Pharmacists Can Bridge Gaps by Collaborating With Employers Outside Their Professional Circles

Pharmacy Times® interviewed Gloria Sachdev, PharmD, president and CEO of Employers' Forum of Indiana, adjunct clinical associate professor, Department of Pharmacy Practice at Purdue University. She discussed the complexities and challenges surrounding pharmacy benefit managers (PBMs) and what employers face because of the lack of transparency in drug pricing and rebates. Additionally, she emphasized the need for pharmacists to get involved and engage with employers outside of their own professional circles to demonstrate their value, attend non-pharmacy meetings, and share their expertise to help bridge gaps within health care.

Pharmacy Times: Can you introduce yourself?

Gloria Sachdev, PharmD: I'm Gloria Sachdev, I'm president and CEO of the Employers' Forum of Indiana. I'm a pharmacist by background and training, and to my knowledge, I'm the only pharmacist that is an executive for an employer coalition. So, I started off in a more traditional way as a pharmacist, I got my BS in PharmD, did a primary care residency, practiced as a clinical pharmacist in primary care settings for 12 years, had a consulting company for 6 years trying to incorporate pharmacists as providers into primary care physician offices and specialty physician offices, helping payers and other organizations understand the value of incorporating pharmacists into team-based care. And then have been in this role for 9 years.

Pharmacy Times: How do employers evaluate the effectiveness of PBMs' managing drug costs and access?

Sachdev: That's a great question with no great answer. Pharmacy benefit managers (PBMs), there's been a lot of consolidation in the marketplace over the last decade. So, while the intent of PBMs was that they would really help employers be a "plug and play" for employers, so they could an employer could just plug into a PBM, such as CVS Caremark, Express Scripts, OptumRx, and then that PBM would have the pharmacy network, if you will. What has happened though, there's been so much consolidation in the market, the 3 PBMs that I just mentioned have [about] 79% of the marketplace, and there are 3 more, and between the 6 of them, they have [about] 94% of the marketplace. And not only have they horizontally integrated, they have vertically integrated, meaning CVS Health has retail pharmacies and specialty pharmacies...and but they also have insurance companies, and now they partner with drug manufacturers, and now they have provider groups, so they are really fully integrated. And then a lot of shenanigans from the employer's perspective, now that they plug into them, can happen.

First of all...for [employers] to ascertain what the value of services they're getting is, they need to have access to their claims data from the PBMs, meaning they need to have at the individual drug level what the drug was paid to the pharmacy, or what the pharmacy sent in as the cost of the drug, what the PBM paid the pharmacy, what the rebates were that the PBM was able to negotiate from the drug manufacturer, and they have no access, they have no line of sight to any of that. They simply get told by the PBM, "This is how much was charged, we negotiated rebates on your behalf, and we're not going to tell them to you at the drug level, we're going to tell it to you in aggregate only." So, they don't get an itemized receipt, they just get the very end of the receipt saying, you got, [for example,] $5 million in rebates this year. And don't ask any questions, and if you want to change the formulary that we have, that might impact your rebate guarantee. So, employers are hidden, if you will, from really what's happening in the entire supply chain, for the most part, by these big 6 PBMs. I do want to say there are some other PBMs that are out there that are considered to be "next gen" PBMs, they're more transparent, there's over 60 of them and they are competing for market share. They're operating in a more transparent manner, which is what employers want. They are sharing rebate information at the prescription drug level. They will partner with organizations like Mark Cuban's Cost Plus program, which the big 3 will not, and they, I should say, Mark Cuban Cost Plus program won't partner with them because one of his rules is that you have to keep the prices as he's got them posted on his website without additional markups. And they, of course, won't commit to that. And so, that's hard for employers that have these PBMs, their patients, employees, people want the best value for their drugs, but they can't even get it from like Mark Cuban's Cost Plus drugs, they have no way of backing into that.

The second issue is, I would say, fiduciary responsibility. So, employers trust the PBM to do what's in their best interest, but the big ones are all for-profit companies. They have a fiduciary responsibility to their stakeholders, they are not operating in what's in the best interest of employers, employees, and working families. So, I think in the pharmacy world, we understand that pretty well, we understand the restrictions that PBMs are putting on pharmacies, but I don't know if folks know that the PBMs are sitting in the middle, right? They're these middlemen, but they're putting all these restrictions on the employers as well from getting their own data, who can do audits, what type of audits they can do on their own on claims data, no transparency for rebates at this specific drug level, or designing their formulary, or clinical programs that they can put in place...the list goes, goes on and on. So, lots of opportunity for improvement there.

Pharmacy Times: Regarding the pharmacist's role, what expectations might purchasers have?

Sachdev: When we say "purchasers," there's only 4 purchasers: Medicare, Medicaid, employers, and people are purchasers. I'm going to take it from the employer lens, since I represent the Employes' Forum of Indiana...and I would say it applies—generally speaking—the concept to all of the other purchasers as well. Pharmacists...we tend to go to pharmacy meetings—they're wonderful, we see our professional colleagues there, [and] walk away super invigorated and motivated and inspired—however, the people that we really need to be talking to about value is not ourselves. I mean, I've been doing that also for 30 years, but we need to start getting out of our comfort zone and start going to other meetings where employers are at.

So, in most states, they have an employer business coalition such as mine, and the National Alliance of Healthcare Purchasers Coalition...they have a website, and they have a list of 45 other coalitions throughout the country. I would really encourage folks to try to join those meetings, because you will hear about all the issues they're having around primary care access, maternal care access, the cost of medications...pharmacists can close those gaps—maybe not every gap, but they can close most of those gaps. The issue is pharmacists don't know about those gaps from the employer perspective, and employers don't know that pharmacists can fill those gaps. So, it's really on the pharmacist...the employers, again, they get limited information, they know costs are going up 7%, 8%, even more every year. They're trying to get total costs down. Clinical pharmacists have a huge role to play. There's [about] 40 years’ worth of literature on it, again, we discuss them in all these meetings, but we need to start getting the message out to insurance companies, but employers...and I kind of separate those, because before I had this role, I thought the best way was to engage with Anthem, and United Healthcare, and the insurance companies because they make payment, if you will, for providers. But you know who hires Anthem and United? The employers. So, if the employers see value, then they will tell their insurance company, third party administrator, "Why don't you have pharmacists being part of the solution?" And I don't think that's been tapped—to my knowledge—in any great degree.

So, make the value proposition really clear to employers, is the short answer.

Pharmacy Times: How can pharmacists better communicate their value to PBMs, employers, and purchasers when improving health outcomes?

Sachdev: Just like when we talk to patients in the clinical space, retail space, no matter what, you have to talk in their language, if you will, right? You can't explain how to manage diabetes at the level we were trained in, you talk about it in terms that they can understand. So, the first thing is understanding the language that employers speak in, and they speak in terms of the business language, and the business language is return on investment (ROI). So, if employers don't know, pharmacists don't know, or pharmacy organizations don't know, what I mean by ROI [is] for every dollar that's going to be spent on this clinical pharmacist or this retail pharmacy service, what am I going to get back? That is just a must. We really can't move forward just by saying, "Oh, I'll spend more time in educating patients, and this, that, and the other." That's not going to get the job done. They are spending hundreds of millions of dollars on health care, and unless that value crop is really clear in terms of ROI, they're not going to be able to easily pull the trigger, and that can be done because we have all this ROI data for chronic disease management in the literature, but they don't know it, for pharmacists versus usual medical care.

The other place where pharmacists play a big role is in wellness, and there's not a huge ROI in wellness, and they already know that. So, I would break it up into wellness is prevention, and they want a healthy workforce. They know that there are opportunities for their drugs to be managed better, they're not necessarily on the right medications, they're on brand...drugs, when biosimilars are available, they're getting their infusions done at places that are affiliated with a hospital system where the markup on the drug is super high, plus, there's this hospital facility fee for the infusion, and a pharmacist could help them steer their population to an independent infusion clinic where the drug is sent directly to that that infusion clinic.

There are so many opportunities in there to optimize patient outcomes and show return on investment, cost savings. So I would bucket it only in those 2 things: How am I going to improve patient outcomes? If it's a focus on diabetes, hypertension, hyperlipidemia, you need to say, well, we're going to do population health management—they may not be familiar with that term—for your employees. So we're going to see how many patients, they'll know from their claims data, how many employees and their covered lives. Covered lives means employees plus their families, you know, children and spouses. How many of their covered lives have diabetes? Because they can see it from their claims data for the ICD-10s. And then you would come in as a pharmacist and say, let's start bucketing everyone. If you've got, I don't know, 1000 folks with diabetes, how many of them have hemoglobin a1cs above 9, between 7 and 9, and less than 7, they're not going to know these numbers, because they're not. They have no clinical background, and most of them have no chief medical officer or anything like that. So, you can make them red, yellow, green...almost like dials, if you will. You've got a lot of people in red, some in yellow, some in green, And every quarter, every 6 months, you should start seeing more yellow and green and less red. That will make sense to them. So, don't be so clinical [and] meet them where they're at. Think of employers as talking to patients, and how you would explain the value of pharmacists to patients is how you're going to need to explain it to employers, except for having that business piece about ROI.

Pharmacy Times: How can pharmacists work with employers and purchasers to address rising costs without compromising patient care?

Sachdev: We talk a lot about the corporate practice of medicine, but there's the corporate practice of pharmacy also, right? We have way less independent pharmacists, and so pharmacists don't have a lot of flexibility in most practice sites that they're working in, including in academic practice sites, whether the faculty members are partially funded or spending part of their time in a hospital, or in a physician clinic, or in a retail pharmacy. I mean, there are a lot of pressures on them to see a high volume of patients and regarding outcomes. Employers don't know the value that pharmacists can provide, so even though everyone's super busy, it's critical for pharmacists to track their outcomes. How many phone calls, how many medication reconciliations you're doing...those are, I would say, process-oriented, those are important. But the most important are the improved patient clinical outcomes in any capacity...there's so many opportunities here, really, the list is endless, and I strongly believe and know that pharmacists add value to any equation. It's just that we're talking to ourselves and we're not articulating our value as clearly as we should to the right folks, and I...hope I made the case for you...that the employers are the ones to talk to.

Now, some might say, "How would I find an employer in my community? And how would I talk to them?" There are employers in every community, small employers that are getting killed by high health care costs, and I just want to make it clear, when their health care costs go up, it hurts their businesses and it hurts their employees. It hurts their employees and themselves, because they're paying more for premiums every year. So, more and more is coming out of their pocket, and employees' pockets—which means out of the employees' paychecks, because they share that with them—and so, premiums keep going up for a family...the average family [in the] United States, family premium is over $25,000 right now. I mean, employers are paying that, and employees are paying that. Employers are...on average paying two thirds of that, but every year it's going up, and so, they're having to cut back services. Pharmacists can help reduce readmissions, they can help reduce admissions, they can help reduce urgent care visits, emergency room visits. So, you'd have to partner with that employer to...implement this, but then look at your claims data to see if, [for example,] ED visits in this asthmatic population decrease over time. They are really ready for someone to step in and help them, because with all this consolidation that we discussed in the PBM and, actually, in the medical side with insurance companies and PBM, they're all vertically integrated now...patient quality measures are not shared with them, so they are very much interested in looking at data and improving the outcomes. Because a healthy workforce is a productive workforce, that's what they know. A healthy workforce is a productive workforce, so, however you can keep their population healthy and present, they're not taking off more time for sick days...that's the language that they speak in and that they'll understand.

Pharmacy Times: Any final/closing thoughts?

Sachdev: You know, I am a pharmacist, I can see all the opportunities that are widely available. I did my residency 30 years ago in primary care, and we were talking about this then, and so, I really want to encourage folks to get out there and commit to yourself as an action item, to go to at least 1 non-pharmacist meeting, and also, another commitment would be another ask, I would say is get on a panel. Start telling the value of pharmacists' services at those meetings, maybe you attend 1 this year, and then next year, you go ahead and apply to present at their national conference. We need to start getting the word out. And also, publishing the information in those journals that they read. There's a big policy journal called Health Affairs, a lot of opportunity around pharmacist provider status can be addressed by policy changes. So, you know, it seems worthwhile to start publishing in what policymakers read, which, again, is Health Affairs, and other journals as well.

Last little piece of advice I could give to folks as they consider next steps, is that there are so many gaps that are in health care, and it will be easy for pharmacists to see what those gaps are. Right now, it's like health care is a big puzzle, if you will, with lots of missing pieces, and I truly believe that pharmacists...are that missing piece for most of the puzzle, or they hold the missing pieces, if you will, for most of the puzzle, and can just start closing them up. We just need pharmacists to step back from the lens, which is the pharmacy "slice," and look at the whole health care pie.