How to evaluate if your next PBM will put employees first

When your organization is searching for a new pharmacy benefits manager (PBM), let’s face it: The language describing them all starts to sound the same. The contracts are complex, the terms are obscure, the acronyms are abundant and parsing through the miniscule differences can be mind-numbing.

However, while it is vital to evaluate your PBM options thoroughly, selecting the right PBM doesn’t need to be so hard.

Healthier employees mean healthier businesses. When employees are treated as patients, pharmacy benefits can be flexible and customized for an affordable price. Any PBM should offer clear, honest pricing and formularies that prioritize employee health over rebates that inflate its pocketbooks.

So, how can organizations easily evaluate PBMs to discover if their practices are member-focused and transparent? Here are five easy ways to help narrow your options.

See also: The future of GLP-1 drugs for obesity treatment: cost, access and more

1. Check ownership details

PBM ownership can play a critical role in shaping its priorities. When PBMs are publicly traded or accountable to investors and shareholders, there’s a strong incentive to prioritize profits, sometimes at the expense of patient care. In contrast, privately owned PBMs are generally more focused on building long-term relationships and outcomes since their financial interests are less likely to be driven by quarterly stockholder expectations. Venture capital can also be a huge influence. A privately held PBM with a large VC investment will need to provide profit to the investors.

It’s also important to understand the impact of vertical integration—where PBMs, health plans, pharmacies and rebate aggregators can be part of the same organization. This model can more easily hide and inflate overall costs, limit choice and compromise care to ensure their own profitability.

By controlling multiple parts of the pharmaceutical supply chain, these entities can prioritize their own financial gain. This is sometimes at the expense of the patient’s experience, leading to higher costs and less access to the best options for care.

2. Seek out transparency

If a PBM is profiting from rebate fees, they are incented to choose brand-name drugs that offer attractive rebates for formularies. The result is that employers and plan members often end up with expensive medications instead of less expensive alternatives such as generics.

If your goal is to reduce costs, employers should look outside the traditional PBM ecosystem to a transparent PBM model where rebates are passed back to the employer, 100% of the time, no exceptions. Lowest net cost is the goal, not chasing rebate dollars.

PBMs often use spread pricing, a tactic where the PBM charges an employer a higher price than what it pays the pharmacy and pockets the difference to increase its own profits. Instead, look for plain language stating that a PBM will only charge employees what it pays the pharmacy. This is often referred to as a pass-through model. If a PBM is offering a traditional model, be aware of definitions. What is a generic? What disqualifies guarantees?

3. Determine who is shaping your PBM performance

Pharmacists are highly skilled in evaluating medication therapies, managing drug interactions and tailoring solutions to meet an organization’s specific health goals. Pharmacists should be at the forefront of PBM decision-making. They bring a patient-centered perspective that considers the unique health needs of each individual.

Additionally, integrating additional in-house experts such as nutritionists, infusion nurses and other healthcare professionals into clinical programs allows for more comprehensive, holistic care.

4. Be informed by data

Organizations should receive line of sight into data and claims to inform decision-making with regular touchpoints along the way. You need assurance that a PBM leverages data to help customize programs for better employee support and lower costs.

PBMs that do not offer visibility into their claims data may be hiding overcharges, spread pricing, price inflation and more.

5. Look for a human touch

When patients have questions and need to pick up the phone quickly, will a human be on the line? Chatbots and AI-driven phone triage create employee/patient frustration with endless automated prompts.

When live representatives are available to answer calls, members receive expert assistance for their pharmacy benefit questions. Live assistance helps resolve issues quickly, and plan members are more satisfied with the service. Quick access to a human being should be an expectation, not an exception.

Don’t fall victim to PBM issues that leave employees behind

Too often, the PBM industry fails to provide genuine healthcare. Instead of a patient-first approach, patient needs seem to fall to the bottom of the priority list.

But you don’t need to fall victim to deceptive practices and opaque contracts that leave your employees behind. Evaluating PBM options that unapologetically prioritize the health and wellness of your employees over profits can help ensure your pharmacy program is a success.