The Employer's Guide Blog for Overseeing PBMs

The Definition of Oversee: to watch over and direct (an undertaking, a group of workers, etc.) in order to ensure a satisfactory outcome or performance.

Massachusetts Health Policy Commission report: Non-fiduciary PBMs are driving up health care costs

Drug benefit managers are increasingly profiting off pharmacies and insurers, according to a new state report, driving up the state spending on health care. The report, issued Wednesday by the Massachusetts Health Policy Commission, focuses on the pharmacy benefit managers (PBMs), which negotiate rebates to drug manufacturers and payments to pharmacies on behalf of insurers.

Pharmacy benefit managers can negotiate on behalf of several insurers at once, leveraging their size to drive down the price of drugs. The practice consolidates insurer bargaining power with a few entities, so that insurers aren’t tasked with negotiating the price of every drug with every pharmaceutical company individually.

Tyrone’s Commentary:

The most important point made in this entire report is this, “Despite the focus, the commission said it lacks transparency into how PBMs conduct business. To figure out how much money PBMs are making.” Think about this for a second. How in the world can you say you’ve won a transparent much less fair deal with your PBM when you don’t even know how much you are paying the PBM vendor? Here is the truth if as a CFO or HR Executive you fall short of knowing how much your company pays a PBM for the services it was hired to perform then you fail in your fiduciary responsibility. Relying heavily on your broker or consultant to help make the decision? This too could be a failure in your fiduciary responsibility. Benefits brokers and consultants are not equal in the services they deliver. Like PBMs, some put the needs of their clients above their own and others do not simple as that. Take a peek at the comment (image below) from an anonymous poster who if I had to guess is a benefits broker themselves. The comment was made in response to this post (Top 7 Reasons the PBM Industry is Ripe for Disruption).

Click to Enlarge

In Massachusetts, the MassHealth Medicaid fee-for-service (FFS) reimbursement for most drugs is the acquisition cost of a drug plus a dispensing fee of $10.02. But these requirements do not apply to MCOs; therefore, PBMs can used spread pricing in MassHealth MCO contracts.

The pricing differences for generic drugs between the MassHealth FFS and MCO programs are significant. Looking at data from the fourth quarter of 2018, MCO prices were higher than 42% of FFS prices for unique drugs.

On average, an MCO price exceeded an FFS price by $15.97, despite being a less-expensive drug than the FFS prices for 58% of unique drugs. In fact, MCO prices exceeded the FFS price by at least $10 for nearly 25% of unique drugs and $50 higher for 10% of unique drugs.

[Read More]

Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

Leave a Reply