Hot Topics with Meritain Health: Pharmacy Bundling

In our latest In the Booth podcast, we are pleased to have Bridgette Cassety from broker engagement and Catherine Ratcliffe, Principal, Vice President of Operations at OneDigital, Tampa discussing bundling pharmacy with medical.  

Transcript

Welcome to another edition of in the booth. My name is Bridgette Cassety and I'm head of broker engagement here at Meritain health. And I'm thrilled today to have a guest speaker with us. That's joined us before, but not for a long time. And that's Catherine Ratcliffe from one digital. And it's always great to be with Catherine because she's in the, in the field on a regular basis and has a lot of interaction with customers and is tied into the industry in a way that offers a lot of great insight. And Catherine, I thought the topic that would be great for us to discuss today and to get your perspective on is something that I'm hearing more and more about. And it's really around this idea of, gosh, is it better to have the pharmacy and medical package together? Is it better to have it carved out?

So sort of this idea of bundling medical and pharmacy or unbundling it, or some people call it carving in and carving out. And so I know that you have a lot of passion around this particular topic, and I thought it might be great if you could maybe start us off with maybe giving your perspective about why you think some people think it's better to unbundle or carve it out and, you know, sort of where maybe that idea came from. So can you maybe jump in and give us some thoughts about the thinking that's maybe gone around to bundle or to unbundle pharmacy benefits?

Sure. Thanks so much, Bridgette. And it's, it's great to be back with you today. I think, you know, the, the biggest thing with pharmacy is really understanding that it's complex, right? And so anytime you're diving into something that's complex, it provides opportunity. For folks who, you know, are, are looking to create an edge or to, to pull it a string and, and to, you know, just unravel a, a program that we have, and it's easy to throw out horror stories out there about big medical costs. And of course, everybody wants to talk about share price and where that's going and the profitability of these programs for the big the big three, right? And I think that that's, that's a fair point to start the, the educational process. And certainly from, from our practice, we have always looked at the value of unbundling versus bundling.

And I think if, if somebody's looking for an opportunity to really familiarize themselves with it, you should start there. You should look at what are we talking about? Because a lot of the terms that you'll hear, or a lot of the programs that you'll hear is re around the formulary regarding the contract, talking about rebates, talking about limited distribution networks, all of these things. And for a lot of folks, especially if you've been more in a fully insured environment or an environment where you just don't have a lot of data, it's hard to understand what folks are talking about. And so I think that's where some of these programs start to stem in, in creating a little bit of doubt about what's going on, how do we know where these drugs are, you know, coming from, how do we know that they're appropriate? And we see the cost trends going up, and I think everybody's looking for a solution to, to help control costs. And so I think that's, that's the premise of, you know, it it's complicated. We don't really understand it. And so we're looking for an opportunity to get some education and to save costs. I think that's where it starts.

And I think the word that you use there, Catherine, that that is spot on is complexity, right. Is so the complexity of it is, is something that drives people to say, oh my goodness. Maybe, maybe because it's so complex would be better served doing this instead of that. And I'm just curious, you know, when you think about complexity and you think about, like you said, education, and you talked about things like formularies and rebates, you know, why in your mind with all of that complexity and all of those things that you mentioned, you know, why do you think in your experience that it makes sense to, to bundle it together or to integrate pharmacy and medical? Like what, what's your, what's your take on that?

So my take on it is because fundamentally at the end of the day, we are in the people business. And when you unbundle solutions too much, which pharmacy is, is so directly tied at the hip to medical, you unbundle it, you start to have gaps, you start to have breakdowns in communication and it starts to affect the member. And I think on paper, you can put a lot of things together and you can show some crazy numbers. That'll say you'll save X and you'll save Y. And I think the first thing that we lose sight of is what does that do to the member experience? And, you know, with pharmacy, there's really no guarantee because you're looking at a retrospective group of drugs and you're projecting forward what the drug pattern will be for next year. And, and that's very complicated to do because you've got all kinds of things happening from a member level, from a, you know, turnover perspective, new drugs, coming to market, all those kinds of things.

So it's easy to kind of play the shell game of moving money around. But when you look at these things and you look at what happens to that member, and you think about the barriers of care that, that come up and how this can negatively affect your plan in a much bigger way. That's where I start to get really, really passionate about it. And, and don't get me wrong. I, I, I think you do need to go through and vet all these options, but you need to keep the member forefront. So when you start looking at things like forcing folks to you know, file for a patient assistance program, well, what if your member doesn't qualify for a patient assistance program? What if your member doesn't understand it? What if they don't go through with it? What if they're embarrassed by it? What happens to that member who needs that medication?

You know, what is that medical outcome that is affected? You look at the, you know, the thought process of let's bring medications in internationally. And you think about, again, does the member go through with it? Do they understand it? Do they have concerns? And those concerns can be on a bunch of different issues, right? So we've all heard supply chain issues. I sort of feel like if I hear supply chain issues again, I might lose it, but I've stood there in a pharmacy line too, waiting 35 minutes because there's only one tech back there. So what happens when, you know, there's not enough drivers for ups or FedEx or the postal service or whatever we're doing with these medications beyond just the tech of wherever this is coming from, what happens to that member when there's that breakdown? So I think those are some of the fundamental issues and then the ability for it to be a one stop solution, right?

You've got the ability to ask a question about the medical. If a provider is going to J code a medication, infuse it, as opposed to prescribing it, you're able to talk to one, one point of contact, one team that can kind of go back and forth with, what does that look like? How do we manage that versus dealing with all different folks and, and understanding how does this affect my outta pocket, or where am I at with my deductible? And, and what will that mean if I've, you know, filled this here or filled that there those questions can't be answered in that moment by that provider. It affects us on the consultant side because the data is, is not the same. It's not real time in the same way as it is when it is bundled. And we can get those, those notes and, and the prescription data. It's much more credible when it's, when it's bundled,

You know, Catherine, when you were talking to, yeah, I wrote down a couple things that I, I hadn't thought about before, but this member centricity idea and member centricity is very important to us here at Meritain and creating that right member experience. And, and one thing that you talked about that I think is important when we think about, you know, bundling and unbundling with, with pharmacy is, is how that does impact the member, right? So in our world and in our industry, you know, we know it, it seems easy, but for the member, that's a whole nother challenge. And I think that's an important point to think about when making those decisions. Like you say, you wanna look at everything, you wanna take everything into consideration, but making sure that the members at the center of it, which is what, you know, at the end of the day, who we're trying to serve is a really important point along with, I think you mentioned the data integration as well.

And so having that, that picture combined. So as a consultant, you can sort of decide the right decisions to make together with your customers is also a good point. So I, I think that I think those are two excellent ideas when we talk about the advantages of bundling versus not. And one thing I'm curious, just to ask you about is, you know, what's your experience with Meritain when you when you put that together, what experience do you find when we talk about that member experience, or we talk about data integration, what's been your experience with us when you've been able to do that.

So I will say we've been able to provide a much better member experience and, you know, let's be honest, nobody accesses a healthcare program because they're coming from a place of peace, love, and joy, right? There's something that's gone wrong. Nobody is excited when they're being prescribed diabetes, medication or oncology medication. So it's never a hundred percent positive, you know, birthday cake type of type of relationship. They're, they're upset usually that they're in this situation. And especially if they're calling in, there's something that, that has gone a little bit left, right. It didn't, they're not sure about the medication or it didn't get approved right away. They've, they've got questions. And so having that, that single point of contact is, is really, really important, right? Because when you think about chronic disease management, you've got a couple of opportunities here that are just fleeting, right?

And members don't ask a lot of questions. So your opportunities to really engage with them are so, so few. And, and there's a general mistrust out there, right? About anything and everything. And there's a lack of, of patience and tolerance. And, and so people get frustrated quickly, hang up times are, you know, really, really short. So we, we need to make the most of this opportunity and what we've seen with Meritain when we get into this chronic disease management is we're able to pull in from both sides. So a lot of times pharmacy is your first line of defense of knowing, Hey, I've got a bunch of hypertensive here, right? And we've got 15 people that are newly diagnosed. And so the conversations that can start to happen from a consultant perspective, from a Meritain perspective, where I can reach out to the team and say, Hey, we need to get some education around this, right?

So you think about something as basic as cold and flu season. So somebody is prescribed hypertensive medications. I can get a communication out about which cold and flu medications you should be taking that are over the counter. You don't have that capability when everything is carved out. And those are important things. And we don't necessarily know when something starts to go more wrong with that individual. You know, what is the root cause of this? And sometimes it's just those, those breakdowns of understanding, Hey, we're not able to get this education out in the same way. So I think, I think that has really been a benefit. And we see that benefit come through on a net claim, cost savings. We see that benefit come through on a stop loss savings. We find that stop loss carriers give us better pricing when it is bundled, because there is a validity to what is going on in the communication flow.

And Catherine, when I think about this conversation, and we appreciate you taking the time to talk with us today, that the things that I wrote down that I really took away, that our listeners will wanna contemplate, right. Is they contemplate how to manage total cost of care with their customers is to simplify the complexity. Right? And I think you spoke real, very strongly around how do you simplify what seems very complex? The second thing I really heard you talk about is around, you know, member centricity, right? Keep the member experience at the forefront of, of what you do, cuz it's gonna be the right answer in the long run. And then third, I think you talked around the you know, pharmacy is being that first line of defense and how to maximize that interaction because by maximizing that interaction that you described, that's your opportunity to reduce that total cost of care, whether it comes in the form of stop loss or identifying future claims earlier and often, and then most importantly, what creates that value, the value proposition that goes along with it. So I, I can't thank you enough for spending some time with us today. We appreciate you joining us for this, for this topic and for your time for our listeners. Thank you for joining us for another edition of, in the booth. And we look forward to you joining us again in the future.