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Expect More From... Support of Head of Benefits!

Writer's picture: Christine JohnstonChristine Johnston

Can you name the most powerful position in healthcare that touches 60% of Americans? Numerous clinical and supportive healthcare positions raced through my mind: Primary Care Physician, Pediatrician, Pharmacist. Nope, think again! I was shocked to hear the answer – Head of Benefits. WOW!


Per Dr. Bricker, “Corporate Head of Benefits is THE MOST IMPORTANT PERSON for improving employee health, reducing suffering and increasing longevity for the 60% of Americans that have Employer-Sponsored Health Insurance.”


Combining Dr. Bricker’s perspective on the direct health impact above with the fiduciary requirements identified within the J&J lawsuit, the Head of Benefits has a significant burden to bear. Head of Benefits must balance costs, access, quality, and member experience in their decision making. One such decision under immense scrutiny is the pharmacy benefit due to rising costs, compliance, and complexities. Therefore, a frequently asked question we’re receiving is “How do you know when you need a new PBM?” We applaud all those curious individuals seeking to confirm how to define and measure “value” when it comes to drug spend and the services offered by a PBM. Let’s take a look at what not to do followed by some suggestions for an alternative approach.


Common red flag responses we receive:


  • My advisor’s block of business is all with one entity since they always have success.

  • My advisor went to a recent conference and is suggesting all their clients move immediately to the latest and greatest PBM!

  • We hired a new advisor since the last was not aligned with our interests, but the first recommendation is to change all our vendor partners!

  • No one was ever fired from hiring the Big 3. (J&J lawsuit may change this soon!)

  • The only way to measure PBM success is in the financial metrics.

  • I keep explaining my concerns to my advisor and/or PBM and no one seems to be listening.

If following the crowd or reviewing financial metrics in a vacuum is the proposed path forward, you are stopping short of reaching your full potential. Push back against the tide.


Here are other thoughts to consider when seeking to understand if your PBM is the right partner:


  • Changing your PBM partner to “fix” the problem shouldn’t be the first step. Have you clearly stated your concerns with the existing PBM partner and given them a chance to respond to your requests?

  • Completing the PBM RFP and selection process is not the final step, rather the beginning of an on-going relationship. Did you dedicate enough time to the implementation and on-going performance monitoring?

  • No need to feel intimidated or overwhelmed by the pharmacy data. Take a page out of the J&J lawsuit! Isolating an egregious payment for a specialty generic drug is easier than ever. Utilize the Top 25 savings report from Mark Cuban’s Cost Plus Pharmacy. Ask your advisor and/or PBM to compare your utilization and spend on these top drugs to a publicly known cost-plus arrangement. “The rebate offsets the high invoice cost” won’t pass the test today when we know the published price (and rebates typically do not apply to this list of drugs!)


Still unsure? We’ll let you in on the secret to feel confident in knowing if your PBM is the right partner. The moment the PBM is not listening, not helping to find the solution, is the time you know you need a new PBM.

 


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