The global pandemic has significantly impacted our day-to-day lives, from how and where we work to how we shop and socialize. One considerable impact that may be here to stay? How we access and utilize healthcare services.
The Growth of the Healthcare Industry
From increased use of mental health benefits to telemedicine becoming the norm and not the exception, consumers, providers, and third-party solutions have all seen the reshaping and growth of the healthcare industry in what seems like real-time.
The Centers for Medicare and Medicaid Services (CMS) recently released some staggering national health expenditure statistics, showing growth in both access and utilization. For example, in 2020, national healthcare spending grew 9.7 percent to $4.1 trillion, accounting for 19.7 of the U.S.’s gross domestic product (GDP). Looking ahead, the CMS projects national healthcare spending will continue to grow, reaching $6.2 trillion by 2028.
Prescription drug spending is also projected to grow. From 2024 to 2028, prescription drug spending is expected to hit 5.9 percent growth, increasing from 358.7 billion in 2020 to 560.3 billion in 2028, as reported by Health Affairs. Additionally, during this time, the “growth in the use and intensity of drugs is expected to accelerate, in part of a larger anticipated impact from new drugs.”
PBM Industry Trends to Watch
With national healthcare access, utilization, and spending continuing to grow, the pharmacy benefit management (PBM) industry also experiences these developing and transitional trends and changes while health plans (and their participants) are continuing to expect transparency and affordability from their PBMs.
Keep reading to learn about 4 PBM industry trends in 2023 and what to expect next.
Trend #1: Specialty Drugs Continuing to Drive Rx Spend
Specialty drugs remain – and will continue – to represent the fastest-growing area of pharmacy spend, accounting for 53 percent of spending, up from 27 percent in 2010.
Over the years, specialty drug growth has been driven by the adoption of new, innovative drugs, such as those for oncology and autoimmune therapies. According to the IQVIA Institute, an average of 50-55 new specialty drugs will be launched annually over the next four years.
Moving forward, specialty drugs will continue to evolve, helping to cure or curb symptoms for patients with complex or chronic medical conditions. As new drugs hit the market and as prices continue to rise, health plan sponsors will continue to look to their PBMs to help address the cost and accessibility of prescription drugs.
Specialty pharmacies, which is a “team of pharmacists who help patients take specialty medications,” provide numerous benefits to plan sponsors and patients alike. For example, specialty pharmacies can:
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- Improve patients’ care experiences
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- Improve the health of specific populations through the use of “evidenced-based patient care management guidelines”
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- Improve care coordination between providers “with notifications of patient-reported issues, resolutions, or recommendations”
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- Decreasing overall health care costs while improving health outcomes with higher-touch care
In addition to these benefits, specialty pharmacies continue to redefine healthcare’s inventory and supply strategies, disrupting traditional supply chain methods, such as buy-and-bill.
According to the Pharmaceutical Care Management Association (PCMA), PBMs and specialty pharmacies will “save payers and patients an estimated total of $250 billion on the cost of specialty medications and related non-drug medical costs [over the next ten years] when compared to what expenditures would be with limited use of PBMs and specialty pharmacies.”
Trend #2: The Growth of Innovative PBM Pricing Strategies
Another PBM industry trend that we expect to continue through 2023 and beyond is the continued evolution of PBM contracting model and pricing strategies.
Examples of PBM Strategies
For example, to counteract the high prices of specialty drugs, PBMs are embracing outcomes-based contracting. According to a recent study performed by a national healthcare consulting firm, 56 percent of payers have entered into outcomes-based contracts as of September 2021. This study was based on responses from 51 US-based health plans and PBMs, representing approximately 59 million covered lives.
Another alternative PBM pricing strategy includes the growing use of innovative utilization tools. Advanced technology, the intent to continuously improve patient outcomes, and the desire to increase patient adherence to medications continually help utilization management tools evolve. By optimizing these outcomes through utilization tools, PBMs can identify opportunities for cost savings while improving patient outcomes.
Trend #3: Increased Utilization of Real-Time Performance Optimization
To optimize and increase utilization of real-time performance, plan sponsors are looking to better understand PBM contracts while using PBMs that implement new data analytics solutions and insights, such as those found through AI and automation tools.
The pharmacy benefits industry is a complex one. And one that continues to evolve. Before deciding the best course for optimization, plan sponsors must first understand their PBM contracts. According to Milliman, “[b]eing able to pinpoint changes and areas for improvement within [the PBM’s] contract can significantly reduce pharmacy program costs without having to change members’ benefits.”
Milliman further advises that “[e]ffective control starts with understanding these complex [PBM] documents, effectively auditing and monitoring adherence to the contract, and results in optimizing this important and critical relationship.” Once plan sponsors understand their PBM agreements, including contractual pricing guarantees and excluded drugs, then the plan sponsor and PBM can decide the best path to optimization.
One way to take advantage of real-time performance optimization is to incorporate new data analytics solutions into the PBM relationship. For example, through AI and automation advancements, PBMs now have access to platforms that automate daily claims information and insights in real-time, so instant recommendations on optimization can be made to plan sponsors.
The ability to automatically analyze data trends allows PBMs and plan sponsors to pinpoint areas for improvement and alert clients of immediate savings opportunities – regardless of the number of data sources. According to Advisory.com, new, emerging PBMS could play a role in “focus[ing] on their ability to lower drug costs through transparent pricing or total costs of care through improved medication access, or specific disease state management.”
Trend #4: The Continued Decentralization of Pharmacy Management
For years, we’ve had a centralized pharmacy services model, where medications are primarily distributed from a centralized location. However, pharmacy management’s continued decentralization is one of the top PBM industry trends to watch.
Generally, health care bundling refers to who is providing the benefit. For example, if you have a BlueCross BlueShield (BCBS) centralized health plan, then BCBS is managing both your medical and pharmacy benefits.
However, if you carve out your pharmacy benefits from your BCBS health plan, then the pharmacy benefit is decentralized from the medical benefit. Taking a decentralized approach to your pharmacy benefits can optimize your health benefits while increasing cost-saving.
As we’ve found, one-stop-shops aren’t always the best solution, especially when it comes to pharmacy management.
Through decentralization, you gain additional insight into your claims, understanding where your money is actually going.
Today, the market is demanding better services across the board. Companies want greater control over their performance while delivering optimal results around access, quality, and cost of health care. To achieve this, we can no longer rely on what we’ve done in the past. We must look at the provision of health care through a new lens.
For example, let’s look at the decentralization of specialty drugs – a top driver of healthcare costs. Often, grueling time and effort are put into understanding specialty drug utilization and trends, such as copay alignment, overseeing rebate performance transparency, and running complex predictive modeling and forecasting reports.
Through a decentralized solution like Xevant’s analytic optimization, not only do these tasks become less onerous, but you have a real-time opportunity for expert pharmacy and claim repricing analysis, more efficient retrospective drug utilization reviews (RUDR), rebate optimization and transparency, and better client management, just to name a few.
The New World of Decentralized Healthcare
PBM industry trends will continue to stay at the forefront of the healthcare sector’s collective mind. As we emerge from the global pandemic, plan sponsors will continue to work with their PBMs to adapt to this new world of decentralized healthcare, while keeping costs under control and participant outcomes top of mind.
To stay ahead of the game, Xevant can help you optimize your pharmaceutical spend with real-time analytics. Whether you’re a PBM, TPA, or benefits manager, Xevant provides the data you need before you need it.
