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JC Scott, President & CEO of the Pharmaceutical Care Management Association, discusses the latest trends, public policy developments, and political challenges impacting drug pricing and healthcare.
You'll hear the nation's top thought leaders, policy experts, and political analysts on topics like how employers, unions, and others use Pharmacy Benefit Managers (PBMs) to drive value for their members in the face of growing healthcare costs. You'll also learn about advancements in gene therapy, biologics, other cutting edge therapies, and the patient benefits and cost challenges that come with them.
The Pharmacy Benefit will also analyze the latest news from inside the industry and give you an educated perspective on where things currently stand and where we think they're headed.
JC Scott (00:08):
Welcome to The Pharmacy Benefit, a podcast that highlights the role of PBMs in serving millions of patients and consumers throughout the country. I'm JC Scott. In the midst of all the roar and ranker about drug prices, often overlooked are basic questions of access and use of prescription drugs as part of a patient's clinical care plan. And what's very seldom discussed is the role the pharmacy benefit managers play in patients clinical care.
On today's episode, we're going to talk specifically about all the work PBMs do in the area of clinical care. If you're listening to this podcast, if you have insurance, and if you've ever taken prescription drug, I want you to have a clear idea of how your PBM works with your pharmacy and with your provider between the time your prescription is ordered by a doctor, to when the drug is in your hands, and throughout your whole care experience.
Joining me is a person with a tremendous amount of experience, knowledge, and passion about how PBMs can work with health plans and providers to improve patient care. Dr. William Fleming is the Segment President Pharmacy Solutions and Chief Corporate Affairs Officer at Humana. In that role, William is responsible for Humana's transformation of pharmacy solutions, including its pharmacy benefit management and prescription delivery models, as well as Humana's Medicare prescription drug programs. He received his bachelor of science degree in pharmacy from the University of Kentucky College of Pharmacy, where he went on to receive his doctor of pharmacy, and where he became brainwashed into the cult of UK basketball fans.
Finally, William is also chairman of the board of directors here at PCMA. William, it's good to have you back on The Pharmacy Benefit.
Dr. William Fleming (01:40):
Yeah. Thanks for having me, JC. And the cult lives, go Big Blue.
JC Scott (01:46):
You know, William, my very first podcast experience was sitting down with you on your Will Talk podcast at the Humana offices. So thanks for repaying the favor.
Dr. William Fleming (01:56):
No worries. Happy to do it. And thank you for doing it then.
JC Scott (01:59):
So before we get into the meat of our conversation on the clinical aspect of PBMs, I'd like our listeners to learn just a little bit about you. How did you get started in pharmacy and why did you pursue it?
Dr. William Fleming (02:10):
That's a great question. I grew up in a small rural town in Eastern Kentucky, population, 4,000. We got a Walmart after I left for college. And was raised by my grandparents. And I knew that I wanted to be in healthcare. I had an inkling that pharmacy was the thing. So I went to a small undergraduate school in Lexington, Kentucky called Transylvania University. It's a private liberal arts school. And it's there that I applied for pharmacy school. Didn't know if I was going to get in between my junior and senior year, ended up getting in.
And so it really pushed me down a path of pharmacy, because at some point there, I thought I was going to become a physician and go down the physician path. Pharmacy showed itself to me. I was more opportunistic. Between my freshman and junior years, I did work in a local apothecary in my hometown. And it really opened my eyes to the value around pharmacy, and to that pharmacist, doctor interaction. Small community, the role the pharmacist plays. Candidly, for the longest time, I thought I was going to go back and just take over that type of apothecary setting. That didn't play itself out, and here we are today having this podcast conversation.
JC Scott (03:31):
So tell me why you didn't take that path? Why you chose the road less traveled, if you will, with your pharmacy degree.
Dr. William Fleming (03:38):
One of the things that I recognize about myself, you don't know what you don't know, as you're growing up. You think you're 18, 19, 20, 22 years old, and you think you know a lot. And you think about all the innovation that we've seen in our lifetimes. And for me, I guess the real driver was this notion of population health. Working in apothecary, working in that type of clinic setting, working in a hospital, doing clinical rounds, that's awesome work. It's important work. You've got to lay hands. It's valuable. It's something that I can say I've done, but I can also say it didn't inspire me. What inspired me was looking at a population and saying, can I help this population? Can I help this community? Can I help this state?
And as I started understanding more about this managed care thing, this PBM thing ... you can imagine in the 90s, growing up in Kentucky. Born and raised from Kentucky. This little thing called Humana was a hospital company. It really wasn't this managed care company. And I joined the company, probably about less than a year after we divested the hospitals. And so that was in our really formative managed care days. But I would say it was that journey to really wanting to deal with populations of people, as opposed to people by the ones.
I found that, although I could do it in my early days of being a pharmacist and working in a hospital or working in a retail pharmacy or working in ... you name the place. I tried several of them. But once I got into working for a Medicaid PBM, and then the Humana thing came calling, it really opened my eyes to population health. And how we can really do things for large groups of people, if we put our mind to it.
JC Scott (05:32):
So you've been around this work for a while. You're obviously passionate about it. What kind of progress have you seen in your 20 years at Humana on some of these questions? And how payers and PBMs of pharmacies are all working together towards that goal of better population health?
Dr. William Fleming (05:46):
Oh, JC, it's night and day difference. And the first thing that came to my mind listening to your question, there was the role of technology, the role of analytics, the role of data, and how all that comes together. And I do think that we've seen tremendous progress over the last 10 to 20 years. Today we have generic dispense rates that are 90%. When I started in this business, it was in the low 40s. So you just see that of transformation. When we started in the business, we didn't even know what a specialty drug was, and today it consumes every other pharmacy dollar.
And so we've come a long way in innovation. We come a long way in the science. But we've also come a long way in the role of technology, the role of analytics. The role of really trying to use data to inform, who are the people we can target to help them? What help do they need? And then, how do we employ the right engagement programs to make a difference in their lives? And I would tell you that pharmacist interaction is an important thing, because you have refills. You don't have refills on your MRIs, typically. Or your CT scans, or you name the medical thing. But drugs do have refills. And that engagement's a big deal amongst that patient population. And I think pharmacists sit in a unique role to be able to bring that together.
JC Scott (07:11):
So let's talk a little bit about the specific role of the PBM within all of this. And I'll describe how I've thought about it in the past, and you can tell me if I'm wrong. And it's okay to tell me I'm wrong, because I'm still learning this stuff. But I've always thought of it almost like a hub and spoke model, where the PBM in some ways is at the center as the hub, connecting the patient, the provider, the health plan, the pharmacy, to help with that care coordination, the medication aspect of all of that. Am I thinking about that in the right way?
Dr. William Fleming (07:39):
Well, JC, surprisingly, being a Duke grad, you are. You're thinking about that perfectly the right way. I had to get that out. You knew I was going to bring that up at some point. JC and I have this ongoing little thing between Kentucky and Duke. But yeah, I do think that the PBM sits in a really unique situation, largely because of the data. And because so many of them are tethered today to other payers. And it's that integration between medical and pharmacy that makes all the difference in the world.
So many folks think of pharmacy as a standalone thing, but I think of it as the last part of the medical supply chain. From not feeling well, seeking care, getting a lab done, getting the final diagnosis, getting the intervention ... the intervention may be a drug. And then finally getting to the counter. Or getting it by mail order. And it's that whole supply chain that matters, and pharmacy's a piece of it. That interaction and that knowledge transfer is really important. I think that PBMs sit in a unique spot because they can see the medical stuff happening if they're integrated. They know the pharmacy stuff because they see the e-prescribing now, which is another amazing innovation in the last 20 years that has come forward.
And they can bring that together to look at gaps in care. To look at things that should be happening, that aren't. To look at, not only physician behaviors ... who's prescribing what? But also patient behaviors. Who's choosing to not get what prescribed? In days of old, I will tell you, when I first started at Humana ... put it this way, JC. One of the things we did when I first started, we had all these staff model pharmacies. And we used to number the prescription pads, one through 100. And then we would go back and say, all right, we started on one today. How many prescriptions did the doctor, write? Okay. They wrote 70. How many prescriptions did we get for that doctor into the pharmacy? Oh, we got 62, 8 are missing. What happened?
And what we would find is oftentimes, between physician office, walking across the hall to the pharmacy counter ... there was no e-prescribing, right? The patient would make a conscious decision, Doc wrote me five of these. I'm only going to get four filled. So there's one that I'm going to choose to not get filled, for a variety of reasons. And so I think of that as primary non-adherence. That the physician tried to do something, the patient said, I can't afford it, or I don't want it, or you name the thing. And so just being able to navigate through some of that was interesting.
Today, that stuff's real time, it's online. We can see the e-prescribing, see the Doc e-prescribed five. And now today we can see, patient picked up four. The good news is, now we know that one that didn't happen. And when the patient doesn't do it, we can have a feedback loop back to the physician, almost real time saying, patient didn't get it. So a lot of innovation, but the PBM sits at the core of that translation of the data and how the data can go back and forth.
JC Scott (10:43):
Well, that's really illuminating. Because a lot of what you've talked about, I think of in population health terms where you're identifying trends in prescribing patterns and adherence patterns, and adjusting policies to try and benefit bigger groups of people. But I also want to understand what my PBM is doing for me as the individual patient. And you started to talk about that a little bit with my individual decisions on refills, things around adherence. And I understand there's work you do around drug interactions and safety related questions. But what are some of those things that you bring to bear for an individual with the PBM tools?
Dr. William Fleming (11:19):
When you start looking at the individual, that's where I would say the eCommerce world is starting to come alive. And the role of data and analytics and giving real feedback to patients about their utilization patterns when they're behind on their medication. Ways they could save money in their drug profiles. And there's a whole host of things that we can do to engage, and put clinical programs around it, with things like medication therapy management. Where we can either engage the retail pharmacies to deliver the service, or in some cases we do it ourselves. Whether the retail pharmacy can't do it, they don't want to do it, you name the thing. We have pharmacists that work inside the PBM, nearly 1,000 of them in our world, who truly deeply engage on a variety of clinical programs to engage with the patient or the member directly.
And it's through that engagement that we feel like we can deliver some, and have delivered some really neat health outcomes around med adherence. Around getting people on medications that they need to be on, like statins if you have diabetes. And importantly, and you mentioned it there, avoiding adverse events. So many medications work, but it's the adverse event that's the problem. And how we navigate through that helps avoid the hospitalization event in terms of that whole ecosystem.
JC Scott (12:40):
How do you find all this work is received by the patients you're working for and the providers and pharmacies that you're trying to work with? Are there abrasion points that you sometimes have to push through?
Dr. William Fleming (12:51):
There are. Probably the biggest abrasion point that we hear about a lot is prior authorization. And some of the things we do to try to push on the costs of medications, if all things are equal clinically, we might have on our formulary, two of the five medications and the physician writes the third one. And then we may go through a prior auth process to figure out whether the patient can tolerate the two that we picked. And so that's an often quoted concern. And frankly, a fair one, in part.
But the broader perspective if you move beyond that is, I will tell you, most of our students who come in from ... you name the university. Including the University of Kentucky. And they do our clinical programs. A lot of them have no idea the depth of the clinical engagement that we have, both with the physician and the patient. And it's powerful. At the same time, I will tell you, the provider community tends to engage with us and like these, because they have the role of improving quality metrics. And in the Medicare program, that's called stars. And then what higher the stars results can get, that obviously helps them. And so pharmacies can help the physician community on that.
On the patient side, I'd tell you that it's a bit of a mixed bag. If it's a program or a thing that we're engaging with a patient directly on, they see amazing value in it. If it's something behind the scenes, they obviously don't see it. If it's something that we see in their profile, is it better for us to go directly to them? Or is it better for us to go to the physician? We got to make a call on that.
JC Scott (14:33):
Getting back to your point about the abrasion and that individuals sometimes feel around utilization management, right? The prior authorization tools that we understand to be absolutely necessary as cost control mechanisms, given the high price of prescription drugs. But just to push you a little bit, William, do you think that PBMs could do better? I mean, you're talking about the deployment of a lot of technology solutions around these questions. Is there more that could be done to make that a more real time, seamless experience for the patient and provider than is being done today?
Dr. William Fleming (15:08):
Yes. The short answer is yes. Utilization management is an important tool, and these capabilities are super important, there's no question. But there is the role of data. There is the role of analytics. There is the role of evidence-based guidelines. And there's the role of looking at typical patterns of how people are doing their day-to-day job. And so we have launched at Humana ... or helped launch. A company that's intended to help us, I would tell you, in part simplify utilization management. By balancing what has happened historically that's delivered good outcomes in disease acts, with evidence-based medicine.
So that a physician, when they diagnose X, we can look at them and say, here's all the labs you can have approved. Here's all the procedures, here's all the tests, here's all the drugs. If you just stay within these guardrails, then you get one authorization. You don't have to come back for each thing, you get one blanket authorization. It's when you go outside of those guidelines that you got to come back. And so we're trying to simplify it by using history and using analytics with it, but also the evidence-based medicine to advance that.
And that's a company that just got launched about a year and a half ago. It's called Cohere. And it's a company that I think will end up making a really interesting difference in pharmacy as the use cases evolve. They started with musculoskeletal, and they're going to advance beyond that as the next few years come and go.
JC Scott (16:37):
That sounds like an exciting innovation that is just underway. When you look across the landscape, not just Humana, but the PBM industry and their work in clinical care and care coordination, where's this all headed in the next five to 10 years?
Dr. William Fleming (16:50):
If I had to pick out one word and one thing, it's the interoperability. I think the PBMs sit in such a unique position with the data and the tools and the technology. That the engagement with the electronic medical record vendors, the engagement with the patient directly through the health plan, largely, and using that type of thing, that the interoperability between the physician community, between the patient behavior, and between how the data shows up is going to be the thing that makes a difference in cost. It makes a difference in quality. And ultimately, whether the patient's in the hospital or not. And it's how that shows up that matters.
But JC, it's the interoperability. It's that engagement with Epic or Cerner, you name the thing, that will bring that alive, at Humana, we have a program that we've been working on now for ... Golly, probably six to seven years. Called in Intelligent RX. And its goal is to put this information on the glass in the physician exam room, so that as they're sitting there with Mrs. Jones and they're prescribing X, that they truly deeply know the alternatives. They know what it costs at the counter or by way of mail order pharmacy. And if Mrs. Jones has been non-adherent, they can have that conversation too, because we're giving them the data.
You can imagine, so many physicians show up today, patient comes in. And they think they prescribed drug X for the patient, whatever drug X is for diabetes. The patient comes in, the diabetes metrics, they're all out of whack. It doesn't make sense. They think they prescribed X. The metrics are out of whack. So therefore, I've got to prescribe something else because it's not working. When in reality, the patient's been non-adherent, but they didn't know it. And so they were going to change a drug, when the first drug didn't have a chance to work, right? Because the patient didn't take it.
And it's that deeper engagement and that piece of information that a physician needs to know in terms of, do I need to prescribe a new drug? Or do I need to address the behavior of, what is the barrier to drug adherence? And I think it's these types of interoperability tools, like Intelligent RX and like we have, and like many other PBMs have, that are the difference maker and will be the difference maker going forward. And how we're able to bring that forward into that whole care continuum.
JC Scott (19:22):
So a quick, second to last question for you, William. Hearing you describe that, I can't help but reflect that primarily, PBMs are known in the ecosystem for the savings that you're able to deliver, and the savings you're delivering to plan sponsors. Which is good for everybody who's on a health plan. But what's the main message, the main thing you would want to convey to people about your objective for them as a patient, for them as an individual?
Dr. William Fleming (19:47):
We really want to deliver the right clinical quality. Medication is an important intervention, but it's how that fits in their life. And their social determinants matter, right? If they don't have edible food at home, or food that's appropriate for diabetes, but they're being prescribed a diabetes medication, we've got to have the right tools and interventions to unpack that and help them with those things. And so I think that PBMs have a unique ability and sit in a unique position to help the pharmacy community, help pharmacists more broadly unpack some of that work, because we're able to have access to that type of data. And how we translate it out does matter.
JC Scott (20:27):
William, thanks so much for a great conversation. Thanks for joining me today and sharing your passion for the work that you're doing.
Dr. William Fleming (20:35):
Thanks, JC.
JC Scott (20:36):
And thanks to all of you for listening. I encourage you to subscribe to The Pharmacy Benefit and download all of our podcast episodes. You can do that on Google podcasts, Apple podcasts, Spotify, or wherever you find your favorite podcast. I'm JC Scott. Thanks for joining me.