WithMe Health serves as a preferred Pharmacy Benefit Manager (PBM) partner for Centivo due to its emphasis on price transparency, no ‘spread’ pricing, and medication guidance that addresses utilization in addition to unit price.
Ashok Subramanian (AS) – Hello, Joe, and thanks for agreeing to this Q&A to help our blog readers understand the relationship between WithMe Health and Centivo. Can you first tell us a little bit about WithMe Health?
Joe Murad (JM) – Happy to, Ashok. WithMe Health is a modern PBM with a passion for helping members with everything related to their medications. We call what we do personalized medication guidance. I’ve been fortunate to serve as CEO since 2019, after building other digital health businesses throughout my career.
AS – WithMe Health is also what’s known as a “transparent PBM,” which to many of our readers will equate to the phrase “jumbo shrimp” – a total contradiction in terms. Yet we know they both exist, so could you react to that analogy and why it matters, especially to our employer clients?
JM (laughs) – Ashok, that is an awfully good (pun intended) analogy. If you have read anything in the healthcare media in the last few years, you’ll know that traditional PBMs are being held up as the ‘worst of the worst’ when it comes to price and cost transparency. Many consider it the opaquest corner of the entire multi-trillion-dollar healthcare spend in this country, and that is really saying something.
AS – But you’re doing things differently?
JM – At WithMe Health, we are part of a class of PBMs trying to change this status quo. We are transparent, meaning we’re making it possible – and easy – for our clients to understand what we are doing with their pharmacy benefit offering. In other words, they get a clear understanding of where money is coming from, where it’s going and why. And we are also “pass-through,” which means we charge a simple and straightforward per member per month fee, then pass any rebates, discounts, costs and so on straight through to the employer. Employers and members pay actual drug costs plus a small dispensing fee whereas, in most of the industry, the purchase price is not actually connected to the cost of the drug. We don’t retain or skim off the top.
AS – If we didn’t know better, that is what I would assume a pharmacy benefit manager should do. But to go back the “jumbo shrimp” analogy, the fee structure that you describe above is NOT what traditional PBMs do for clients?
JM – Unfortunately, that is absolutely the case. Traditional PBMs operate a “spread” model – they make money on margin, charging clients significantly more than what they reimburse pharmacies. They also steer members to their own mail order and specialty pharmacies. What this means in practice is that the higher a client’s pharmacy spend, the more money the PBM makes. And so this kind of PBM’s profit is totally unrelated to how well they are managing a population or serving their client. It’s a real conflict of interest that has gone on for far too long.
Probably the most famous, or infamous, practice surrounds rebates.
AS – I know rebates are distorting the way prescription drugs are paid for. How does that play out?
JM – Rebates are a very sweet deal between traditional PBMs and pharmaceutical companies. Basically, a pharma company rewards a PBM for driving a big enough volume of a certain drug by giving that PBM a “rebate.” The PBM usually drives this volume through the design of their formulary.
In practice, a traditional PBM pays the pharma company, then the pharma company gives the PBM back “rebate” money. But the problem is, what does the PBM do with that money? Do they give it to their clients?
AS – I know they keep a surprisingly high percentage. And there’s very little accountability or visibility.
JM – That’s right. And this practice hurts clients and hurts members. It drives up healthcare costs by encouraging more and often unnecessary drug utilization, impacting the cost of medications throughout the market. It is a major problem in the US healthcare system. And we want to make the US healthcare system work better for more people. The first step is letting everyone see what’s happening – being transparent to our clients and the industry at large. Every dollar a client is spending or saving, we can show them where it is and what it’s doing.
AS – This is exactly why WithMe Health is part of our suite of pre-integrated solutions into the Centivo health plan platform. We also are rooted in ‘to the penny’ accountability and a simple fee structure that passes along anything else to the client.
JM – And that’s all too rare in the market today.
AS – But can I ask: in a quickly growing field of transparent PBMs, what are the important differences we should all should keep an eye out for?
JM – Beyond transparency and the pricing model — in this cohort, most of us have pass-through pricing – there are many different axes a PBM can center itself around. You can tell a lot about a PBM by how they talk about themselves.
AS – Can you tell me a little more about that?
JM – Look at their websites, at their social media and at the materials they produce. Some talk about algorithms. Others talk about price. But it doesn’t matter if you process a claim a nanosecond faster or have fractionally better pricing if the medication doesn’t work for a good portion of your members.
At WithMe, we talk about demystifying and improving the member experience. And we talk about clinical efficacy and how this and the member experience come together for better medication management. Those are at the core of nearly everything we do because they are what we place the most value on. So that is the advice I would give you – pay attention to what a PBM talks about most and you’ll have a good idea what they value most. And know that what they value is where they are deploying their time and resources.
AS – At Centivo, we’re really focused on being a health plan that brings together affordability and quality. And you’re right, these are the things we talk about all the time. Like the challenges you’re tackling in pharmacy, affordability and quality seem like they should be the backbone of how every health plan operates. But they aren’t. So we’ve had to re-imagine what a health plan can be.
JM – Exactly. And it’s why we like working with you Ashok. There is strength in numbers when you’re trying to change the world.
AS – And ours is certainly a world ripe for change.