As we begin a new calendar year, employers are once again under enormous strain to prepare clean-slated approaches to managing their employee benefits spend. This is particularly true in the Rx area.
With another open-enrollment season in the rearview mirror, your clients cannot afford to take a wait-and-see approach that allows pharmacy benefits managers (PBMs) and drug manufacturers to dictate the fate of
Drug spending in the U.S. ballooned to more than $535 billion in 2020, and was projected to increase by another 4-6% by the end of 2021. Two culprits include faster price increases and higher growth in utilization. With drug costs and pharmacy spend on the rise, reducing the cost of Rx benefits is a top priority for many of your self-funded employer clients.
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To put it simply, sticking with the status quo is not the best option in 2022. Here are three reasons why.
1. Dollars are being left on the table.
When employers contract directly with a PBM or carved-in
2. Inappropriate medications are creating safety and financial risks.
When patients use high-cost specialty drugs, we assume that the prescribed medication and dosing are appropriate. Unfortunately, this scenario is not always true. Our team of pharmacists conducted numerous independent reviews and found that inappropriate prescribing accounts for an additional 7-10% of unnecessary pharmacy costs. This is especially alarming considering that specialty drugs can be 12 times more expensive than widely used brand-name drugs. Inappropriate prescribing also can pose safety risks to members.
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For example, our clinical team discovered an issue with a member taking Gattex for short bowel syndrome. This drug is prescribed on a weight-based dosing regimen, and the medication comes in vials of 5 mL or 3.7 mg; each vial costs more than $40,000. In this case, the doctor’s prescription was based on the member’s weight, who was calculated to need 3.8 mg, so the patient needed two vials per month for dosing.
However, people with short bowel syndrome can have fluctuations in weight. The clinical team found that the member had, in fact, lost weight — and now only one vial was needed to meet the specific dose requirements of the medication. After reaching out to the physician, the prescription dose was corrected. Optimizing the dose saved the plan $40,000 and ensured the member was taking the appropriate amount.
3. Service is lacking.
Many employers fear member disruption, during what has already been a challenging two years, causing them to hesitate making a change to their pharmacy benefits strategy. It’s an important consideration. However, the current member experience is subpar for many employers. Their members are often unable to get quick answers to their pharmacy questions from the PBM’s or carrier’s customer service team. They are left on hold for long periods of time until they hang up out of frustration or leave the pharmacy without their medications — and then complain to the HR team.
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Making changes to the pharmacy benefits plan or provider will undoubtedly cause some disruption, but if it will result in a superior service experience and less everyday frustration for members, it’s worth examining.
With employers facing an overheated talent war, rising costs and other challenges, the stakes are high this year – and it’s important to take a hard look at pharmacy benefits plans with fresh eyes in 2022. By making a move to optimize pharmacy benefits, your self-insured clients can lower prescription drug costs and improve medication safety and quality of service for their members in the year ahead.
