What is a PBM?

Pharmacy Benefit Managers, or PBM's, are third-party intermediaries that administer prescription drug programs for health insurance plans, employers, and other organizations.

The largest Pharmacy Benefit Managers (PBM's) are owned by or with the largest health insurance carriers including Cigna (Express Scripts), UHC (Optum), and Aetna (CVS). Did you know these carriers make more on the PBM's than they do on Medical Insurance or Storefront? 

If your PBM is owned by the same company as your health insurance, it's time for a change.

The Rising Rx Cost

Name-brand and specialty medication costs have skyrocketed and continue to climb exposing extreme financial challenges to both employers and employees. In fact, specialty drug spend has increased from 15% to 50% of cost relative to all other prescription types resulting in 30% of Americans report not taking prescribed medications due to high prices. Making matters worse, a staggering 33% of hospitalizations in the U.S. are due to medication non-adherence.

Understanding Spread Pricing

In spread pricing, PBMs charge health plans or employers a certain amount for prescription drugs and reimburse pharmacies a different, usually lower, amount for the same drugs. The difference between the amount charged and the amount reimbursed is the "spread." PBMs typically retain this spread as their profit. This is where most of your Rx OVERSPEND is occurring.

Solutions

What can we do? There are other options!

You don't have to use the same old, giant PBM owned by the large national carrier. We work with companies that have a transparent, fee-based ONLY revenue model. This, when coupled with effective sourcing strategies such as international pharmacy programs and manufacturers' assistance programs, results in an AVERAGE savings of 70% per medication. 

"We'll fight for you"

Have you ever heard your broker say, "Good news, your premiums only going up by 10%," or "It was going to be 31% but we fought for you and negotiated it down to 14%"? The reason for this is your broker does not have power over the insurance carriers and the insurance carriers have no incentive to give you a 0% increase. You're already expecting a 10% increase after all. This was made clear by Terry Shook, the former Director of Market Development at Blue Cross Blue Shield of IL turned "Healthcare Supply Chain Engineer and Status Quo Disrupter". As he explained how renewals are handled at big carriers, it's less about looking at the actuarial sciences and making a statistical argument for the quoted premium price and more about "justifiably" pricing insurance as high as possible while not ticking off the client enough that they move to a different carrier. And by "justifiably", we mean they set the price and the broker has to figure out how to justify it. 

Solutions

It's a simple solution that sounds scary... regain the power by negotiating with someone who has something to lose. Yeah it's true the insurance carrier wants to keep you around, they're making money. But if you're company left, how much would it affect their stock price? The key is finding an Advisor you trust who can build a Transparent, Decentralized plan that puts you back in the driver seat.

Where you go matters!

Most of us know you can get different prices by shopping around. The same house design could have wildly different costs based on location. But when you begin to understand and are able to quickly and easily access the pricing for the same healthcare service, the correct decision becomes painfully obvious in a hurry.

A study was run in 2022 in the St. Louis area to determine the cost of an MRI based on where the patient received care. What they found:

• Barnes Jewish Hospital - $2,841

• Mercy - $1,954

• SSM - $1,621

• Excel Imaging - $238

That's not a typo. You could receive the same images, provided directly to your doctor for less than 10% of the cost in some cases just by comparing costs.

The carrier you have matters!

What about the same service at the same hospital? Pricing has to be about the same, right? I'm sure you know where this is going.

In a related study, Emergency Room Visits at St. Luke's Hospital were compared with the only difference being which insurance carrier the patient had. Their results:

• Aetna - $1,424

• Cigna - $1,136

• Humana - $914

• Blue Cross Blue Shield - $854

• UHC - $572

• Cash Pay - $323

Now ask yourself, is healthcare really that expensive, or is the system expensive?

Solutions

If they're going to charge us less for paying cash, let's pay cash! What sense does it make paying the carriers for a network discount when the network discount is more expensive? It's like using a coupon for 10% added. This doesn't mean you'll be sent out without a safety net. Most plans will include Stop-Loss coverage to protect plan sponsors from abnormally large, unavoidable claims. Your current plan likely has this feature already built-in, which again begs the question, why are we paying for a discount program that costs us more at point-of-service? 

Why bother?

Let's say you are an average patient looking to see your primary care doctor for a routine check. What does that look like? Well:

• It is going to take 19 days between when you call to set your appointment to when you are seen. At least, that's the national average, here in St. Louis the average is 33 days.

• You're going to spend 136 minutes from the time you leave your house until you return and of that time, only 13 minutes are spent with your doctor and nurse. 18 minutes are spent waiting after you've checked in.

Add in the price uncertainty and general fear of going to the doctor and you'll understand why only 1 in 45 people have visited Primary Care Physician in the last 5 years. And that matters because the cost of Deferred Care really adds up, averaging $14,000 per incident when compared to a related maintenance program. 

Let's say I do go but now my doctor is recommending I get follow-up care with a specialist at the Hospital System's main campus. How much is that going to cost? And how can I be sure my doctor isn't incentivized to send additional people for treatment regardless of medical need? A little-known fact about the healthcare world we live in is that many hospital systems pay their surgeons based on a "Conversion Rate", i.e. whether or not they can 'sell' you on getting a procedure when you come in for a consultation. 

Solutions

83% of people surveyed would sign up for Direct Primary Care ("DPC") when given the option through their employer. This has driven membership numbers up 250% over the last 5 years. DPC's offer transparent, subscription-based pricing for concierge care meaning you take a variable cost, transfer it to a fixed cost, and your employees get white-glove medical care. 

They're the best... I think

Is your go-to hospital a good one? Is it safe? How would you even go about finding out?

Approximately 200,000 people die EACH YEAR due to preventable mistakes in hospitals according to the Journal of Patient Safety. 

Solutions

The data is available and companies like The Leapfrog Group have sifted through that data and provided simple reports we can use to understand the benefits and concessions of each doctor and hospital available to us. Using services like this coupled with Case Management can ensure that your employees are seeing the right provider.