HEALTH PLANS/PBMs: Employers are dumb and therefore get punked

I couldn’t write about this yesterday because I spent the day hanging out in airports, but plenty of people emailed me about Barbara Martinez of the WSJ and her continued journey into the seemy side of employer benefits. As I’ve mentioned before Martinez is the best investigative journalist working in health care, and she consistently shines her large flashlight on some of the murkier goings-on in the health plan and PBM world. Yesterday she had two articles (one of the front page). The first looked at the scummy practice of consultants providing advice about which health plan to use. And just like in the Marsh & Mclennan scandal in New York, yet again the consultant/broker allegedly working for the employer is instead in the pay of the insurer. The only difference here is that the insurer was willingly colluding with the consultant rather than in the M&M case apparently extorted by them, but that’s a fine, fine line. And of course, true to many of its recent business practices the main insurer she finds involved is UnitedHealth Group—while most of the consultants involved are small regional outlets. Pity this poor Ohio school district:

Payments to a consultant are at issue in an Ohio case involving the South-Western City School District, which encompasses suburbs southwest of Columbus in the central part of the state. In 1996 the district hired Joseph James & Associates of Dublin, Ohio, to help it choose a health insurer. The district had fired its previous consultant after learning he had financial ties to health insurers. Superintendent Kirk Hamilton says the district made clear that it expected Joseph James not to take money from district health-care vendors. “We wanted to make sure the people representing us were solely working in our best interest,” he says.

Each time the health-insurance contract came up for bidding in subsequent years, Joseph James managed the process. Each time, UnitedHealth won the business. Over 10 years, the district paid the consulting firm about $380,000 for its services. Earlier this year, Dr. Hamilton discovered that Joseph James also was getting paid by UnitedHealth. The district quickly sued both the consultant and the insurer in Franklin County Common Pleas Court. Documents filed in the suit showed that Joseph James was receiving 1% of premium dollars paid by the district. The consultant received more than $645,000 from UnitedHealth from 1999 to 2004 for bringing in the district’s business, according to the documents. Joseph James, in court filings, says it became eligible for the bonus as part of a “recognition program” by UnitedHealth rewarding its “overall contributions.”

But she doesn’t stop there. In particular in the PBM world, she also notes that several of the big benefits consultants are also working both sides of the street—helping the PBM with pricing while auditing them for their clients. Mercer, Hewitt et al brush off the allegations by saying that the work is from different business units and there’s no conflict of interest. That’s not a bad argument. Until of course little incidents like this crop up:

Joseph Sawicki Jr., the comptroller of Suffolk County on Long Island, N.Y., discovered the ties between consultants and PBMs after the county sought a routine audit of its PBM, Express Scripts Inc., in 2003. The county hired Mercer for the job. Mr. Sawicki says officials didn’t realize at first that Mercer also serves as Express Scripts’s employee-benefits consultant and had other consulting arrangements with the PBM. Mercer says it did disclose the ties.

Mr. Sawicki wasn’t happy with the audit’s results, which initially found that Express Scripts had overbilled the county by more than $1.1 million but later suggested that the overbilling amounted to only $14,000. Mercer charged the county $93,000. Mr. Sawicki withheld half the payment and asked Mercer to return the half it already had received, saying he doesn’t pay for “shoddy” work. A spokeswoman for Mercer, Stephanie Poe, says Mercer made clear its initial estimate was likely to be reduced and it did a good job on the audit although it wasn’t allowed to complete its work. The dispute over the $93,000 is unresolved.

The county didn’t pursue any refunds from Express Scripts in connection with the billing Mercer had audited. It then hired another auditor to review Express Scripts’s billing in subsequent years. That review led to a settlement in which Express Scripts paid the county $865,000. A spokesman for Express Scripts said the company has saved “millions of dollars” for Suffolk County. He declined to comment on the settlement.

The second Martinez article asks even more about an area she’s been following as long as THCB has, the role of PBMs in “adding value” to their clients. Or Not. She highlights the work of a consultant called Pharmaceutical Strategies Group which actually gets openly paid by the PBM on a per member basis for handling its clients contracts. 

Mr. Watson says clients are getting their money’s worth. “If you paid us $500,000 and we saved you $50 million, how do you feel about the $500,000?” he asks. In an emailed statement, the carpenters’ union concurred with Mr. Watson’s analysis, saying it expects to save more than $30 million under its new prescription-drug program and is “extremely satisfied” with it.One blue-chip client of Pharmaceutical Strategies is Exelon Corp., an electric utility in Chicago with 17,000 employees. A 2003 internal document from a consulting firm later purchased by Pharmaceutical Strategies says the firm received revenue of $629,012 from a PBM, Caremark Rx Inc., of Nashville, Tenn., in connection with the Exelon business. The document doesn’t specify a time period. Exelon’s head of health benefits, Carole Schecter, says the company ended the arrangement last year and now pays Pharmaceutical Strategies directly. The company declined to discuss its reason for the change, and Caremark declined to comment.

Last year I tried to get a very savvy major Fortune 100 CEO to tell me what he thought of PBMs, and he told me that they were run by smart people and must be doing something right but couldn’t say quite what. Given that he’s one of the better ones, I’m quite prepared to believe that the carpenters et al are a couple of 2 by 4s short of a full load on this issue. Of course the really smart employers (and there aren’t many of them) have kicked out the PBMs altogether. University of Michigan is the poster child.

But as long as most employers don’t look too closely at their PBMs or their health plans — and the value they bring, then we can expect Martinez to stay very busy!

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