Episode 133 of Health in 2 Point 00 is brought to you by the letter P — that’s P for PBMs, of course. In this episode, Jess and I talk about Genome Medical extending their series B and getting another $14 million on top of the $23 million they already raised for their remote genetic counseling services, the FCC adding another $198 million to their rural health program, bringing the funding to a whopping total of $802 million, Anthem’s PBM IngenioRx acquiring pharmacy startup Zipdrug, and Capital Rx, a startup PBM, announced a deal with Walmart. —Matthew Holt
Jessica DaMassa asks me about PBMs, Amazon Prime for Medicaid, Patents and more–all in 2 minutes — Oh, and if you want to sponsor this and reach a bunch of people here & on Linkedin, let us know! — Matthew Holt
Yesterday Medco offered itself up to smaller competitor Express Scripts, creating an entity with more than 50% of the PBM market. PBMs originated as specialized claims processors that supposedly were able to reduce drug costs. But in the 1990s drug costs soared. Somehow PBMs didn’t lose employer clients, further confirming that employers are dumb about how they buy health care. Most employers didn’t understand that PBMs made much of their profits on rebates they were paid by drug companies to keep particular drugs on formulary. Almost none of that money went back to the employer. After that game ended, PBMs replaced almost all those profits by making huge margins on generics until Walmart showed that it could make a profit by charging only $4 a fill. Now it looks like extracting a bigger piece of the pie from pharmacies and charging more to employers may be the only game left for PBMs. And that’s probably the driver behind the merger.
This post came as a comment by SR to Dr. Kibbe’s piece on electronic medical records. It’s a great consumer perspective and worth reprinting in full. — THCB Staff
Health Care consumers and patients have a wide range of interests,
needs and values that vary across our lifespans and circumstances and
hopefully there will be many different tools, products and services
provided to both providers and users of health care.
For example, my 70-year-old retired father is the head of a neighborhood
wellness program with over 3,000 people and maintained a family blog
during my mom’s cancer treatment but doesn’t own a cell phone and would
rarely change physicians despite differences in quality. I am rarely
ill, and yet expect SMS alerts if a lab test is done and want my
clinical records to link with my Nike tracker in my shoe as well as
apps on my Iphone.
I envision a system similar to the financial sector (bad example
right now perhaps) where you are able to move your information from
clinician to clinician (online bank statements = EMR) supplement that
with information gathered via other ancillary providers (investment
account at E-trade) take all of that information into my PHR (without
entering most of the data so it is similar to downloading into
Quicken) adding in some personal data (from my nike+ sensor and mobile
apps that track my diet and yoga classes) and generate reports (like
turbo tax) to share with some of my providers
George Van Antwerp is a Vice President at Silverlink Communications where he focuses on developing healthcare communication solutions across the industry with a focus on the pharmacy space. He and I have been conversing back and forth by email for a couple of years (since before he joined Silverlink who are—FD—sponsors of THCB & Health 2.0). He blogs regularly on both topics at Patient Centric Healthcare and today is his first post on THCB
I think an onion is the right analogy for healthcare for three reasons: (1) it can make you cry; (2) every time you pull off a layer you learn more; and (3) what you see from the outside is a lot different than what you see from the inside.
The Group Guy: new blog from a benefits broker who is not too impressed with PBMs or the average knowledge level of his customers about generics.
In Brief non HIMSS news (as I’m still having a little insomnia from jet-lag, and I took it much easier last night on Bourbon street)….
Most THCB readers know that I’m just a wee bit cynical about the “value” provided by PBMs. Much of the data for that view comes from a Creighton University professor called Robert Garis. Well, he’s back:
“We found that brand-name drugs were slightly less expensive when purchased by mail, but generic drugs were more expensive by mail. When we combine the prices for brand-name and generic prescriptions, any differences virtually disappear,’ said Robert I. Garis, M.B.A., Ph.D., associate professor at the Creighton University School of Pharmacy and Health Professions.
And don’t forget that since 2002 (when the data for this report is from) PBMs have moved towards more generics as the rebates have become less important parts of their business and they’re making way more profits on generics. Medco for example increased total profits in 2005 after having its profits from rebates fall dramatically as it passed them back to customers. Margins on generics more than made up the difference. Now Garis is clearly on the side of the retail pharmacies, but given what we know about the PBM business, especially the stories from University of Michigan, I’m inclined to believe him when he says this:
Given a continued increase in generic-drug use by both mail and retail pharmacies and the practice of high markups on generics by PBM-owned mail outlets, he added, retail pharmacies ultimately may offer the better value. He noted that recent reports show generic drugs account for more than 55 percent of all prescriptions dispensed through both mail and retail channels.“Employers need to ask PBMs more questions about their markups on generics, just as they would when purchasing ink, paper or other supplies,” Garis said. “The truth is that PBMs are racking up record profits through an increased use of generic drugs and an increased use of PBM-owned, mail-order facilities.”
I have purloined this and reprinted almost in full from AISHealth.com’s Government News of the Week.
Caremark Rx, Inc. did not breach its fiduciary duties when negotiating drug prices and managing the formulary for a multi-employer health fund because it was not acting as a fiduciary, a federal appeals court ruled last month. The pharmacy benefit management (PBM) industry hailed the opinion, saying it sets a precedent for other lawsuits and state initiatives that claim PBMs have fiduciary responsibilities. In a Jan. 19 ruling (No. 05-3476), the U.S. Court of Appeals for the Seventh Circuit upheld a lower court ruling that found Caremark was not an Employee Retirement Income Securities Act (ERISA) fiduciary for the Chicago District Council of Carpenters Welfare Fund (Carpenters). The fund had sued Caremark, claiming it breached fiduciary duties under three multiyear contracts to provide Rx benefits to union members.The parties disagree about the nature of Caremark’s obligations under the contracts, according to the ruling. Carpenters portrays Caremark as its fiduciary, responsible for, among other things, negotiating prices with retail pharmacies and drug manufacturers on behalf of Carpenters. Caremark claims only to have agreed to provide the stated benefits at prices determined via "arm’s-length negotiations between Caremark and Carpenters," the ruling says.In fact, each contract provided that Caremark "was not a fiduciary as that term is defined by ERISA, and that Carpenters possessed the sole authority to control and administer the plan," according to the ruling. "Nonetheless, Carpenters alleges that, under the three contracts, Caremark has discretionary authority over the management and administration of Carpenters’ drug benefit plan and also exercises discretion and control over Carpenters’ assets," according to the appeals court. The fund contends this "discretionary authority" gives rise to fiduciary duties under ERISA, the ruling adds.Specifically, the union alleges Caremark has discretion (and therefore fiduciary duties) in four specific areas: (1) negotiations with drug retailers over drug prices; (2) negotiations with drug manufacturers over rebates and other discounts; (3) the management of the formulary program; and (4) the management of the drug switching program. Among other things, Carpenters contends that Caremark breached its fiduciary duties by charging the fund a higher price than Caremark negotiated with retail pharmacies, and by choosing drugs for the formulary that were more expensive so that Caremark could pocket extra rebates it obtained from drug makers, according to the ruling. The district court, however, found nothing in the contracts that required Caremark to pass through cost savings to Carpenters, according to the appeals court.Stephanie Kanwit, special counsel at PBM trade group Pharmaceutical Care Management Association (PCMA), described the appeals court decision as an "important ruling" that will set a precedent for other cases. <SNIP>. At least 20 states rejected PBM fiduciary and/or disclosure bills in the first half of last year, according to PCMA. The latest appeals court ruling makes clear from one of the most economically sophisticated courts in the country that these are matters of contracts, Kanwit contends. "It doesn’t do any good and, in fact, harms the interest of customers like this union to start claiming breach of fiduciary duty. That’s a red herring."Kanwit says PBM customers generally don’t want their PBMs to be fiduciaries. "Customers want the PBM to do what the Carpenters did here, enter into a contract," she says. "You do not want them to be in charge of what this court calls ‘discretion.’ There is no discretion about it. In a contract, here it is, here is the price. It’s spelled out."Others say the ruling on the federal ERISA law will have a limited effect on state efforts to impose PBM fiduciary duties. Some states have adopted or are considering legislation that says fiduciary duties exist between a PBM and any company or health plan that hires a PBM to negotiate rebates and other discounts from a drug company, says Sharon Treat, executive director of the National Legislative Association on Prescription Drug Prices, which has worked with states to develop PBM fiduciary laws."That legislation really isn’t affected by a decision that interprets ERISA, because these laws aren’t intended to interpret ERISA," she says. The legislation, rather, defines the relationship between contracting parties as a "fiduciary relationship under state law," Treat says, adding that states have had the right to regulate contracts since time immemorial. "How courts rule on ERISA is, in some cases, beside the point," she adds.
This may sound like complex legal stuff. And it is. I don’t know whether its reasonable or useful to call a PBM a fiduciary with the obligations that go along with it. But one hopes that, whether or not it is legally obligated to serve its clients’ interests, at least the PBM sincerely believes that its interests and those of its clients are the same. But I’ll leave you to be the judge of whether it really does.
Libratto is a blog written by a senior exec from a PBM, Bob Neaser at Express Scripts. I haven’t exactly been polite about PBMs or more accurately about their customers’ willingness to explore their business models over the years. I’ll be interested in watching this blog and seeing what Bob thinks. He’s been posting a little the last two months and I want to encourage him to make the arguments. He started with a rants about why employees should demand less waste in their health care benefits and I (and probably Eric Novack) would agree. But of course one man’s waste…
Still I’m looking forward to more from Bob, especially with the CVS/Caremark deal apparently changing the PBM model.
You should also look at Adam Fein’s blog Drug Channels. He has lots of interesting things to say about PBMs, pharmacy chains et al—even if he’s a little less cynical than I am!
CVS has noticed that big PBMs are now making all their money on mail-order pharmacy, particularly from dumb clients who can’t be bothered to cross check what the PBM is charging for mail-oder generics with the price they can get at (say) Drugstore.com. So the chain stores “logical” next step is to buy the second biggest mail order pharmacy — Caremark —and get the attached smoke screening benefits management organization thrown in with the deal. The NY Times (surprise surprise) is focused on the wrong end of the deal, thinking that Caremark is a “middleman”. But the key is that all the profitability of PBMs comes from their mail order pharmacies, now that the rebating game is drying up.
And that profit comes from selling generics with huge mark-ups. So when Wal-mart puts CVS’ margins on their retail store cash business under threat, it’s not a stupid defensive move to acquire a big mail order house. On the other hand they’d better hope for better luck than the last time (part of) Caremark — the then PCS— was bought by a drug store. Rite-Aid bought PCS in 1998 for $1.5 billion, and sold it for $1 billion to Advance Paradigm in 2000.
But the Medpartners/Caremark guys, ten years after their disastrous foray into physician management, aren’t dumb. The generic mark-ups are about the last place the PBMs have to run to maintain their incredibly profitable business. And that party will end too, when the employers wake up.
Given what the stock has done since they changed their focus to the small PBM they found that they owned by accident in the late 1990s, it looks to me that they’re sneaking out at the top.
UPDATE: Apparently the top wasnt quite as high as some punters this morning thought it was. Caremark opened at 54 spent most of the day at 51 and then fell when the final offer was revealed at 48 and change.