Manager (PBM).

This purported mismanagement led to inflated costs for the plan participants, including higher premiums, deductibles, and out-of-pocket expenses, while potentially costing the plans and their beneficiaries millions of dollars. The case underscores the complex interplay of corporate practices, legal responsibilities, and the financial well-being of employees in the healthcare benefits landscape.

Pharmacy Benefit Managers (PBMs) play a critical role in the healthcare system by acting as intermediaries between employers or health plans and the pharmaceutical world. Their primary functions include negotiating discounts with drug manufacturers, determining the list of covered medications (formulary management), and setting the amount pharmacies are reimbursed for drugs. PBMs aim to reduce prescription drug costs and improve convenience and safety for patients, but their practices and the transparency of their operations have been subjects of debate and scrutiny in the context of overall healthcare affordability and access.

Employers can mitigate the risk of litigation like the Johnson & Johnson case by investing in education around Pharmacy Benefit Managers (PBMs), specifically through Certified Pharmacy Benefit Specialist (CPBS) training. CPBS training equips employers with comprehensive knowledge on how PBMs operate, strategies to ensure that their PBM contracts are cost-effective, and insights into maintaining transparency and accountability in their pharmacy benefits management. By understanding the intricacies of PBM operations and learning to navigate the complex healthcare landscape effectively, employers can safeguard against excessive prescription drug costs and ensure that their benefits plans are managed in the best interest of their employees.