Is Your PBM Really Different?

Every time I talk to a PBM, they want to convince me that they are unique.  And, that is important to me (and should be to you).  If they are simply driving generics, getting network discounts, and filling mail and specialty scripts, they’re clearly in a commodity space.  It’s a race to the bottom, and they’re fighting very large companies – Express Scripts, CVS Caremark, and CatamaranRx.  And, none of those companies are standing still.  Of course, the other PBMs that are part of United Healthcare, Humana, and Kaiser are all looking at how they leverage the care assets and broader solution which they can bring to the client.  (And, I’d put Prime Therapeutics somewhere in the middle based on their ownership by the Blues.)

But, as I’ve seen, value isn’t just about cost. That maybe one leg of the stool, but you need to improve outcomes and the consumer experience (i.e., The Triple Aim).  With that in mind, I created a checklist of what I want to know to see if a PBM is really different.

1. Engagement – What channels do you use to engage the consumer? How do you integrate those channels? What percentage of members engage with you when you outreach to them?  What is your A-B testing strategy?  What consumer insights can you share with me?  How do you measure engagement (e.g., PAM score)?  What is your segmentation approach?  Do you have someone in charge of the consumer experience?  Can you show me your customer journey maps?
2. Digital – What is your digital strategy? What percentage of your members have downloaded your app? How often do they use it? Why do they use it? How long do they keep it on their phone? What value do they get from it?  How are you using other channels?  Are you using social media with a purpose or just trying everything (see new whitepaper on digital transformation)?  Where do you members congregate online?  How does this vary by age, gender, condition, number of Rxs, etc.?  Does your involvement make a difference in engagement, outcomes, adherence?
3. Innovation – What’s your biggest innovation?  Are you making money off it?  How does it help you sell?  How does it help your customers to differentiate themselves?  Do you have a budget?  Resources?  Is it just an ivory tower exercise?  How do you sustain it?  How are you using crowdsourcing?  Are you working with any VC firms or incubators to develop new ideas?  What percentage of ideas come from your clients?  From your employees?  What’s your innovation funnel look like?  How many ideas die after a pilot?  Are you able to scale pilots that are successful?
4. Big Data – What types of data do you get – medical, lab, EMR, patient reported, device? Do you buy data? How do you integrate this data? Do you have predictive models? How are they used? Do you have published studies on the results?  What insights have you gained from the data?  How have you integrated the data into your solutions?  How do you move things from data to insights to action?
5. Integration – What type of integration do you have – with POS systems and retailers, with physicians and practice management systems, with providers and EMRs, with mobile solutions, with remote monitoring companies?  How do you create a simplified consumer experience across the care continuum?  Are you working with wellness and disease management companies?  Are you coordinating care for complex patients?  Do you provide support for cancer survivors?  How do you work with pallative care companies?  How do you support the family or the caregivers?
6. Partnerships – Who are your partners?  How does 1+1=3?  What’s unique about the relationship?  How do customers benefit by your relationship?  How do consumers benefit?  How do providers and pharmacies benefit?
7. Physician Strategy – How do you work with physicians?  What data do you give them about their patients?  What insights do you give them?  Do they just see you as a block or have you found a positive way to collaborate?  What do you do to influence physician’s prescribing habits?  How are you working with physicians to address adherence?  How are you using your data and predictive models to integrate them into providers evidence-based medicine algorithms?
8. Outcomes – What programs do you offer to clients and consumers that are focused on an outcome that may reduce Rx utilization?  How do you work with dieticians or social workers?  What percentage of your members have a PDC of greater than 80%?  How do you track lab values and clinical values versus just an Rx count?  What are you doing to reduce readmissions?  How are you impacting all of the STARS measures (not just the pharmacy ones)?
9. Pharma – How are you working with pharma?  Are you helping them to extend “beyond the pill”?  How early do you get involved in their pipeline?  For complex conditions, are you helping them to demonstrate outcomes?  Are you looking at how to collaborate with key medications – e.g., oncology?  Have you looked at how to blend care with prior auth with Rx for conditions like obesity?
10. Payment – What’s your approach to transparency?  Is it just pass-through pricing?  Do you do risk based pricing?  How?  How do you contract with pharma?  Have you worked directly with any ACOs?  Have you taken risk?

This isn’t new…I’ve been talking about this for years.  Here’s my whitepaper on this from 3 years ago.

And, here’s a presentation that I’ve given on this topic at several conferences.