Representatives from employers, pharmacy benefit managers, and others discussed methods of improving pharmacy access and affordability in health plans.
Panelists at the 2022 Asembia Specialty Pharmacy Summit, held in Las Vegas, Nevada, May 2-5, discussed employers’ efforts to improve care quality, equity, and affordability as related to specialty drug management.
Moderated by John O’Brien, PharmD, MPH, president and CEO of the National Pharmaceutical Council (NPC), the discussion focused on the disconnect and lack of transparency between employers and their pharmacy benefit managers (PBMs) and potential vendors.
As O’Brien pointed out, drug benefits being used now were designed for blood pressure and cholesterol medicines in the 1990s, and not new and often expensive cell and gene therapies.
That benefit landscape “is increasingly being managed by fewer and fewer companies who are integrating vertically and owning a number of different entities in the pharmaceutical supply chain,” he explained, adding these entities can create “perverse incentives.”
On the panel were experts representing large employers, like Warren Brown, MD, vice president of medical affairs and clinical strategy at Whole Foods, and those from the PBM side, like Greg Baker, RPh, founder & CEO of EmsanaRx.
Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health, which represents 40 jumbo purchasers including employers like Walmart and Boeing, also offered insights along with Amanda Faulkner, senior benefits specialist at Louisville Gas & Electric.
Describing the growing level of frustration among purchasers, Mitchell outlined how the COVID-19 pandemic increased focus on marketable health benefits for employees to attract talent.
“[Our purchasers] want to pay for quality outcomes, value and now equity; that is their strategic aim. So what they are doing is when they are finding that their partners won't help them with this, whether it's a health plan or PBM or consultant, they're starting to do it themselves,” she explained.
About a quarter of the companies represented by the Purchaser Business Group on Health contract directly with accountable care organizations, primary care, or hospitals to get around PBMs, “because their frustration level is off the charts.”
Lack of employer access to PBM data was cited as a universal challenge among panelists, as was difficult-to-decipher and overly onerous contracts. “These are truly the customers unable to get access to the care, the information, the services that they really deserve,” Mitchell said.
EmsanaRx was founded by the Purchaser Business Group on Health to help address some of these hurdles.
These purchasers had no transparency to data, didn't understand what they're spending, how much they're spending, what manufacturer rebates look like, and that opacity gets worse on an annual basis, explained Baker.
Not only does this pose challenges to those receiving insurance through employers, but the impact PBMs have had on community pharmacies in the last decade led to cuts at these institutions, including closures in less affluent neighborhoods, resulting in even more restricted access to pharmacy services.
In an ideal scenario, increased direct communication between purchasers an manufacturers could help alleviate some of the roadblocks in the process, but the existence of PBMs in this space and non-solicitation agreements in contracts with PBMs hinder these efforts.
Pharmacy has also grown to be 33% of all spending in plans and will only increase with the advents of new and more expensive treatments.
For Whole Foods, an integrated, whole patient approach has been successful, according to Brown. Although year-over-year drug spending may go up, Brown stressed that when individuals are correctly taking their medicine, medical care spend decreases, as there’s less spent on emergency room and inpatient stays.
“You can take an increased plan paid, decrease the number paid on the drug side through our PBM, and reduce total cost of care and reduce the medical side,” Brown said. “The total expense compared to the same cohort in another model is overall reduced, so the member sees reduced drug costs for them. Whole Foods sees a [reduction] in the total cost of care plan paid side on the whole thing, the whole time,” all the while working with the PBM.
One key component to devising this patient-oriented plan is the availability of data, Brown noted, but finding flexible and transparent partners can be challenging.
For Faulkner, incorporating medication adherence data and other metrics into a data aggregator has led to improved insights on employees they serve, so plans can better tailor to specific populations.