Understand your universe: There are many key players in the prescription benefits universe, including patients, doctors, pharmacists, employers, employee benefit consultants, prescription benefit managers, pharmaceutical manufacturers, and more. It’s important to understand the role of each and what motivates them, as that is key to designing programs that maximize savings while also minimizing the impact to patients, employers, and prescribers.
Mark is an experienced healthcare executive with a focus in all aspects of the pharmacy benefit management industry. He began his 22-year pharmacy career with a Doctor of Pharmacy degree from the University of Tennessee and a Board-Certified Residency in Geriatrics at the Veteran’s Administration of Memphis. From there, Mark went on to hold numerous positions such as President and CEO of Innoviant Prescription Benefits, Vice President of Prescription Solutions, and President of Health Information Designs. He joined RxBenefits in 2017 where he serves as Vice President of Clinical Solutions.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
I graduated from the University of Tennessee School of Pharmacy in 1994 and completed my residency in Geriatrics in 1995. A few years later I landed an opportunity in Wisconsin with Wausau Insurance Companies to help develop their strategy for managing prescription benefits. It was in those early years that I found my passion and established a number of valuable connections with managed care pharmacists across the country that helped me hone my approach to managing prescription benefits. And this passion is still just as alive today.
What do you think makes your company stand out? Can you share a story?
RxBenefits is unique in that we are the industry’s first and only technology-enabled pharmacy benefits optimizer (PBO). We are not a PBM, TPA or coalition; rather we work independently to ensure our employee benefit consultant partners and their self-insured clients receive the best clinical and economic value out of their prescription benefits program.
The prescription benefits world is big and can be complex. Prescription costs are on the rise and it is often hard for people — and employers — to understand the cost of therapies. To illustrate, just one high-cost specialty drug is all it takes for an employer to experience a claim that could cost its pharmacy benefits plan more than 250,000 dollars in a single year. This era of super high-cost medications poses a challenge for employers. On the other hand, if you were diagnosed with Chronic Myelogenous Leukemia in 2003 and are alive and well today because of Gleevec or other medications, your perspective is likely to be very different. Employers are not clinical experts — and they don’t want or need to be — but they need an advocate to watch out for their financial interests and the best health of their employees, to help them understand when something is right and when it’s not. That’s where RxBenefits comes into play. For example, recently one of our clinicians identified a patient on Somatuline for the treatment of acromegaly, more commonly known as giantism. The cost of the medication seemed to be out of line with expectations. On further review, we determined that the patient was receiving four times the Food & Drug Administration’s recommended dose. We contacted the provider who in turn wrote a new prescription which we provided to the specialty pharmacy. This one intervention saved that client 25,000 dollars per month and ensured the patient was receiving the proper dose. That patient had been receiving the wrong dose for at least a year. This issue was not brought to the employer’s attention by the PBM, the manufacturer, the pharmacy, the provider, or the patient. That is not to say that there are any bad actors in this scenario, but rather to point out that there are significant gaps in the system that can lead to suboptimal care or inflated costs. As an independent PBO, RxBenefits identifies and remedies those gaps.
How often do issues like this come up?
More likely than most people would think. Roughly one in 10 employers has a single member on one or medications totaling 250,000 dollars or more per year. Additionally, roughly one in 10 members with a prescription cost over 100,000 dollars per year are likely to have an opportunity to improve their quality of care, drug costs, or both. With the PBO model, RxBenefits has saved self-funded employers an average of 26% the first year through contract savings alone, and another 3%-7% through clinical programs.
What advice would you give to other healthcare leaders to help their team to thrive?
I’ve been extremely fortunate in my career to have worked with hundreds of skilled and dedicated people during which I’ve discovered a few common threads.
- Have a clear focus: Knowing exactly why you’re doing what you are doing and having a clear purpose is essential. As a clinician, it is important for me and my team to know that clinical value is job number one, and that managing costs to help employers preserve their benefits — while also very important — comes next.
- Understand your universe: There are many key players in the prescription benefits universe, including patients, doctors, pharmacists, employers, employee benefit consultants, prescription benefit managers, pharmaceutical manufacturers, and more. It’s important to understand the role of each and what motivates them, as that is key to designing programs that maximize savings while also minimizing the impact to patients, employers, and prescribers.
- Use data to drive results: When I entered managed care, there were no specialty medications. Today, specialty drugs account for 1.5% of claims and 45–50% of prescription costs for most employers. In addition to the overall cost of specialty medications, the number of extremely high-cost therapies designed for rare conditions can significantly impact an employer’s program cost, cash flow, and even their ability to provide benefits. Data is essential to understanding how these trends and patterns impact employers. Data also can point to outliers, which in turn can point to opportunities. For example, a few years ago my team identified that the cost for certain oral cancer medications could fluctuate between 240,000.00 dollars/year and 960,000.00 dollars/year. As we dug deeper, we learned that many oral cancer therapies are parity priced — meaning in this case four 1mg tablets cost four times the cost of one 4mg tablet. Access to and the ability to sort and analyze data can really drive results — and results can drive teams.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
- First and foremost, I want to recognize that healthcare in the United States has tremendous opportunity for improvement, both clinically and economically. That being said, it’s also important to highlight that the nine countries listed on this list have a combined population roughly equal to the U.S. In addition, the U.S. is culturally diverse, geographically expansive, and does not have a universal health plan. While some countries can cite lower per capita costs, all benefit from the innovation that comes from the U.S. healthcare market. Many believe that universal healthcare could reduce costs, but I would contend that unit economics are part of the solution — not the answer. The broader answer is in how key stakeholders relate and share responsibility for outcomes and costs. Here’s an example. Say a person sees an ad on TV for a new medication to treat Psoriasis. They go to their doctor, the doctor prescribes the medication that they saw on TV, the patient pays a 50 dollars copay, and the employer pays for the rest. Sounds good, right? What if that medication cost 10,000 dollars a month? And what if there were an alternative that cost only 3,000 dollars a month? The challenge is that the patient and prescriber are driven by the clinical endpoint without regard to the economic endpoint. For a time, the industry tried sharing costs with the patient, but with very high-cost medications, this can lead to hardships and ultimately caps on patient copays — which puts us right back to where we are today.
- While this is just a single illustration, here is what I believe we can realistically work toward:
- Patients should be invested in their health every day. Lifestyle cannot prevent everything, but it plays an important role in key diseases that can affect quality of life and the cost of care. Diabetes is a good example here.
- Providers have always had the power of the pen and try to prescribe appropriately, but times have changed and many prescribers aren’t familiar with parity pricing or the economics of ordering certain size tablets versus others for their patients. Decisions should always be clinically motivated, but giving providers better access to costs can reduce unnecessary pharmacy spending.
- Focus on drug pricing reforms for employer plans. More than half of Americans receive healthcare from Medicare and Medicaid programs, and the government receives discounts for these programs that are not available to commercial payers. This dynamic pushes more cost to commercial payers to make up for thin margins from government programs. Ensuring access to healthcare is important. However, it will be critical for the government and industry to continue pursuing reasonable and sustainable efforts to lower drug costs for employer-sponsored pharmacy plans and members.
You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
- Normalize pharmacy purchasing discounts so that commercial payers can achieve the same unit economics as the government. Prescription drug purchasing continues to be a scale-driven enterprise, so this is especially important for small to mid-size employers.
- Bring a united focus to pre-diabetes and diabetes. For many, diabetes can be preventable, treatable, and reversible — but when unmanaged, the consequences can be life threatening and costly. In fact, by 2016, insulin accounted for 31% of overall healthcare costs for a person with Type 1 diabetes. Patients should focus on their lifestyle and diet, with physicians also educating the public on the disease and how to combat it, and when necessary, monitoring and treating it. More medication is not the answer, rather new monitoring tools, greater education, and individualized coaching — along with available therapies and access to clinicians — can result in better outcomes.
- Change medical reimbursement contracts to a tangible schedule. Many employers pay “billed minus.” Let’s say the discount is 30%. That sounds like a good discount, but if the billed amount is not tethered to a predictable point of reference, the discount becomes irrelevant. A good example of this is the billing of prescription claims under the medical benefit. This often is submitted at a rate of two or three times Average Wholesale Price and can result in a plan paying two times or more what they would have paid through the prescription benefit. This can cost employers hundreds of thousands of dollars for a single patient. This is another reason employers need an advocate in their corner to ensure they have a transparent pharmacy benefits contract with the best rates and rebates, optimized for their specific needs.
- Keep healthcare local whenever possible. Healthcare is a business of passion, with people seeking compassionate treatment from trained clinicians. There is no substitute for the human element. Forging a relationship between patients and providers can lead to better trust and better outcomes for all.
- Bring back the Certificate of Need In the US. Because it is a competitive market, we don’t meter the number of hospital beds, MRI machines or other diagnostic and treatment facilities. Because of this we can have markets that are oversaturated and ultimately increase the cost of care. Some would say competition helps drive costs down and in many cases I agree, but if twenty doctors open an office and provide MRI scans, cost will ultimately go up if the unit cost of scans does not go down.
Ok, its very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
Great question. The US healthcare system is a constantly changing work in progress.
- We’ve put a lot of effort into public health awareness during the coronavirus pandemic. And I believe this is a great opportunity for us to eventually shift focus to other major health concerns in the U.S. like diabetes. As mentioned earlier, individuals can become more invested in their own health, especially as it relates to chronic conditions.
- The pricing mechanisms for medications in the US are elaborate and make it very difficult for most to truly understand the value of a given product. On the one hand, we can easily say that a generic blood pressure medication that is working and costs 20 dollars/month is a good value. But when you consider Psoriasis treatments that cost 3,000 dollars or 10,000 dollars per month, it becomes more challenging. What is the cost of that treatment after the rebate? Is one more effective than the other? If so, is that clinically material? There will always be some flexibility required to ensure the best clinical outcomes, but if corporations could get to common published prices and provide the same discounts for commercial payers and self-funded employers that are available under the federal fee schedule, that would go a long way to providing a better common understanding of cost and value.
- Public health is an amalgamation of our DNA, our environment, and our habits. Communities that provide opportunities for education, socialization, exercise and resources for disease prevention, as well as treatment, are in the best position to improve quality of life and the cost of healthcare. Having a single payer system will not prevent disease, but having a community focus can help to prevent disease in some people and improve outcomes in many more.
Are you working on any exciting new projects now? How do you think that will help people?
The RxBenefits team is always innovating in an effort to better serve our customers. At present, we are focused on developing a program leveraging data analytics to help self-funded employers manage the financial impact of very high drug costs related to a single member. For example, say a company has an employee that is newly diagnosed with a disease such as Hereditary Angioedema (HAE). Managing HAE can easily cost an individual up to 700,000 dollars a year, which results in a devastating financial impact. Under our new program, RxBenefits can provide employers fresh starts, with relief up to as much as 337,500 dollars a year. Given the hard year many companies had, we know this solution will be much needed and will help some employers keep their doors open.
Thank you so much for these insights! This was so inspiring!