The Cold Hard Facts

According to BenefitsPRO, 93% of employers considered switching pharmacy benefit providers in the last year due to the rising cost of prescriptions and complicated PBM contracts; smaller employers are more likely to re-evaluate their pharmacy benefit plans than very large employers; and future company health plan designs greatly concern majority of employers (BenefitsPRO, 2023). 

Prescription spend continues to exponentially rise in the United States. Unfortunately, there is no end in sight to this problem significantly impacting company bottom lines and many employers are searching for new health benefits that will positively impact the trajectory of their company in the coming year(s).

Analyzing the Tool Belt

Healthcare is episodic, meaning there is a start and end date. Most medications, however, do not have an end date making them a reoccurring expense. Insurance is designed to cover the risk of unknown loss making this the wrong tool for this problem. Insurance makes services, including medications more expensive. Almost every medication is cheaper without insurance if you know where to look. That is the key!

Employers are Craving Change

The first step in making a change is recognizing that the tool employers have been using was never meant to take care of this problem. The next step is to acknowledge insurance is the wrong tool and seek out a better one. Just like any other expected expenses that companies plan for, procurement, not insurance, is critical for having confidence that those expenses are managed properly. 

Many employers crave the change that prescription procurement can provide. However, they may be unaware of the treasure. Prescription procurement is a high-value strategy utilized to effectively acquire a medication that a person needs. It allows employers to give their employees a better experience, not just have the option to access mediocre discounts on high-cost medications at the local pharmacy and deal with the bureaucracy of insurance.

A Financing Vehicle? More Like a Roadblock.

A self-funded employer acts like a traditional insurance company, collecting premiums from enrollees and taking on the responsibility of paying employees’ and dependents’ medical claims. It makes sense that they would hire PBMs and expect them to make sure that all expenses are essential and appropriate. The higher the cost of the drug, the more questions will be asked. To get answers to these questions, it puts patients in the middle. This often creates obstacles to care, causing frustrations with prior authorization protocols that, while necessary, are suffocating to a member just trying to take the medication their doctor prescribed.

It becomes an aggravating exercise with members and providers trying to prove that the medication they are trying to fill is needed. It frequently involves letters from the provider explaining why the member requires a specific medication while trying to steer the member to an alternative therapy, which is usually based on rebates to the PBM and not clinical outcomes.

It is assumed that if a patient does not use health insurance, it is impossible to afford the outrageous cost of the medications, but the reality is that insurance is the element patients cannot afford to use. This is where the illusive value of insurance comes into play.

A Fair Cash Price

No doubt, PBMs are incredibly smart and good at making money, so they put prohibitions on your local community pharmacies from offering patients fair cash prices. If there was value in having health insurance, then not having health insurance should make things harder. However, not having insurance has continued to prove that it actually makes things cheaper and simpler. From personal experience, I have learned when you stop asking for permission from insurance companies to attain what you need, the entire process becomes easier.

To further illustrate the point, cash only pharmacies, like Mark Cuban’s pharmacy, do not accept insurance and the prices are better than local retail pharmacies any day of the week. Why? Because not participating in insurance allows them to offer patients a fair cash price. The second a pharmacy benefit network enters the picture; a fair cash price is prohibited. This is what entangles most companies today.

Adjusting the Tool Belt

By implementing the right tool, (aka prescription procurement), a more predictable healthcare budgeting process is created. It allows employers to take control over what is being offered and how it is being offered.

Employers and employees alike despise the oversight and burden that using insurance creates, but they are not sure that they have any other choice. They do and SHARx is here to help. Trying to negotiate a better discount and rebate has never and will never solve this dilemma because that relies on the system that created the problem to also have the solution.  To truly solve this issue, you have to opt out of the system and only then can the answers be found.

SHARx exists to serve members that have been lost in this journey – the employer and the employee. Our passion is to give the ‘lost’ a voice and seat at the table. Unfortunately, other parties involved in our healthcare system profit on the problem, but that is not what we do or why we do it.

The SHARx Solution

SHARx navigates this messy healthcare issue with knowledge and expertise to lead our clients in a direction that benefits all parties involved. There is great value in the experience SHARx brings to the table when routing these debilitating problems that individual employers might greatly struggle to pilot on their own. SHARx is made up of trained individuals who have done the research and continue to do so. We know what to do and where to go for the members that need our help.

We believe people deserve to get what they need. With SHARx, employers can control one of the bigger variables in the game which are the medications that insurance was never meant to control anyway.

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Are You Sure About Insurance for Medications?

Insurance was meant to cover the risk of unknown loss. Many Human Resource managers have implemented pharmacy insurance into their companies’ benefits because it has been engrained in them that insurance is what you do for your employees. However, in doing so, they are often creating a major roadblock to their company’s success. Many employers are finding insurance has made covering high-cost medications for their employees unstainable, causing businesses to struggle to stay afloat. This makes sense when you realize that medications are a very known and predictable expense.

The insurance administration is outsourced to pharmacy benefit managers “PBMs” causing employees to jump through hoops and fighting just to get medications crucial to a person’s survival, which sadly has become the ‘norm’. These hoops include things like the prior authorization process and dealing with the PBM owned pharmacy. Many employers have found that insurance essentially suffocates the process, causing frustration for them and their employees. Perhaps there is a better solution than using insurance for predictable expenses.

Navigating the Machine

No one enjoys navigating a bunch of inconvenient steps. PBMs claim to provide great value but time and time again, they have demonstrated through complicated processes that they neglect the care for the patients and their struggle to secure the medications they need.

Unless you have experienced the process, you may be unaware of the navigation that this takes. Many members are under the impression that there is no other way to attain their medications. As a society, we have been conditioned to believe the big machine known as insurance is the only way. Employers and employees are waving their white flags begging to be disrupted from their current situations. Fortunately, there is another way for those employers that decide to opt out of a system that was never built for them or their employees to find a better path.

We have been told that insurance is necessary to afford to seek care and manage disease. In my experience, using insurance creates so many headaches and barriers to accessing needed medications. Employers are at a crossroads of needing to find a way to offer a health plan that is sustainable and taking care of their most valued asset, their employees. But what can they do about it? By using the right tool for the problem, I have learned attaining high-cost medications becomes affordable and simple.

Breaking the Barrier

Suffering in silence is real. An absence of people complaining does not mean that the current process is working. My philosophy is that if you value your people, then you should provide them with something better.

SHARx understands that there is an issue. With positive disruption, employers have the option to stop using insurance for those expected expenses as it has proven to be an unsustainable solution. By partnering with SHARx, members gain access to prescriptions they need in a much simpler way, bypassing all the headaches that insurance causes. When selecting this avenue, insurance is no longer a barrier to getting medications.

There is always the option to stop covering drugs and never hire SHARx to help but is that any way for employers to show that they actually care about their people?

For Eric Hasty, CFO at Buchheit and longtime SHARx client, caring for his employees is top priority. He explains, “It would go contrary to our values as a company to not have an option for these folks. If we care about our team members, we put resources behind a health plan and we want it to work for them. This is a way that allows us to really benefit the team member even more and save those astronomical costs”. Hasty chose to opt out of the insanity and hire SHARx because he valued his company’s people. He took a stand, and his business and employees have benefitted tremendously.

A Biased Mentality

As a former broker, I will admit that we created the insurance bias and promoted the use of insurance. This bias causes employers to feel as though they need to have it. However, there comes a point in time when many employers find that they cannot sustain the rising cost of health care. They recognize that their original choice is not serving their business any longer. They have done the best they can with the plan they were given with the information they had.

Changing the Narrative

Expectations of our current systems have gotten us to where we are today, so it is important to define what is possible. It is possible to change the mindset that many of us have had about insurance up until now. I know because I lived in this world and played the game too. I realized that I was just as complacent as everyone else until I had a need for a high-cost medication for my children and had to face the music. I was unaware of the frustrations and limitations that were in place until I was forced to be a hyper user of health care.  I recognized that the answer to my problem as the patient was not more insurance but rather less. It was a realization that changed the way I viewed the entire process.

Moving forward, we can change the way in which we think about solving some of these issues. What if you or your clients took a stand? What if you decided to join in with your peers in choosing to make a decision to do something different?

Prepping for the Future

Every year, employers must make tough decisions. Many choose to eat the cost of high-cost medications for their employees but at some point, everyone hits the end of the line. Unfortunately, the smaller you are the faster you hit that wall. Our goal at SHARx is to get rid of the headaches altogether.

For Brian Hall, CFO at McCray Lumber and SHARx client, the end of the line was quickly approaching, and he knew had to make a valuable change for his company. Hall encourages HR managers contemplating to take the leap as he states, “I always tell them that you never know when something is going to change. You need this, your company needs this. The only push back and the folks that don’t engage immediately are ones that don’t believe they have a problem, but they could have a problem next week. You never know when you are hiring people what kind of issues they have when they walk through the door or what you are getting and how they are going to affect your plan.” He emphasizes the importance of getting in front of the problem before it ends up being too late and companies are forced to shut their doors. Are you ready to take the leap?

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Disruption is a good thing! To put it simply, disruption means to break the normal course or continuation of some activity, process, etc.

To many, disruption alludes a negative connotation. With disruption comes change. Change is scary because it opens the door to the unknown. I am advocating to change that narrative. Change needs to happen. It allows companies to test new approaches for the betterment of their business both internally and externally.

Human Resources and the Standard

For many Human Resource managers, the thought of making changes to a company’s health plan seems terrifying. Through the years, I have found that one of the biggest reasons why a potential client declines the services of SHARx is because HR does not want to disrupt their current processes.

Truth be told, most health plans produce headaches, but HR departments continue to implement what they know believing that their employer and employees like it. In reality, almost no one likes it. However, most HR departments are too afraid to stop what they are currently doing because of the unknown outcomes.

Taking the Leap

Disruption can be positive if done the right way. Sometimes it just requires taking the leap of faith.

Brian Hall, CFO at McCray Lumber and longtime SHARx client, took that leap and he’s glad that he did. Hall states, “If you roll it [SHARx] out, the implementation is not near as painful and if you explain it, just be open and upfront with your people and all your employees. They’ll understand and ultimately, they’ll embrace it and view it as a large benefit like all the rest of us do. If HR looks at this and says we are going to give it a try, they could end up being a superstar in the eyes of their finance people. If they roll it [SHARx] out and have the kind of experience that all of SHARx’s clients have, they will end up being viewed as a superstar.”

Empowering Everyone Involved

Hall decided his blue-collar marginalized company needed disruption. Where margins are thin, every dollar matters. Hall recognized his company could not stay on the same path it had been on for the past two years. Instead of trying to get better insurance, he stopped letting insurance dictate what happened in the health plan. Hall turned to SHARx to empower his employees.

Year after year, the trend line on the cost of their medications continued to rise despite shifting cost share to the employees and moving PBMs regularly.

It would have been simple to just exclude these drugs from coverage, but Hall wanted his employees to have access to the medications they needed and knew that something had to give. “Maintenance medications – It’s a bill that the employer sees on their plan month after month as long as that employee works for them instead of a $20,000 surgery that would go away,” says Hall. He needed a way to solve this financial dilemma for his company without losing some very valuable team members and knew there had to be a better way.

By taking a stand early, utilizing what was available on the market, and attaining access to it, Hall was able to keep premiums the same, no longer had to pay for the drugs that he had to pay out of pocket for before, and reinvested the savings into keeping his employees’ cost shares flat. By implementing SHARx, Hall took back control of his company.

We do not have to accept the status quo. Doing something different can benefit your clients both financially and administratively. Disruption is a good thing! Are you ready to take the leap with SHARx?

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