You can hold your PBM accountable. It is not that complicated.
Part 1 of 2: Contracting
In this this part we focus on actions payers should take contractually on the front end of a new PBM program or during renewal with your current PBM. This is the point of maximum leverage and every payer, during the contracting phase, should think like a fiduciary.
Payers have a fiduciary responsibility to act in their self interest and the best interests of their members or employees. Holding PBMs accountable is one of the steps payers can take as a fiduciary.
Accountability for PBMs can come in different flavors such as taking specific actions to ensure transparency, cost-effectiveness, and optimal patient outcomes. At Prodigy, we are writing the blueprint for payers to hold PBMs accountable. We believe in empowering our clients with information to hold us accountable.
Here are some strategies for payers to fulfill their fiduciary duty and hold PBMs accountable:
Pay attention to your contractual arrangements. When negotiating contracts with PBMs, payers should clearly define their expectations and require transparency in pricing and rebate arrangements. The contract should explicitly state that the PBM must act in the best interests of the payer and its members, prioritizing cost-effectiveness and patient outcomes.
Establish performance metrics and oversight. Institute performance metrics and key performance indicators (KPIs) to evaluate the PBM's performance. These metrics can include drug utilization, formulary compliance, generic substitution rates, medication adherence rates, and member satisfaction. Regularly review and assess the PBM's performance against these metrics to identify areas for improvement or potential breaches of fiduciary duty.
Demand transparent pricing. Require them to disclose the actual costs of drugs, including any discounts, rebates, or other financial arrangements they have with pharmaceutical manufacturers. This transparency allows payers to assess whether the PBM is securing the most cost-effective options for their members.
If it seems like it is too challenging, it shouldn’t be. Remember, it is never a bad idea to evaluate alternative PBM arrangements: Periodically assess the performance and value delivered by the current PBM. Consider soliciting bids from alternative PBMs to evaluate their offerings, pricing models, and track records. This evaluation process ensures that you are receiving the best possible services and cost-effective prescription drug management.
If you try and try again but are getting nowhere with your current PBM, call Prodigy. We are happy to show how this can be accomplished seamlessly. Sometime the grass is greener on the other side.