Utilizing The Same PBM For WC and Health Insurance?

While on the surface this seems like a natural opportunity for synergies, I’m not sure I really see this happening or simply wishful thinking by those in both businesses (see article about this).  Since it’s not possible to track the same consumer as they move from one group to another within a PBM for historical data (i.e., when I change employers but stay with the same PBM), I can’t imagine aligning consumer profiles across divisions like Worker’s Compensation and Health Insurance.

And, while the market may be changing, there are real differences such as:

  • Management objectives (get back to work and off the drug)
  • Plan design (no copays, different formulary)
  • Processing (different BIN at POS)
  • Eligibility (there is no “eligibility” file until an incident happens to create a claimant)

In Worker’s Compensation, you also have an adjuster to deal with who is in the middle of the process and different legal frameworks to operate.

On the flipside, I agree that applying some of the processes that have worked in the traditional PBM business to WC has value it’s going to be very different.  As the consumer, why do I want to use the generic when I don’t pay anything?  There should also be some clinical value in coordinating the data, but the question exists of whether the consumer can be viewed with the same member ID in the adjudication platforms.

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