The Business of Empathy: How Pharmacists Can Improve Their Work by Enhancing the Human Connection - MedCity News

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Public outcry and federal scrutiny over high and opaque prescription drug prices are fueling exciting new opportunities for health plans. After several decades of steady, steady outsourcing to pharmacy benefit managers (PBMs), payers are seeking new opportunities to manage and administer the prescription drug benefits they provide to their members.

To set the stage for this shift in the creation process, consider the increase in public scrutiny of PBMs over the past year. In June, the Federal Trade Commission (FTC) announced that it did an investigation the role of PBMs as drug “middlemen.” Also last summer, a bill was introduced in the Senatebacked by a handful of Republicans and one Democrat, which aims to increase drug pricing transparency and hold PBMs “accountable for unfair and deceptive practices that drive up prescription drug costs at the expense of consumers.”

PBMs negotiate with drug manufacturers on behalf of health plans, but their business practices affect drug prices and potentially increase costs, so policymakers and consumer groups rightly question the motives and role of PBMs. One big reason for the growing appetite to look at the PBM industry is that the largest insurance companies in the country own the largest PBMs.

Lawmakers and regulators aren’t the only ones questioning the PBM industry. Recently industry research found that PBM satisfaction and net promoter scores (NPS) were in decline among health plans and employers.

As federal authorities target these pharmacy middlemen, health plans are considering steps they can take to regain more control over prescription drug benefits. Of course, large insurers with their own PBMs are likely to stick with the “traditional model” that has worked to increase profitability. But new and smaller health plans, regional insurers, health systems, employers, unions and others that develop and operate their own health benefit programs have more incentive than ever to ask whether they can do better than traditional PBM.

In working with these health plans, I’ve found three key themes that drive them to look for ways to take more control of their pharmacy benefits:

Transparency and compliance

It’s worth stressing: PBMs are under the watchful eye of state and federal governments. The PBM of the future isn’t a gas-guzzling, polluting SUV, for example, it’s an efficient, state-of-the-art, fully customizable electric car. It is regulatory compliant and uses the best technology to ensure a fair pricing methodology, financial value and a great member experience.

Instead of shrouding drug prices in secrecy, new PBM business models rely on transparency. The best way to create an efficient and fair marketplace is to allow both the buyer and seller of the transaction to communicate freely about how drug prices, discounts, and other important information are determined.

On the compliance side, plan sponsors must recognize and understand how their health plan generates revenue for their benefit brokers and consultants (eg, are they compensated for referrals for pharmacy benefits or another aspect of health benefits?). The Consolidated Appropriations Act of 2021 imposes new fiduciary responsibilities on entities that provide health benefits, and plan sponsors must require their broker or consultant to disclose how they are compensated.

Improving the Member Experience

Members of an employer-sponsored health plan have no say in choosing a PBM. In terms of ease of use, PBMs have historically scored low. Anyone who has tried to get a new prescription or refill of specialty drugs can attest to the number of hoops they have to jump through to get their medication. Additionally, delays caused by insurance approvals and requirements to use PBM’s mail order operation can cause significant harm to patients.

Health plans looking for new pharmacy benefit options want to improve the member experience. Benefits designed with the member experience in mind – especially when it comes to more personalized choices – are more likely to lead to member or employee loyalty and lower costs.

Efficiency through technology

Providing a better member experience often requires the use of technologies and workflows that are not possible through the traditional PBM path. Because PBMs have built their technology stack over decades, it is difficult and expensive for them to maintain and upgrade these outdated systems.

Administrative costs for processing pharmacy claims are totaled. Technology-advanced pharmacy benefit administration platforms can automate and scale administrative processes to reduce overhead costs, allowing savings to be passed on to prescription drug users.

Whichever way you choose a health plan with prescription drug benefits, one thing is certain: There are more options than ever. Health plans today must consider what they want from their pharmacy benefits and how to achieve something better for their members. And when they look to new platforms and processes that provide greater transparency, an improved member experience, and simplicity in establishing and maintaining technology, they will likely find that they don’t have to do things the way they always have.

Photo: Ligorko, Getty Images

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