A NEW APPROACH
Winter is coming! Can you hear the winds of change blowing?
The Cold Hard Facts
According to BenefitsPRO, 93% of employers considered switching pharmacy benefit providers in the last year due to the rising cost of prescriptions and complicated PBM contracts; smaller employers are more likely to re-evaluate their pharmacy benefit plans than very large employers; and future company health plan designs greatly concern majority of employers (BenefitsPRO, 2023).
Prescription spend continues to exponentially rise in the United States. Unfortunately, there is no end in sight to this problem significantly impacting company bottom lines and many employers are searching for new health benefits that will positively impact the trajectory of their company in the coming year(s).
Analyzing the Tool Belt
Healthcare is episodic, meaning there is a start and end date. Most medications, however, do not have an end date making them a reoccurring expense. Insurance is designed to cover the risk of unknown loss making this the wrong tool for this problem. Insurance makes services, including medications more expensive. Almost every medication is cheaper without insurance if you know where to look. That is the key!
Employers are Craving Change
The first step in making a change is recognizing that the tool employers have been using was never meant to take care of this problem. The next step is to acknowledge insurance is the wrong tool and seek out a better one. Just like any other expected expenses that companies plan for, procurement, not insurance, is critical for having confidence that those expenses are managed properly.
Many employers crave the change that prescription procurement can provide. However, they may be unaware of the treasure. Prescription procurement is a high-value strategy utilized to effectively acquire a medication that a person needs. It allows employers to give their employees a better experience, not just have the option to access mediocre discounts on high-cost medications at the local pharmacy and deal with the bureaucracy of insurance.
A Financing Vehicle? More Like a Roadblock.
A self-funded employer acts like a traditional insurance company, collecting premiums from enrollees and taking on the responsibility of paying employees’ and dependents’ medical claims. It makes sense that they would hire PBMs and expect them to make sure that all expenses are essential and appropriate. The higher the cost of the drug, the more questions will be asked. To get answers to these questions, it puts patients in the middle. This often creates obstacles to care, causing frustrations with prior authorization protocols that, while necessary, are suffocating to a member just trying to take the medication their doctor prescribed.
It becomes an aggravating exercise with members and providers trying to prove that the medication they are trying to fill is needed. It frequently involves letters from the provider explaining why the member requires a specific medication while trying to steer the member to an alternative therapy, which is usually based on rebates to the PBM and not clinical outcomes.
It is assumed that if a patient does not use health insurance, it is impossible to afford the outrageous cost of the medications, but the reality is that insurance is the element patients cannot afford to use. This is where the illusive value of insurance comes into play.
A Fair Cash Price
No doubt, PBMs are incredibly smart and good at making money, so they put prohibitions on your local community pharmacies from offering patients fair cash prices. If there was value in having health insurance, then not having health insurance should make things harder. However, not having insurance has continued to prove that it actually makes things cheaper and simpler. From personal experience, I have learned when you stop asking for permission from insurance companies to attain what you need, the entire process becomes easier.
To further illustrate the point, cash only pharmacies, like Mark Cuban’s pharmacy, do not accept insurance and the prices are better than local retail pharmacies any day of the week. Why? Because not participating in insurance allows them to offer patients a fair cash price. The second a pharmacy benefit network enters the picture; a fair cash price is prohibited. This is what entangles most companies today.
Adjusting the Tool Belt
By implementing the right tool, (aka prescription procurement), a more predictable healthcare budgeting process is created. It allows employers to take control over what is being offered and how it is being offered.
Employers and employees alike despise the oversight and burden that using insurance creates, but they are not sure that they have any other choice. They do and SHARx is here to help. Trying to negotiate a better discount and rebate has never and will never solve this dilemma because that relies on the system that created the problem to also have the solution. To truly solve this issue, you have to opt out of the system and only then can the answers be found.
SHARx exists to serve members that have been lost in this journey – the employer and the employee. Our passion is to give the ‘lost’ a voice and seat at the table. Unfortunately, other parties involved in our healthcare system profit on the problem, but that is not what we do or why we do it.
The SHARx Solution
SHARx navigates this messy healthcare issue with knowledge and expertise to lead our clients in a direction that benefits all parties involved. There is great value in the experience SHARx brings to the table when routing these debilitating problems that individual employers might greatly struggle to pilot on their own. SHARx is made up of trained individuals who have done the research and continue to do so. We know what to do and where to go for the members that need our help.
We believe people deserve to get what they need. With SHARx, employers can control one of the bigger variables in the game which are the medications that insurance was never meant to control anyway.