As costs continue to rise, employers are looking to the levers they have available to get their arms around this challenge, and a new report examines some of the strategies they're considering.
Analysts at the consulting firm Pharmaceutical Strategies Group released its annual drug benefit design report on Tuesday, where it found that there is a growing awareness among employers about new contracting models, including "unbundling," where a plan sponsor would decouple certain services from the main PBM contract and rely on other vendors.
The study found that 48% of employers had heard "a little" about unbundling, while 15% said they "heard a lot about it." About a third of health plans, or 35%, said they'd heard a little about unbundling, and 40% said they had heard a lot about the topic.
The most prominent use of this model is Blue Shield of California's Pharmacy Care Reimagined initiative, which ditched the insurer's traditional PBM relationship with Caremark to lean on multiple vendors to provide different elements of the experience. While it's sticking with Caremark for specialty pharmacy, Blue Shield tapped Amazon for home delivery and Prime Therapeutics to negotiate with drugmakers, among others.
The study also found that just 28% of employers are "not at all likely" to look further into an unbundling model for their own pharmacy benefits. Josh Van Ginkel, vice president of employer pharmacy benefit consulting at PSG, told Fierce that the firms that are exploring this route are taking it slow.
Rather than jumping in feet first as Blue Shield did, they're considering a carve-out for specialty pharmacy services or formulary development. Or, they're considering a combination of one or two potential pieces to unbundle, he said.
He added that there are a lot of point solutions that can be adjusted in a modular manner, which is another way an employer can dip their toes into unbundling.
"What we don't see with employers is trying to do the giant piece," he said.
For employers that are considering this approach, they anticipate it could pay off in better cost management and greater transparency. However, they also expressed concern about connecting all the dots between vendors and ensuring the patient experience isn't disrupted.
The study also delves into employers' perspectives on GLP-1 drugs and how they're looking to benefit design to manage costs in that arena. Larger employers were more likely than smaller businesses to offer coverage for GLP-1s for weight loss, the study found.
Sixty-five percent of employers said they were very concerned about the cost to their plans related to these drugs. And given those concerns, 42% of firms said they would not be willing to cover the drugs at any price for obesity.
Just 6% said they believe GLP-1 coverage would have a significant impact on recruitment and retention.
"We talk endlessly about the affordability concerns around GLP-1 coverage, especially if we start looking at expanding coverage to GLP-1s for obesity," Morgan Lee, senior director for research and strategy at PSG and one of the report's authors, told Fierce. "It was really interesting to continue to see this year that payers are continuing to have sort of mixed views on whether it's appropriate to cover drugs for obesity."
The study also found significant concern among employers about off-label use of GLP-1s that are prescribed for type 2 diabetes management but are actually being used for weight loss. About a third (32%) of employers said they were very concerned about off-label use.
Van Ginkel said that some employers are responding to GLP-1 prescriptions for diabetes by asking to see the chart notes and lab testing to confirm the diagnoses, and "they've been surprised by the number of withdrawn requests."
"We had a lot of respondents who actually didn't know what percentage of their type 2 diabetes, GLP-1 use is off-label, and so that can represent a tremendous amount of cost," Lee said.