Spotlight on Utilization Management with Sharon Phares, PhD, MPH & Stephen Mackie



Sharon Phares, PhD, MPH
Stephen Mackie
December 1, 2021

 

Utilization management (UM) programs are a vital tool in the clinical and cost management of drugs. These programs are offered in various forms by most pharmacy benefit managers (PBMs). Typically, there is an additional charge, but the value proposition purports these programs save overall costs by ensuring appropriate utilization. Because of their importance, this year’s report takes a closer look at satisfaction with UM programs.

Three themes emerged when respondents shared what PBMs could do to improve satisfaction with UM programs:

  1. Lower or no cost for programs
  2. Better reporting
  3. More thoughtfully approaching improvement of member experience

 


 

More than two-thirds of respondents reported they currently use prior authorization (PA) (88%), formulary exclusions (87%), step therapy (85%), and opioid management programs (69%).

The least frequently used program is gene therapy financial protection programs (13%). It also has the least awareness (36% not aware if offered by PBM).

No significant differences by size of PBM were found.

 

 


 

The satisfaction with promised savings is highest for opioid management programs, clinical savings guarantees, pharmacy trend guarantees, and gene therapy financial protection programs.

 

 


 

Average satisfaction with member experience for programs with little to no member impact, such as savings guarantees, were rated highest. On the other hand, programs with a more direct member impact, such as step therapy and copay accumulator programs, ranked lower in satisfaction.

 

 

 

 


 

Receiving timely, understandable, and accurate reporting provides plan sponsors with the information they need to know if a program is working as expected. Appropriate reporting provides evidence of value. Respondents whose organizations are currently using a program revealed their satisfaction was highest with gene therapy financial protection programs (8.3), followed by pharmacy trend guarantee (8.2). Step therapy reporting ranked lowest at 7.6.

 

 


 

Let’s return to the three key takeaways that emerged from this research about how PBMs could improve satisfaction with UM programs (lower or no cost for programs; better reporting; and more thoughtfully approaching improvement of member experience).

This respondent quote illustrates plan sponsor insights around improving member experience:

UM satisfaction is highest for the UM programs that provide cost-savings for plan sponsors without significantly impacting their members at the pharmacy counter or interrupting therapy.  Plan sponsors need to balance the cost savings and member experience. It is a tricky balancing act.

 


 

Review the complete report to learn more about how your plan can strike the right balance.

 


 

This annual report summarizes overall satisfaction with pharmacy benefit managers (PBM) and satisfaction with over 40 PBM functions and services beyond overall satisfaction. It is the most comprehensive research of its type for the PBM space. This report is widely recognized for the comparative information it provides to benefit executives responsible for researching, selecting, and managing PBMs.



Sharon Phares, PhD, MPH, is the Senior Vice President of Research for PSG and an Assistant Adjunct Professor of Clinical Pediatrics and Assistant Adjunct Professor of Internal Medicine with Washington University in St. Louis. Prior to joining the PSG, Sharon was Vice President of Research and Analytics at Express Scripts where she led research strategy and execution for one of the largest PBMs in the nation. She has also held leadership roles in health and economic outcomes research, survey design, pilot and program design and evaluation, analytics and research consulting, advanced analytics, and the development of predictive models at Walgreens, LabCorp, and Landacorp. She was an instructor at North Carolina State University and provided evaluation research for various state and local government agencies before joining the private sector.

Stephen Mackie is passionate about discovering innovative solutions to lower healthcare costs and improve health outcomes. He has ample experience in the PBM landscape with demonstrated success in balancing creative problem solving with analytics to achieve best-in-class results. Stephen is known in the industry for his effective management of his client’s ongoing needs in PBM oversight, pharmacy request for proposals (RFPs), market checks, data analytics reporting, and operational support. He has served as a strategic leader for an employer coalition, representing 60,000 lives and $100 million in revenue. Stephen earned a Bachelor of Arts in Biochemical, Cell and Molecular Biology from Drake University.