As we navigate the post-pandemic world, the Pharmacy Benefit Management (PBM) industry continues to evolve, driven by the growth of the healthcare industry. Statistics from the Centers for Medicare and Medicaid Services (CMS) show national healthcare spending grew 9.7% to $4.1 trillion in 2020, and it is projected to reach $6.2 trillion by 2028.
Health Affairs reports that prescription drug spending is also rising, expected to grow from $420.3 billion in 2023 to $560.3 billion in 2028. 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.”
Positioning of the Top PBMs
In 2022, the top pharmacy benefits managers included CVS Health, Express Scripts, and OptumRx, to name a few. CVS Health held the largest share of the market, with Express Scripts and OptumRx followed closely. Other noteworthy PBMs included Humana, Prime, and MedImpact. According to Statista, market share percentages going into 2023 were as follows:
1. CVS Caremark – 33%. Since its inception in 1993 as MedPartners, Inc., CVS has evolved into a leading healthcare company, with significant milestones including the launch of RxZero in 2020. In 2022, CVS held a full one-third of the PBM market in the United States.
2. Express Scripts – 24%. Founded in 1986, Express Scripts has grown from a small operation of five employees to a major player in the health care industry, with significant innovations such as developing the first-ever formulary in 1989.
3. OptumRX – 22%. A key division of UnitedHealth Group, OptumRx has been a transformative force in the PBM landscape, leveraging data analytics for improved operational efficiencies and demonstrating a strong growth rate of 15% in the first quarter of 2023.
4. Humana – 8%. Founded in 1961 as a nursing home company, Humana Inc. has evolved into a leading health insurance provider in the United States, ranking 32 on the Fortune 500 list in 2022 and generating over US$90 billion the same year. In 2023, the U.S. News and World Report recognized the company as the Best Overall Medicare Advantage Plan Company.
5. Prime – 5%. Prime Therapeutics, a PBM with 38 million members, has demonstrated consistent growth, moving up by 200+ places in the Inc. 5000 ranking. It recently secured an agreement with Kroger Health to access over 33 million new members and received accreditation from the National Committee for Quality Assurance.
6. MedImpact – 4%. Established three decades ago, MedImpact earned a URAC accreditation in 2023, scoring 100% across all quality standards. The PBM is recognized for its innovative use of pharmacogenomics to personalize medicine and improve patient outcomes.
PBM Industry Trends to Watch
As we navigate 2023, PBMs are also experiencing change, while health plans (and their participants) continue to expect transparency and affordability from their PBMs. In this dynamic landscape, four key PBM trends are shaping the industry in 2023 and beyond:
Trend #1: Specialty Drugs Continuing to Drive Rx Spend
Specialty drugs continue to represent the fastest-growing area of pharmacy spend, accounting for 53% of spending, up from 27% 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, 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 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 comprise a team of pharmacists who help patients take specialty medications, providing 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 40-50% on annual drug and related medical costs compared to what they would have spent without PBMs.
Trend #2: The Growth of Innovative PBM Pricing Strategies
Another PBM trend that we expect to continue through 2023 and beyond is the continued evolution of PBM contracting model and pricing strategies. For example, to counteract the high prices of specialty drugs, PBMs are embracing outcomes-based contracting. According to a recent national healthcare consulting firm study, 58% of payers had entered into outcomes-based contracts as of 2022.
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
The trend toward decentralization in pharmacy management is gaining momentum. By carving out pharmacy benefits from centralized health plans, companies can gain additional insight into their claims and understand where their money is actually going. For example, if you have a BlueCross BlueShield (BCBS) centralized health plan, BCBS manages 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. Through decentralization, you gain additional insight into your claims and understand where your money is going. A decentralized approach to your pharmacy benefits can optimize your health benefits while increasing cost-saving.
Healthcare Through a New Lens
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.
The New World of Decentralized Healthcare
With a decentralized solution like Xevant’s analytic optimization, not only do these tasks become less demanding, 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.
PBM trends will remain at the forefront of the healthcare sector’s collective mind. As we emerge from the global pandemic, plan sponsors will continue working with PBMs to adapt to this new world of decentralized healthcare, while keeping costs under control and participant outcomes top of mind.
Xevant can help you optimize your pharmaceutical spending with real-time analytics to stay ahead of the game. Whether you’re a PBM, TPA, or benefits manager, Xevant provides the data you need before you need it.
