The Truth about Prescription Costs. Prescription drug benefit costs has increased 1150% since 1987 This is the ABQ Business Podcast with your host Jason Rigby. Each week we interview leading business leaders to inspire the vision and the spirit that is in every entrepreneur. We discuss strengths, weakness, strategies, systems and the problems we can all solve together to fulfill a shared vision of a new future for Small Business. About Well Life ABQ: Well Life ABQ is your simple way to Solve your Healthcare Costs! This is from their website that you can go to here Are the costs of employee healthcare making you sick? We can help you fight back! Schedule a free business review. When we understand your healthcare needs, we can develop the best plan customized to your needs. For $75 per month plus tax, companies cover 80-90% of their employee's health needs.

PROBLEM

Prescription drug benefit costs has increased 1150% since 1987
1. Since employers are the main providers of health insurance benefits, they are bearing the brunt of these costs. Is there any other line item in a company budget, that has increased this much?
2. Patient costs have also increased 182% since 1987
3. Both employees and employers bear the burden of these huge cost increases. (CEOs guide)
4. All companies that provide insurance benefits, run a health care business. It is likely the 2nd biggest operating cost after payroll.
5. And if you don't provide benefits, you have a tougher time recruiting top talent.

As with all complex problems, there is not a single cause.

COST DRIVERS

There are two main drivers of increasing prescription drug prices.

Pharmaceutical companies (most people know this)
1. According to RealClearHealth.com "PBMS fail to pass $120billion back to consumers and retain another $30billion in additional out of pocket costs.
Pharmacy Benefit Managers <--- this is the real dragon

PHARMACEUTICAL COMPANIES

Brand name drug prices are possibly justified
1. Research and development has a wide range, but is around $985million
2. Average cost of FDA approval for a new drug is $19million alone.

PBMS

History
1. Originally processed prescription claims for a small administrative fee.
2. Great system at first…then these middlemen began to exert more and more control. They developed formularies and controlled which drugs were "allowed" to be prescribed
3. Began to concentrate their power. Larger PBMs gobbled up smaller ones. Some even merged with actual insurance companies or drugstore chains ie CVS Caremark. CVS Health just acquired Aetna. And Express Scripts was acquired by Cigna. OptumRx is affiliated with United Healthcare…and Im sure many of has noticed the DaVita clinics signs now say Optum. So now they are infiltrating the frontlines of healthcare. This is a disaster. It reduces competition and limits choice. Three major PBMs control 76% of the prescription drug benefit transactions in the US - ONLY THREE
4. The largest PBM had a net increase of 70% in net profit in two years!
1. Rebates. "kickbacks" Legal extortion - They negotiate with the pharma company to place their drug on a formulary, they demand a rebate. Pharma has to PAY TO PLAY or their drug doesn't get placed on the formular. PBMs even take this farther and say not only will we not carry your drug, we won't place ANY of your drugs on the formulary…even your generics.
2. 1. These PBMs pocket most and sometimes all of the rebate. EMPLOYERS BEAR THE BRUNT OF THIS COSTLY GAME
  2. 25% of the drug cost is attributable to rebates - this means we are paying 25% more than we should
  3. I see this 25% pretty regularly in practice. For about 80% of the prescriptions we write, we could save a company about 25%. More about this in solutions.
  4. As a prescriber, I have had MANY scenarios where the more expensive drug is the one on the formulary and the cheaper option was not "covered". I always thought "that doesn't make sense". Now that I have seen the light, I have no doubt that a rebate was the reason.
3. Fees - They of course also collect fees for their so-called "services
4. Spread - The PBM will reimburse the pharmacy a lower price and charge the plan sponsor (YOUR COMPANY a higher price). The company that is footing the bill, has no idea.
5. There's more - specialty drugs are filled by a specialty pharmacy that is owned by the PBM and the consumer is forced to only use this pharmacy. So the PBM STILL wins. The consumer and the company lose.
HOW

SOLUTIONS

Awareness
Employers must demand price transparency and a flat fee systems that eliminates hidden and conflicting/perverse incentives
Link up with a Direct Primary Care provider like Well Life ABQ. In many circumstances we can dispense at a lower cost. And when we can't, we are partnered with a pharmacy that can still direct bill and skip the insurance claim. This allows us to choose the most appropriate and economical option.

STORIES
1. Several years ago, one new member signed up after his cardiologist referred him to us. He had been on the generic Viagra, which is sildenafil 25mg. The usual effective dose is 25mg to 50mg. At the time, he was paying about $150 per month from a Canadian pharmacy. This member is a savvy consumer. I became of aware of this when he asked me to send a prescription to the pharmacy. I informed him that I could dispense 20mg tabs and it costs about $7! Right off the bat, I saved him MORE THAN the cost of his membership for him and his wife. Since then the 25mg dose has come down in price and he can get it for about $13 at the pharmacy --- WITHOUT INSURANCE
2. Earlier this year, we had another member of a large company forget to update his insurance information when we drew labs. We ran the labs through insurance it was denied because we had old information. He got a bill for $700. Of course, he called us. Normally, we would just update the lab with the correct insurance information. But in his case, his new insurance was Presbyterian which means the lab we used was out of network. That would have likely driven UP the price. Instead we contacted the lab and swapped him to client bill…which is our contracted prices. He paid $54. He was pretty happy.
3. This same patient spends a significant amount of time out of the country. He has some daily medications that were a real hassle to get enough filled to cover his trips. The medication was generic, so we ordered him a six month supply and dispensed directly. He paid $56 for six months and skipped the insurance hassles. Not to mention, his out of pocket costs were about the same!

OBJECTIONS

I want to address two main initial objections related to Direct Primary Care

"I can't limit my employee's choice of PCP to only one clinic" and I absolutely agree that you can't.
1. First you already limit their choice due to insurance networks. Then every time you change insurance providers, you force them to start over. It's a nightmare.
2. Second, the DPC model isn't about forcing, it is about incentives. When employees hear $0 copay, 30-60minute appointment times, no waiting and texting/virtual options, they get pretty interested. When their out of pocket costs for labs and medications go down, they get darn right giddy. When they need the free and included 24/7 telemedicine option, they really love the program. You aren't forcing anything.
1. Well Life ABQ has been doing this since 2017. It works and it works well.
2. These costs pull back the curtain on the costs of healthcare and it is shocking.
"The cost is only $75 per employee and $30 per additional household member to cover about 80-90% of healthcare needs. How can it be that cheap? Or sounds too good to be true."

RESOURCES

Hacking Employee Healthcare - just email hello@welllifeabq.com for access
The CEOs Guide to Restoring the American Dream - Dave Chase
Relocalizing Health. The Future of Health Care is Local, Open and Independent - Dave Chase
The Price We Pay - Marty Makary

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