Pharmacy Benefit Management, and Beyond

Do I have a Pharmacy Benefit Management (PBM) program for my employees for their work injuries? Do I need one? What is the actual benefit to the employee/company and what, if any, difference is there between PBM vendors?

These are not uncommon questions heard when discussing the hot button issue of pharmacy management with HR, Risk and WC Managers at employer groups. Most do know the answer to the first two questions. It’s very rare to find an employer, whether they are fully insured, self-insured, or even self-insured/self-administered, who doesn’t have a PBM program in place. The answer to both is most likely a resounding “yes”. However, when trying to understand the root of the benefit and how one program can differ from another, many don’t realize the link between the two questions and how profoundly it can impact their business.

When diving into the “B” in PBM, most executives start and end with the cost savings found when using a managed network with built-in discounts at pharmacies all over the country. Many take a step further into the analysis of “cost” by noting there are two components that make up your cost. Cost = Price x Utilization. Price is easily addressed by contractual relationships with the pharmacies. Utilization is a much stickier topic and one that PBM’s have spent a lot of time drilling down on in their approach. We live in an age of advanced technology being combined with pharmaceutical experience to spot trends in drug usage, abuse and provider negligence. All three of these are critically important when managing a pharmacy program to ensure utilization is being limited to appropriate drugs and appropriate dosages. Most PBM’s will easily check this box and help control your costs.

But why stop there? The benefits of a pharmacy management program should extend beyond simply reducing the hard costs. Technology, knowledge and experience are the tip of the spear. So much more can be done if a PBM is ready, willing and able to go the extra mile for patients and clients. Innovative scientific breakthroughs like Pharmacogenetic testing can not only help providers avoid dangerous drug interactions but also identify which drug will provide the maximum therapeutic effects for each specific patient. Aka – the right drug for the right patient. This knowledge increases the safety and therapeutic impact on your employees while also driving down wasted costs on ineffective drugs and all of the negative impact that comes with it – significant concerns like potential narcotic addictions, dangerous side effects and additional medications needed to offset the damage. Technology, including sophisticated algorithms, can identify provider dispensing trends before your employees are being over-prescribed dangerous narcotics. Education is paramount to an effective pharmacy program and that is for all stakeholders – from the patient to the prescribing provider. Successfully working with a Physician to change their prescribing habits toward a more conservative approach, rather than one more heavily tilted toward a narcotics-first approach, can have immense positive effects for their patients well-being that extend far beyond cost.

Knowledge is incredibly important but so are things like compassion, empathy and service. Is the PBM dedicated to your employees as much as they are to your revenue? When an employee, or you for that matter, call the PBM, does a human answer the phone or do you spend five minutes weaving through a labyrinth of automated options? Does the service representative spend time with the patient to ensure they understand everything needed about their prescription and how the process works? Is there a genuine interest in each patient’s well-being? If not, you are losing valuable equity with your employees. The patients are risking much more if they don’t understand what drug they are taking and how it could interact with others not related to their work injury.

A lot of factors can, and should, play a role in your pharmacy management program. If your PBM partner does not take the time to talk through all of these right from the beginning, chances are they aren’t the right fit for you. Technology, knowledge, innovative solutions and genuine service are most often where you will find the differences between one PBM vendor versus another. That doesn’t mean cost won’t play a factor as well. While I would never recommend using price as the most important differentiator, you certainly can tell a lot about how important you are to your vendor by how much you pay. If you aren’t sure how much you pay or even what method is used (AWP-based, cost-plus based, MAC, etc…), that is a good place to start. Ask your PBM or, if you are self-insured with a TPA handling your claims, ask your TPA Account Manager what your rate is and what their rate is with the PBM.

Conducting due diligence on your PBM partner can have an enormous effect on your employee’s lives and your bottom line. Decide for yourself where you rank on the priority scale. Do you feel like a big fish or a little fish in a giant pond? Ask questions about their use of innovative solutions. Ask questions about their technology and customer service. Most of all, just ask questions and get a feel for whether you have a true partner. If not, start asking yourself questions like who else might be a better fit for me….?

Learn more about Splashlight RX.

Article by Dan Ziemer

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