Episode 19 – Special Guest Tracy Spencer of Pharmaceutical Strategies Group

Mike Stull (0:09)

Hi everyone, this is Mike Stull and welcome to this month’s episode of the Employers Health HR Benecast, your source for expert commentary and insights on current health benefits related news and strategies. I hope you’re enjoying what has certainly been a unique summer. If you haven’t already, I encourage you to register for the last two webinars in our Summer Benefits Camp series.

The next webinar on August 27th features the Employers Health Clinical Team, where they’ll share the impact of custom utilization management programs that we put in place for a number of our clients and the results of those programs on the Pharmacy Benefit Plan.

Also, after a short hiatus, we’re excited to bring back virtual sightlines, a clear look at pharmacy benefits. Join us on September 30th.

I won’t be doing these presentations myself. I’ve actually recruited some of my colleagues to do these, so you’ll get a different perspective this time on what’s going on in the industry and their take on what the best strategies and some of the best practices are for employers and other plan sponsors.

Finally, Right Direction, an initiative of the American Psychiatric Association Foundation’s Center for Workplace Mental Health and Employers Health has a great webinar for those in the construction industry on August 26th.

Mental health, depression, and ending stigma in the construction industry will cover how to engage in creative campaigns to help employees feel psychologically safe in an industry with one of the highest rates of suicide. So again, August 26th. I hope you’ll tune in with our friends from the Right Direction initiative.

You can learn more and register for this and all upcoming Employers Health events at employershealthco.com/events. Again, that’s employershealthco.com/events.

In today’s episode, I sat down with Tracy Spencer, Senior Vice President of Employer Groups and Strategic Clients at Pharmaceutical Strategies Group.

Tracy will tell you more about her experiences, including roles in consulting, health plan and PBM as we get into the interview. But in her position today, she works with executive leadership at a number of Fortune 100 companies and evaluating market trends. So, I hope you enjoy hearing from Tracy.

All right. Hi, Tracy. Could you, for the audience, go ahead and maybe introduce yourself and your organization?

Tracy Spencer (2:47)

Sure.

Hi, Mike. Thanks for having me. I’m Tracy Spencer.

I’m the Senior Vice President and Employer Practice Leader for Pharmaceutical Strategies Group, also known as PSG. We are one of the largest independent pharmacy consulting firms in the country. I’ve been in the industry, healthcare industry for about 25 years.

I started my career with a full-service health plan. And then in 2001, decided to move over into pharmacy benefits specifically. That’s when pharmacy just started to go on the rise.

And the reporting consisted of a two-page report. One was top drugs by cost and the other was top drugs by volume. And so, I figured if I wanted to stay in this industry, I should probably learn a little bit more about pharmacy.

And I haven’t left. So, I spent about 14 years at CVS Health, always in the large national employer space. I manage national accounts there and teams that manage the national key accounts across the country.

And then in 2015, I moved over into the consulting world here at PSG. And like I said, right now, I lead one of the segments there, overseeing employer and labor clients, as well as some government and TPAs.

Mike Stull (4:04)

Great, thanks for providing that background.

So you mentioned that, you know, you’re in charge of overseeing the teams and do some direct work with employers. Curious what you’re seeing as the biggest opportunity for employers today in terms of improving their contracts with PBMs.

Tracy Spencer (4:24)

So, it’s kind of funny, I wish I could say it was different than what it was, you know, five, six years ago when I got into consulting, but it kind of remains the same, just might be titled a little bit differently.

I think the areas that we see is really providing consistency between what has been negotiated through, let’s say, a competitive procurement process or a renewal process, and then what actually makes it into the contract. I think employers and their consultants alike continue to struggle with the PBMs in order to make sure that they are adhering to the things that they’re agreeing to during those negotiations. I’d say probably the biggest areas that we continue to see where we have to lock things down more and more every single procurement season, it seems, has to do with definitions.

I can’t tell you how many different definitions of a brand drug or a generic drug I’ve seen over the years. Just when you think you’ve got it right, something else is thrown out in the marketplace, and you’re having to redefine how that is going to look. So I would say clients are really challenged with trying to find the right balance of definitions that will protect them not only now but in the future for their contract.

Additionally, I think audit rights have become even more and more important, and as they become more important, I see the PBMs, large and small, really trying to narrow the focus for payers or plan sponsors. They may be requiring that there has to be a mutually agreeable auditor or even an auditor that is selected by the PBM. And in a world where employer plan sponsors are looking for more flexibility and really trying to take the reins back, overseeing their self-insured plans, that’s just not something that’s flying in the marketplace today.

And I think just as important as the right to audit really comes down to disclosure. So you and I have been talking about transparency in the pharmacy world for it seems like now probably decades, but transparency doesn’t necessarily need to be passed through back to a plan sponsor. Many plan sponsors are more interested with disclosure associated with the financials of their arrangement and are willing to pay a fair price to a PBM in order to manage their benefits.

But it’s sort of the hidden details and what’s in the black box that they’re curious and skeptical about. And so we’re looking for, or I would say employers are looking more for information surrounding disclosure and reporting associated with their plans and with the programs that they have in place. I say it all the time, and my boss probably slaps my hand whenever I say it, but a plan sponsor should not have to do a full-blown audit in order to determine how their plan is performing.

So I think those are probably the biggest challenges that we’re seeing right now today related to the PBM contracts.

Mike Stull (7:40)

Yeah, we found that even with the definitions, if you get the definition that you want and it’s not a standard within the PBM, then it ties back into why the audit’s so important, because they may be processing certain claims the way that they do for their entire book of business. And you have to point back and say, no, our definition isn’t your standard definition, and you shouldn’t have treated these claims the same way that you do for all your other clients.

So it’s an interesting circle or loop that starts to occur as you try to get more customized definitions that meet your needs and then making sure that the PBM actually processed the claims according to the contract. So definitely two very important pieces for plan sponsors.

Tracy Spencer (8:38)

It really is, and I think one of the things that we’re seeing most recently, and I’m sure you’re seeing this on your end as well, out in the marketplace, is with various PBMs, there’s things that are now coming up related to over-the-counter products.

So over-the-counter products, test strips, diabetic test strips are probably the biggest example there. Those are highly rebated drugs, lower cost products, but highly rebatable. And unless you have a definition that encapsulates that OTCs are going to be part of that reconciliation, even if you’re getting 100% of the rebates, it’s overly inflating the guarantee that is coming back to you from a PBM.

So we would rather have, and I know you would rather have, a real number associated with what your guarantees are and how that reconciliation works versus some of this shell game of it counts over here, but maybe not over here. I think that just adds to more frustration and skepticism in the marketplace associated with this industry that we’re in.

Mike Stull (9:42)

Oh, yeah.

We’re seeing that all the time. One of the benefits that we have is we work with so many different consulting houses. And so you can tell which houses, based on their evaluation model, have caught those things.

And so it’s just really interested, whether it’s limited distribution drugs, whether it’s the specialty drug list, whether it’s OTCs, the inclusions and exclusions have become such a game out in the marketplace. And they have big consequences in terms of skewing the evaluations one way or the other. But I know with OTCs, I tell when I do talks, I always say, a lot of you may say, well, we don’t cover OTCs.

Well, yes, you do. And those test strips are not only highly rebatable, but there are a big number of claims. So, they’re going to have a big impact.

Tracy Spencer (10:39)

Absolutely. Well, I think that and then the other piece that we’re seeing now, too, is the 340B exclusions. And how many different ways did you think that you could state 340B claims, right? And especially in a self-insured employer world.

So I think as the technology gets better within PBMs, the technology that helps adjudicate the claims faster and more efficiently that allow stronger member engagement tools, et cetera, that same type of technology is also helping PBMs identify different types of claims that they may or may not want to have included in their reconciliation. And so we have seen PBMs that have come back and said, well, this has been an exclusion in your contract or your client contract all along. We just only recently have had the ability to identify these claims.

And that then becomes a large potentially budget hit for a client that has been budgeting based on kind of the status quo moving forward. So I think it’s those types of situations that come up that I think need to be collaborative with clients and PBMs and the consultants to really just talk about what is going on versus just somebody receiving a reconciliation report that looks vastly different than what it did before and having to spend a lot of time digging into the details to find out what’s going on.

Mike Stull (12:04)

Yeah, I think the technical piece of it is just becoming more and more complex.

And even with, like you mentioned, 340B claims, I mean, A, going back to the definition, what is a 340B claim? In a lot of contracts, it’s just a claim that’s filled at a pharmacy that participates in the 340B network, which could be a contracted pharmacy, which could be every Walgreens and CVS in the country. So it is really loose. And it’s a very technical claim level definition.

And if you’re not digging into it, you wouldn’t know about it. And so, yeah, definitely very important.

Tracy Spencer (12:48)

I would just say, I would say one last thing that is probably more recent that we’re keeping our eye on and trying to determine how we’re going to address it through RFP requirements and through contractual requirements are really some of these newly established GPOs with some of the PBMs and understanding that those GPOs are created in order to, but one of the side consequences there is that the fees that are being charged back to the manufacturers from the PBMs to these GPOs are significantly higher than they were before.

And they are being tied to different things. They may be calling them now data system access fees, as opposed to selling de-identified data. And its sort of that reclassification that we’ve battled over the years.

That again, once you think you’ve got a definition that’s going to be all inclusive to cover those things, something else pops up like this that the industry is going to have to address. So I think, you know, the consulting community is aware of this. I know, you know, coalitions such as yourself are aware of these things too, but I think we’re really going to have to nail this down quickly in order to provide production for our clients.

Mike Stull (14:10)

Good discussion. The next one, maybe a whole episode in itself, but just kind of quickly here, you know, a lot going on in the world of rebates. And I thought the rebate rule was effectively dead, but it appears that with the president’s executive order that, you know, we’re back to talking about, do we think that we’ll see a day when rebates go away or at least change pretty dramatically? So curious, your thoughts.

Tracy Spencer (14:42)

Yeah. So it’s interesting when, like I said, when I came into pharmacy in 2001, that’s when rebates were going away. So we’re about 20 years later here and they are larger than they have ever been and, in the forefront, more so than they have ever been.

I wish we could say that we’d be in a situation where rebates could go away. Unfortunately, I think they continue to be a necessary evil. I do think with the language associated with the executive order, I still do think it’s kind of dead on arrival just based on the fact that, you know, the requirement that it cannot increase premiums to the Medicare retirees and the government’s own actuaries have shown that, you know, there’s going to be up to a 25 percent increase in those premiums if rebates were to get passed through at the point of sale or not be passed back through to the plans.

So I don’t think they’re going away anytime soon. I do think that there are plans and employer and plan sponsors out there that are trying to find ways to minimize those. And what I, you know, we are not a firm that is interested in having our clients chase rebates, right, because all we’ve found is that the higher the rebate values that are coming in from the PDM, generally they probably have a higher cost formulary out there.

So we, whenever we’re doing our procurements, we do a very in-depth evaluation of the formularies that are associated with those arrangements to make sure that those rebate guarantees aren’t just offsetting a higher cost formulary. So PBMs are actually getting credit for having lower cost formularies and better clinical management of their formularies. And we like to tell our clients that it’s, you know, the large jumbo checks that you get every year associated with rebates.

It’s really about the 52 checks that you’re writing a year for the drug spend. So I think, you know, we’re seeing more and more clients that are looking to see if they can have perhaps some direct conversations or even some direct value-based arrangements associated with pharmaceutical manufacturers, or even something that might be a little bit more customized with a PDM. But unfortunately, at this point, you know, it’s, as long as the system is set up the way that it is and drug manufacturers are able to charge whatever they like associated with drugs, those rebates are just going to continue to creep up as they are pressed by PDMs for stronger discounts.

Mike Stull (17:36)

Yeah, I always like to compare it to, you know, taking a larger tax deduction out of my paycheck every couple weeks. You know, if I want to do that so that I can say I got a huge tax refund, I can, but that doesn’t seem to make a whole lot of sense. So I think the same thing applies here.

You spend more on the front end to get some of it back on the back end, and that doesn’t always make the most sense.

Tracy Spencer (18:05)

No, and I think, you know, we’re seeing, I guess it was probably when the executive orders came out a year ago, right, a little over a year ago, when you started seeing a big push from the PDMs to talk about point-of-sale rebates and try to really get clients to move to a point-of-sale rebate arrangement, partially because I think they thought that they were going to have to get there to begin with, or at the end of the day, they were going to have to get there. But I think we’re also in a situation where there’s still, as much as we talked about technology earlier on in the discussion, there are still PDMs out there who can’t administer rebates at the point-of-sale.

And, you know, if that became a requirement, it’s only going to limit the competition that is going to be out there, and then in that case, then with the limited competition, how much do prices increase?

Mike Stull (18:55)

Absolutely. So, moving on to the next question. So, from a plan design strategy, are you seeing or hearing anything that’s new or innovative from your clients? One of the big things that I know a lot of big PBMs are talking about, particularly CVS and Express Scripts, are their variable co-pay programs like the Prudent RX or the Save on SP program.

So, I’m curious if you’re seeing any of that from your larger employers and any other innovative strategies that they’re looking at moving forward.

Tracy Spencer (19:35)

Sure. I think specifically related to some of those programs, whether it be the co-pay accumulator programs or what we call the co-pay maximizer programs, if you will, I think historically we’ve seen that a majority of our clients, if they do have the high deductible plans, they are interested in the accumulator programs just to make sure that somebody’s not necessarily artificially meeting their deductibles and their out-of-pocket maximums.

I think that really comes down to a parity issue across their plan. Just because somebody may be on a specialty medication doesn’t necessarily mean that they still need to meet their deductible the same way that I, if I’ve got four kids on multiple different types of medications and I still have to meet my deductible, like I said, from a parity perspective, that’s what the plan sponsors were concerned about related to the accumulator programs. If you and I were having this conversation back in January associated with the maximizer programs, I would say we still have seen very limited interest on the large plan sponsor or employer plan sponsor level associated with their programs.

I do think that they feel that there could be some unintended consequences there and really are questioning perhaps the longevity of those programs. Ultimately, if your manufacturers understand that they’re fighting tooth and nail to get rid of these programs. Ultimately, if they feel that they’re being taken advantage of or misused in any way, they’re going to dry up that money there and apply it elsewhere.

There’s not just this endless bucket of money there, although some may say that there could be, but now with COVID and the challenges that we’ve had in our economy associated with COVID, I do see that we have clients that are looking more and more at things that they historically have been adamantly opposed to. I would say the maximizer programs are one of those cases. We do have more clients that are exploring that now to take a look at for January 1st of this year.

As you know, it does require some changes associated with how the plan is structured, the SPD, SPD language. I think the biggest thing that is coming into play for clients is taking a look at some of those programs because how do you set up a benefit where there may be only 300, let’s say 300 drugs that are associated with those types of programs, yet there are about 1,200 specialty drugs out there? How do they create something that is user-friendly, something that members can understand, yet is still manageable at the plan sponsor level as they administer the plan? As far as some other things that we are seeing, we continue to see requests or exploration, I should say, of potential carve-outs of things that historically have been under a PDM umbrella, whether that be specialty drug management, whether that be specialty dispensing, prior authorization in both the traditional and specialty space, taking a look at networks, and not necessarily narrow networks that are already predefined by a PDM, but really custom networks that some of the very large jumbo employers are looking to put together, whether that be a primary or a premium network with a wrap around it, or if they are just saying that that is going to be their only network, and then using mail order and other entities to wrap around that in order to eliminate some of the spread and additional revenue that is going through those traditional network entities.

Mike Stull (23:38)

Do you think that some of this has to do with, I mean, the way to make some of these plan design changes or these innovations work is employers ultimately have to start to make some choices around, and that is kind of a weird way to say it, but some choices around limiting choice.

When I look at Anthem or I look at the Prime deal with ESI, they are contracting with the big PBMs to get better access to or better rates through the retail network or even the rebate contracting. It just kind of puts into perspective what a volume-driven game this is. I think for even the largest of employers or the largest of employer coalitions, we end up struggling with trying to figure out how to get a better deal.

At some point, employers have to get away from the idea that you have to have 68,000 retail pharmacies in your network, and by limiting some of the choice is the way that they can make some of these innovations come to life.

Tracy Spencer (24:54)

Absolutely, and again, like I said, I think if COVID wasn’t here, we would be having a very different conversation, but so many employers are struggling with furloughs or potential layoffs. Every industry has been hit so hard that they’re faced with making some of these decisions that historically may have been larger number disruptors, and they’re willing to consider those now because if they don’t, then it means people are going to lose their jobs.

You’re right. You don’t need 68,000 pharmacies in the network. We’ve got clients now who are looking at 32,000 or networks that have 32,000 pharmacies in them, and the coverage still is fantastic.

I think it’s a matter of communicating to those members, and it’s kind of like ripping off a Band-Aid. You may have a little bit of noise right at the beginning, probably even before you go live on a one-one but then being able to live through that and finding some significant savings as well as potentially a better member experience at some of those higher quality pharmacies.

Mike Stull (26:08)

I think that’s a good point that you can start to work with the pharmacies on things other than just dispensing drugs.

Tracy Spencer (26:18)

I would say a couple of the things that we’re seeing, and again, I think COVID sort of has been the impetus of this, but I think we’re seeing more and more plan sponsors who are maximizing their ability to move patients with infusions from more safe and cost-effective site of care, not wanting people to go into hospitals or into outpatient settings. So that has been, if there is a silver lining here, that has been a positive from a cost-saving and a member experience perspective. And I think it’s also causing everybody to take a look at their prior authorization criteria and even just their refill limit thresholds, as it relates to both traditional and specialty medications.

When many of the PBMs came out at the end of March and said that they were going to withhold the refill restrictions so that people could have access to medications, as we started working with clients to get those put back in place a couple of months later, we really were having them take a look and say, where should these thresholds be set? Because even thresholds that were set four or five years ago, probably they’re still a bit too lenient and a cost-saving opportunity for a plan to make sure that somebody wasn’t potentially getting 15 to 18 months’ worth of a mail-order prescription in a 12-month period.

Mike Stull (27:53)

Yeah. I have found just through the implementations that we’ve done that if you use the PBM standard refill threshold, it’s too lenient.

Tracy Spencer (28:02)

Yep.

Mike Stull (28:03)

All right. Last area I wanted to touch on.

So we’re in a kind of right after the mid-year here, starting to see some data from mid-year plan performance reviews. Curious what you’re seeing in terms of how plans are performing so far, either before or even after rebates.

Tracy Spencer (28:22)

Yeah.

So, I would say the majority of the PSG clients, I would say, go through either an annual market check, similar to you all, or doing competitive procurement. So, I would say pretty much every one of our employer and labor clients went through some sort of pricing enhancement for January 1st of this year. So initially, you would think that the cost would ultimately be coming down.

We’re probably still seeing trend prior to rebates anywhere from the 2% to 9% range. I do think some of that has to do with depending on which PBM they were with, what they were doing related to COVID and those refill restrictions. We do know that there was a couple of PBMs out there that waived the refill limits, but they didn’t necessarily proactively go out and let people know that.

There were other PBMs that were really allowing patients to maximize specialty drugs. So, allowing a 90-day supply for specialty medications. And it was something that a client would have to opt out of that.

And there really wasn’t any data showing us that there were any issues with patients getting specialty medications at the time. So that seemed to be a bit excessive in our minds. And we’re starting to see that in the data.

Now that is pre-rebates, I think as we take a look at it with rebates, you’re seeing I wouldn’t say flat, but you’re seeing low trend coming into play there. I do think it will be interesting to see if there are additional spikes later on in the year, as some of those procedures that perhaps were held off on earlier this year, or even potentially some oncology treatments that, that perhaps people waited on for a couple months, but wasn’t something that was drastically urgent.

I think we will start seeing some of that in the data as we look at, you know, June, July, and August. I think one of the very interesting things that we’ve seen in the data, and you probably have seen this as well, is a large increase in drugs-associated behavioral health medications, so antidepressants, anxiety medications, those are definitely on the rise, and we’re in the process now of taking a look at, you know, where, where are those scripts coming from, and are they also being tied to therapy, you know, or is it being prescribed by primary care physicians, and there’s not necessarily the behavioral health therapy component that, you know, could and should be associated with that in order to help people manage their, their behavioral health issues. And then the other piece that we have found is, because some of those elective procedures have been, you know, put on hold, we have seen that the pharmaceutical opioid utilization has gone down for the first, you know, six months of the year.

That being said, though, the news everywhere, at least the news everywhere around me, is indicating that the overdose deaths from opioids are on the rise, even with those drugs being, a few of them being dispensed, there being better management associated with that. So that does tell me that people, you know, potentially are moving to the street drugs that are much less expensive and probably easier to get as well, but that’s something that we’re keeping our eye on here and helping our clients manage through.

Mike Stull (32:05)

Great.

Well, I think that, you know, if, if the second half of 2020 is any, anywhere close to the as exciting as the first half of 2020, we’ll be in for a wild ride.

Tracy Spencer (32:19)

I know. I’m hoping for non-excitement, right?

Mike Stull (32:23)

You throw in that thing called a presidential election.

Tracy Spencer (32:26)

Yeah, exactly, exactly. But, you know, as we have in this business, it’s never a dumb moment. We do learn something new every single day.

You know, just happy to be able to help participate in an industry that ultimately is looking to, to manage and improve member health and patient health every little step of the way that we can.

Mike Stull (32:49)

Yeah. And I, I think that’s a great message for the audience is just that there is something to learn every single day.

And you talked about learning at the beginning, and then you talked about, you know, when you figure something out, it changes. And I, I think that’s, you know, just something that has been part of this industry. And for the 15 years I’ve been here at Employers Health, I mean, there is never a shortage of things to learn.

And it’s actually kind of fun at times to try to figure it out, right? It’s like, okay, what are, what are, what are they doing here? What, what’s going on here that’s, that’s making, you know, these, you know, contracts or these deals appear one way, but perform another way. And so, we wish it were more simple, but it’s, it’s also kind of fun from just a strategic challenge to figure out, okay, where’s this going and where do we need to go to, to get out in front of it?

Tracy Spencer (33:46)

It is. You kind of have to put your investigative hat on and try to figure it out.

You just, you know, I, I hope that we can work as an, as an industry for, you know, collaboration to get ourselves away from those situations and really just try to drive some really good beneficial strategies for clients. Again, I’ve never had a client say to me that they don’t think that a PBM should make money. I don’t have, haven’t had a client say that they don’t think that a pharmaceutical manufacturer should make money.

I think it’s just a matter of, they want to make sure that it’s fair and they just want to make sure that they know where their, their money is going. I mean, this is, think about it, drugs and under the PBM world, a drug is probably one of the only products that you purchase here in the United States that you really do not know the true cost or the medication that you are buying. And that’s because it’s under a cloak of confidentiality associated between the PBMs and pharmacy manufacturers.

And if we just had more information, I don’t think anybody would be giving away their secret sauce. I don’t think that clients would be opposed to people making a fair profit. We know that they’re not, you know, they are in here to, to be a profitable company.

But I think collaboration is going to be the key if we want to, if we want to fix what’s broken out there.

Mike Stull (35:05)

Yeah. And I think the industry has a chance here.

And I know we’ve said this before in the history of the industry, but I mean, I do feel like we’re on the clock and, you know, either the industry, you know, figures out ways to make positive movements towards better affordability for individual patients and particularly for employers and other plan sponsors, or you certainly have an appetite by some, some in government to make those decisions for the industry. So I think, I think, I think any, anything we can do to try to, you know, create more transparency and try to make, make medications more affordable will, will go a long way in not only creating a sustainable benefit, but really a sustainable industry as well.

Tracy Spencer (35:59)

Oh, absolutely.

Could not agree more.

Mike Stull (36:02)

Well, thanks, Tracy. Appreciate your, your time and expertise and sharing with our audience kind of your thoughts on some of these hot topics.

Really appreciate you spending time with us and hopefully we’ll, we’ll get to do this again sometime.

Tracy Spencer (36:19)

Yes. Thank you.

Thank you so much for having me. Really appreciate it.

Mike Stull (36:23)

It’s always great to hear perspectives and insights from others in the industry.

And as Tracy said, there truly never is a dull moment when it comes to pharmacy benefits. Our team at Employers Health is constantly working to stay on top of the latest trends in order to provide your plan and its participants with the right drug at the right time, the right place and the right price. And it’s great to have peers like Tracy who are working towards this same goal.

Before we end, I want to share this month’s keyword for the $50 Visa gift card giveaway. This month’s keyword is definitions. Be sure to submit the keyword to be entered into this month’s drawing. Again, the keyword definitions.

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That’s going to do it for this month’s episode. Thank you again to Tracy for sharing her insights.

And thank you to our listeners for taking time out of your day to be with us. But more importantly, thank you for your continued membership and interest in Employers Health. And don’t forget to submit your questions so that we can answer them in an upcoming edition of our podcast.

Be well and we’ll see you again soon.