Newsletter Sign-up

By MATTHEW BRODSKY, senior editor/Web editor of Risk & Insurance®

Since President Barack Obama signed healthcare reform into law on March 23, employers have been fixated on whether it will lead to increased costs for their employee benefits plan. Two recent reports suggest, however, that employers should perhaps devote some attention to their prescription drug plans to trim costs.

A simple example: say a plan sponsor notes a large number of medicines being used by its employee population for hypertension, explained David Dross, a partner with Mercer who leads its Managed Pharmacy practice. Perhaps then the employer should consider launching a disease management program around hypertension.

The two recent studies diverge, however, when it comes to where self-insured employers should get this prescription drug plan data. The one report, released on June 15 by the Bethesda, Md.-based Healthcare Performance Management (HPM) Institute, argues that employers should carve out, or unbundle, their pharmacy benefits, meaning they should hire a pharmacy benefits manager (PBM) or other separate vendor from whichever healthcare insurer is managing their healthcare program.

"The advantage of unbundled data to the employer is timely access to the data. Bundled data is typically controlled by an insurer and is usually not available to the employer," George Pantos, executive director at HPM Institute, told Risk & Insurance® in an e-mail.

Of course, a provider of unbundled drug services, such as CVS Caremark, would agree.

"Many of our more sophisticated clients and prospective clients recognize that knowledge is power in a changing environment and that carving out their pharmacy benefit gives them powerful insights on the emerging population risk, predictive cost analytics and quality of care across health plans," said Jack Bruner, executive vice president of strategic development at CVS Caremark Pharmacy Services.

THE COUNTER ARGUMENT

The second study, released June 3 by Pittsburgh-based Highmark Inc., showed that annual medical expenses averaged 6.2 percent lower for self-insured customers that carve in the pharmacy prescription drug benefit versus those that do not. Highmark customers with carved-in prescription benefits also saw an annual average of 15.8 percent less in outpatient expenses and 7.7 percent less in emergency room expenses for their employees, according to the research.

Those savings were not projections or guesses but based on "real numbers" from claims data, stressed Dr. Eric Culley, manager of clinical pharmacy services at Highmark.

Still, being that Highmark, an independent licensee of Blue Cross and Blue Shield Association, sells healthcare benefits plans with prescription drug services bundled in, wouldn't you say that their research is a little compromised?

Dross at Mercer admitted that carving in does have its good reasons, but the idea that somehow you get more robust medical management from carving in "honestly has yet to be systematically proven."

Dross suggested that carved-out pharmacy benefits provide a more robust solution and the ability to do more ad hoc reporting with the data.

"Generally speaking, the level of reporting you get ... is likely better than if you're carved in," he said.

It could help to explain why about 70 percent of employers with 20,000 workers or more carve out their drug benefits. Besides better data reporting, they might also get lower prices and the simplicity of using one drug vendor across all their locations, Dross added.

Yet Culley countered that Highmark's pharmacy plans can be as customizable as a larger self-insured employer could want, and that his company could provide same-day pharmacy data to clients if they wanted it. He added that perhaps part of the cost savings shown for bundling came from the fact that Highmark was able to use pharmacy data to help guide case management and to integrate it with medical data.

When an employer with an unbundled pharmacy service asks its PBM to hand over drug data to their benefits administrator (like a Highmark), Culley added, marrying with medical data can take some time.

"If you can do that in a month, you're doing pretty good," he said.

Whether your data is bundled or unbundled, Dross advised, the "strongest conclusion" is to use pharmacy and medical data together to guide how you design and adjust your benefits program.

June 29, 2010

Copyright 2010© LRP Publications