The Right Chemistry

HRM. The rising cost of healthcare is a big issue for business. How can a PBM provider help companies manage and control this cost?
William Fleming. First, PBMs can do a better job of aligning their business practices with those of their clients. Employers are concerned with understanding the “net cost” that a PBM solution will provide, and the procurement process inherently focuses on surface level financial variables, discounts and dispensing fees, instead of the true cost of the solution.

It is a primary role of the PBM to ensure that pharmacy and medical are no longer considered separate activities, but are understood to be interdependent when it comes to patient care. The PBM model is best utilized when it works in harmony with core clinical programs that leverage all available data. The PBM can then play a central role in informing and guiding members, in coordination with the medical community, so that evidence-based medicine is practiced.

HRM. What are the key features and competencies that an organization should look for when evaluating a potential PBM provider?
WF. An employer should look for a PBM that understands the financial risks that self-funded employers face when providing healthcare and pharmacy benefits. HPS manages 220 million prescriptions per year. Understanding the impact of the total net cost of medications on the cost of providing care, as well as the need for positive medical outcomes, should be a driving factor in the choice of a PBM.

Employers should look for a PBM that has instilled a culture of providing perfect service. At Humana Pharmacy Solutions, that means continually striving to improve the interaction with customers by getting the basics done right, delivering unexpected value and quality, providing guidance on complex needs and building emotional engagement with those we serve.

HRM. What are the key benefits that both employees and employers can receive from a PBM solution?
WF. It needs to be about guidance. Unfortunately, the entire pharmaceutical industry is geared to drive higher utilization of higher cost drugs because of things like direct to consumer advertising, aggressive drug detailing, rebates for drug list placement and market share and a procurement process that focus on surface variables vs. net cost.

The PBM should play an important role in highlighting the differences in drug efficacy against drug cost. Many physicians, for instance, are unaware of the cost difference between drugs and the value of lower-cost generic products.

One area where guidance can occur is between the PBM and the physician. Many of Humana Pharmacy Solutions’ clinical edits result in conversations with physicians about why costly second-line drugs were prescribed. Frequently, the physician did not realize the member was not being compliant. We find physicians will switch a member’s medication more than 60% of the time when presented with information about alternatives and their costs.

Guidance also is critical around adherence, safety and efficacy. Many members are prescribed multiple medications, with multiple interactions and side effects. The PBM can play a central role in helping them sort it out. When education is provided, adherence increases, generic utilization goes up and overall medical costs go down.

HRM. How is technology reshaping the way PBM solutions operate? Do you predict any further innovations in the near future?
WF. One of the biggest opportunities will come through increased adoption of electronic prescribing. Today, almost every management program used to improve the costs and effectiveness of prescribing happens after the prescription leaves the physician’s office. With widespread adoption of electronic prescribing, PBMs will be able to provide actionable information to the physician at the time the prescription is written.

Another innovation that is reshaping the industry is using consumer segmentation in communications. A PBM’s membership base is not a homogenous population. Each member is different and reacts and responds differently to information. Communication and message can be adapted to elicit the desired response based on the member’s values, ideas and needs.

Dr. William Fleming is Vice President of pharmacy and clinical integration for Humana Pharmacy Solutions. In his position with Humana, he has developed innovative benefit designs that give consumers the information they need to make better decisions about their health and has testified before both the House and the Senate about important pharmacy issues.