Recommend the right match for your group clients
By Gregory O. Callahan
As business partners, pharmacy benefit managers (PBMs) play a significant role to help plan sponsors (group employers) manage their pharmacy benefit. Brokers and the PBM account team play a critical role in this process. At Milliman consulting, we have amassed years of experience and fostered fundamental account management practices that lead to successful relationships between group benefit brokers, plan sponsors and PBMs.
There are many different ethoses and philosophies in running a successful account management program. We’ll look at how PBM account teams can create relationship longevity — including insight into the broker, plan sponsor and PBM trust dynamic and what PBM account team best practices help deliver high financial value and operational excellence. These dynamics can nurture strong relationships over time.
With the support of their group benefit professionals, plan sponsors choose the level of involvement they would like from their PBMs in accomplishing their own internal or strategic goals. A broker can help select a PBM by evaluating their current account management models to assess whether their model is scalable and applicable across all lines of a client’s business.
Relationship management: The role of trust
Why do plan sponsors stay with their PBMs? And why do brokers recommend one PBM over another? In a word, trust.
Trust is the most fundamental component of the relationship between a plan sponsor and the PBM. A plan sponsor that trusts its PBM is more apt to stay versus situations where trust is low or nonexistent. A recommendation from a trusted advisor such as a broker/agent can assure the plan sponsor (group employer) that the PBM of choice is trustworthy.
Broker tips in recommending a PBM
Understand the two main components of trust: perceived cost and perceived effectiveness
Brokers can help plan sponsors build trust by making sure the PBM contract (including all pricing, guarantees, rebates, exclusions, programs, and services) is transparent and financially competitive in the marketplace. Being transparent includes clear definitions, audit and market check rights, effective reporting, and sharing data with the partners of the plan sponsor.
Perceived effectiveness. To build trust, the PBM must consistently deliver a high level of service. The account team needs to be:
- Master communicators
- Proactive and responsive
- Cognizant of the plan sponsor’s fears, risks, and
- Able to consult and make effective recommendations
- Able to address operational issues effectively
- Be an advocate to help achieve plan sponsor’s goal
- Able to maintain a good relationship with the plan sponsor’s professional advisors — group benefit consultants
PBMs become valued business partners when trust is established and validated year over year.
As Figure 2 illustrates, when the plan sponsor perceives that the PBM is in the high-effectiveness/low-cost quadrant A, there is a corresponding high level of value associated in the relationship, which creates relationship longevity. A plan sponsor that trusts its PBM is more likely to stay with its PBM.
FIGURE 2: TRUST PARADIGM
High-effectiveness/low-cost (quadrant A). Plan sponsors in this quadrant score the highest in value. These plan sponsors likely have a consistent account team that is effective at planning, partnering, communicating and executing all aspects of the PBM relationship, including delivering high-value milestones that support the plan sponsor’s pharmacy benefit or organization. In addition, these plan sponsors are receiving competitive rates at or above market. Trust remains high in this scenario.
High-effectiveness/high-cost (quadrant B). Plan sponsors in this quadrant may be reluctant to issue a request for proposal (RFP) to consider new vendors, as the PBM relationship is functioning well. However, the plan sponsor is left wondering if its contract is competitive in the marketplace. Plan sponsors in this scenario are more likely to leave their PBMs, as they may speculate that the PBM is giving new business a better deal. Trust can be fragile in this scenario.
Low-effectiveness/low-cost (quadrant C). Plan sponsors in this quadrant are typically unhappy with their PBMs but tolerate the relationship because they perceive they are getting a good deal. These plan sponsors may issue an RFP but may also stay with their PBMs, as they may be willing to compromise on service for the right price. Trust might be waning in this scenario.
Low-effectiveness/high-cost (quadrant D). Plan sponsors in this quadrant over time might be incentivized to leave their PBMs with or without an RFP. Trust is lost and it is difficult to regain in this scenario.
It is important to note that perception is not always reality. A relationship may not be what either side perceives it to be. A plan sponsor may perceive its PBM relationship is lacking and therefore issues an RFP and switches PBMs. However, in retrospect after moving to the new PBM, the plan sponsor realizes its prior PBM had very strong attributes and thus experiences some level of dissonance post-change. Likewise, the same is true for PBMs that perceive a relationship in quadrant A when we typically see plan sponsors perceive their relationships in quadrants B or C and even sometimes D. PBMs are wise to understand this dynamic and understand a plan sponsor’s perception is what ultimately matters. PBMs should always be focused on how they can help and keep plan sponsors’ perceptions high in effectiveness and low in costs, where trust remains high.
The PBM account team is vital to the success of a PBM, as its members are the owners of the relationship. The PBM account team’s success in building and maintaining trust between plan sponsor and PBM solidifies the perceived relationship as residing within one of the four quadrants.
Steps for building trust
Here are four fundamentals that brokers can employ to ensure a trusting relationship:
- Create, manage and execute a purposeful and measurable strategic plan with the account team throughout the calendar year and the entire relationship — including the broker/agent, plan sponsor and PBM.
- Get buy-in and approval from executive leadership from both plan sponsor and PBM.
- Address any operational issues and the process for resolving issues quickly and effectively, when issues come up.
- Ensure financial costs for the PBM plan are at or better than market value.
Both plan sponsor and PBM track, acknowledge, and appreciate plan sponsor wins while acknowledging bumps in the road. Figure 3 is an illustration of what a high-performing account team year in review might look like using the qualities found in the four fundamentals listed above.
BEST-IN-CLASS PBM ACCOUNT TEAM ACTIVITIES
JANUARY~ Account team works with the plan sponsor and its advisor to create a strategic plan, which outlines goals and objectives for the next one to five years. The strategic plan defines simple, measurable, and achievable goals in three key areas:
The account team must set reasonable expectations with the plan sponsor. The PBM executive sponsor reviews, approves, and works with the account team to monitor the strategic plan.
FEBRUARY~ Plan sponsor executives also review and approve the strategic plan. For the rest of the year, the PBM account team focuses on executing the strategic plan to achieve plan sponsor goals.
MARCH/APRIL ~ The PBM account team conducts an annual review with the plan sponsor, either in person or virtually.
This review covers:
• Retrospective: Review of the prior year’s financial performance, performance guarantees (PGs), reconciliation reports, and key performance indicators (KPIs)
• Prospective: Strategic plan discussion including account team activities to date and updates to the short- and long-term goals.
MAY/OCTOBER~ The PBM account team executes on the strategic plan with defined goals and action items.
NOVEMBER/DECEMBER~ The PBM account team meets with plan sponsor for a year-end check-in that reviews:
• Goals that were met, successful, or
• Plan sponsor acknowledges them.
• Shortfalls and remediation.
• PBM acknowledges them.
• Which goals should continue into the next year?
• Whether the year was an overall success, or not.
• Begin updating the strategic plan in preparation for January/February strategic plan approvals.
Every group employer wants a highly effective, low-cost pharmacy program. Every PBM wants to continuously renew its accounts and foster long-term relationships. The PBM account team is a critical key to this symbiotic relationship as the facilitators and owners of this very important relationship asset.
Brokers can be assured that they are recommending the best solution to administering a cost effective prescription drug coverage program when their PBM aligns with the values explored here.
GREG O. CALLAHAN has been a senior consultant with Milliman since May 2018 in the Greater Orlando, Florida area. Milliman is an independent consulting, benefits and technology firm. They offer expert guidance and advanced analytical solutions to empower leading insurers, healthcare companies and employers to protect the health and financial well-being of people everywhere.
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