Justin Venneri
One of the most powerful deterrents to change is fear. Thankfully, overcoming fear, whether it’s fear of disruption, unknown outcomes, or potentially looking foolish, requires just one thing: trust.
The average commercial PBM agreement is three years, but we know that pharmacy cost trend and member service concerns lead to more frequent “market checks.” Given persistent pharmacy cost trend inflation, it’s somewhat surprising that the majority of plan sponsors are “satisfied” with the status quo.1 “We were worried about transitioning everything and member disruption” is one of the most frequent explanations our team hears from prospects who end up sticking with an incumbent PBM.
On the health plan side – pharmacy benefit administration (PBA) – the duration of legacy pharmacy claims processing systems agreements tends to be much longer (i.e., 7-10-plus years). In some cases, stakeholders may not have all the detailed information needed to “comfortably” switch their PBM vendor because of how old the systems are (e.g., they may not know all the rulesets around the plans).
For the sake of brevity and to not stray from the topic of implementation, let’s proceed under the assumption that the decision to switch PBMs has been made. I asked Kate Koltz, Vice President of Implementations, Tracey Rollins, CPM, Director of Implementations, Jason Barretto, Vice President of Government Program Operations, and Adam Kravitz, CPM, Senior Implementation Project Manager, two things:
- What makes implementations for payers ranging from health plans and health systems to large and small employers, labor unions, and municipalities successful?
- What are a few things you’d suggest people do to ensure a successful PBM - or PBM software - implementation (and go-live)?
Read on for the summary of their responses!
A pharmacy benefit administration partner should…
Handle the heavy lifting throughout implementation and quarterback the process openly and with attention to detail. Long story short, well-defined, battle-tested processes and clear communication help instill trust with payers and lead to successful PBM implementations, no matter how complex.
The standard commercial implementation timeline is 90 days, and there should be a clear plan, frequent calls, and full transparency. For a health plan, 9-12 months is generally the standard implementation timeline. A true PBM partner will make you feel like they are a part of your team during the process. Ideally, the account management team is involved in the process to facilitate a smooth “handoff” after the go-live date.
Suggestions to ensure a successful full-service PBM or PBM software implementation:
For Health Plans
- Health plans are used to big moves with lots of extreme heavy lifting, but you must have clear, concise requirements and target dates.
- Ensure your plan design requirements document is 100% up-to-date and accurate. It’s surprising how many implementations reveal gaps in what was built, and such gaps add weight to the lift to ensure that the intent of the design is accurately captured.
- Ensure that ALL of your decision-makers are engaged. For larger plans, there are multiple owners, and some things may be passed up to the C-suite. If everyone isn’t aware of what’s needed from them, it can lead to delays.
- At Capital Rx, we have a checklist to follow in preparation for go-live. Client engagement tends to decrease during the build and test phases of implementation, and you’ll want to run some test claims and make sure the team is prepared to support what’s coming (e.g., are the benefits set, are phone numbers correct, are the ID cards ready for new plans, etc.). Try to follow the checklist as closely as possible.
For Commercial Implementations (Employers, Unions, et al.)
- Are you keeping the plan design as close to how it was? Ensure that your intake requirements are filled out completely and have been reviewed.
- See if your PBM has a library of member communications collateral (Capital Rx does), or if you have examples, share them. It may help with the member transition and communication strategy, as you know your membership best.
- Your PBM partner should manage this, but be sure to engage any vendors early on – e.g., medical, eligibility, or accumulator vendors.
- Consider continuation of therapy to avoid disruption for plan members on chronic medications.
- Ask to meet your account management team! See how early they’ll become involved. The earlier, the better to ensure a smooth transition.
- Participate in every weekly implementation meeting – it helps. If you don’t have weekly meetings, ask for weekly meetings.
Capital Rx’s approach to implementation.
We’ve proven that implementations do not have to be painful. Whether you have three benefit plans or 200+, attention to detail, modern technology (JUDI®), and refined processes contribute to our 100% implementation satisfaction score year after year.
How does JUDI help?
Having an efficient, scalable enterprise health platform is a huge advantage. Take Benefit Configuration Testing, for example. With a legacy PBM vendor, clients have no way of testing on their own! They must wait for the PBM to provide testing outputs/results, whereas Capital Rx can provide health plan clients the ability and option to perform batch testing independently.
Don’t let fear stop you from switching your PBM vendor.
Overcoming fear is not impossible, but it does take time. The solution is surprisingly simple: engage a PBM or PBA partner with a fundamentally aligned business model and modern technology.
If you're interested in learning more about Capital Rx's approach to implementation or our full-service PBM or PBA solutions, please GET IN TOUCH!
1 Pharmaceutical Strategies Group. 2023 Pharmacy Benefit Manager Customer Satisfaction Report. Dallas, TX: PSG. Available from psgconsults.com/research