It is still commonplace for employers to have their medical and prescription drug benefits bundled together (carved-in). However, new federal Prescription Benefit Manager (PBM) reforms such as the Consolidated Appropriations Act (CAA) 20261 focus on transparency and fiduciary responsibilities, highlighting the importance of understanding where and how your money is being spent.
Do Bundled Benefits Actually Deliver Savings?
Some medical carriers, under a fully insured funding arrangement, impose monetary penalties on employer-sponsored plans who choose to unbundle (carve-out) their prescription drug benefits. These carriers often claim that bundling medical and pharmacy services generates cost savings by enabling integrated data analysis, but where is the proof? In many cases, employers are not provided with clear or verifiable reports that validate such savings.
Consider this… most medical carriers rely on external PBMs to administer their bundled prescription drug benefits—an acknowledgment that specialized expertise is essential in this area. This clearly supports the idea that medical carriers and PBMs do not operate on fully integrated adjudication or reporting systems, weakening the argument for bundled benefits. Additionally, most PBMs are fully capable of sharing detailed, timely claims data with medical carriers, which does achieve the same level of coordination as a bundled model. This raises a fundamental question: if comparable outcomes are achievable without bundling, why are monetary penalties necessary? A valid question to bring to your bundled medical carrier to answer.
What Happens to Benefit Integrity?
Bundling often creates commingled data that lacks accuracy and transparency. For example, medical devices such as insulin pump supplies are intentionally adjudicated or paid under an employer’s prescription benefit rather than the medical benefit. Such inconsistencies can create challenges for the employers, especially during request for proposal (RFP) evaluations, budget forecasting, and the transition process during a carrier change.
What if Medical Cost Savings Could Be Validated Through the Prescription Benefit?
Medication failure is the largest avoidable cost in any health plan—yet it’s often overlooked. Overall, it’s costing $3.5 billion in emergency room visits due to wrongly prescribed medications.2 Compounded by the fact that 50% of medications prescribed are either ineffective or minimally effective.3
The biggest opportunity to reduce spend isn’t where most plans are looking and it doesn’t require collective bargaining or benefit changes. Medication failure often leads to unnecessary emergency room (ER) visits and inpatient stays. Integrating medical and prescription data with a pharmacogenetics program can result in savings to the employer’s medical plan and better member adherence to their prescription drug regimen.
Benecard addresses medication failure head on through personalized medication therapy for members in an employer’s group. This is achieved with the help of clinical pharmacists, PGx testing (type of DNA testing), and data science. The savings are often seen on the medical side through lower emergency room visits and inpatient stays.
Next time you look at a bundled medical and prescription drug quote, consider these factors before deciding to bundle or unbundle your benefit.
Look out for Part 2 on our bundling the medical and prescription drug benefits spotlight tomorrow. In the meantime, if you have questions or would like to discuss with us, please contact us at talktous@benecard.com.
Sources:
1. https://www.congress.gov/bill/119th-congress/house-bill/7148
2. Watanambe, McInnis. Annals of Pharmacotherapy 2018, Vol. 52(9) 829-837
3. FDA. Paving the Way for Personalized Medicine. 10/2013
