Ask The Expert with Michael Navin: Unpacking the Latest Prescription Lawsuits

Hosted by industry expert, Michael Navin. 

Listen in to the latest series of Ask The Expert hosted by Michael Navin. In this brief episode, Michael delves into the growing concern surrounding prescription lawsuits and the risks employers face in managing employee health benefits. 

As lawsuits in the healthcare space come to light, it’s essential for employers to understand their fiduciary responsibility and the implications of working with Pharmacy Benefit Managers (PBMs) and third-party administrators. 

Michael walks listeners through the complexities of self-funding, PBM accountability, and how businesses can make more informed decisions to safeguard their healthcare plans. 

Key Topics Covered: 

• Employer Fiduciary Responsibility & ERISA Laws 
• The Role of Third-Party Administrators & PBMs
• Transparency in Prescription Drug Pricing
• Preventative Measures for Employers
• The Path Forward for Employers & the Healthcare Industry

Hosted by:
Michael Navin & Dr. Randy Vogenberg

Michael's LinkedIn

Randy's LinkedIn

Sponsored by:
Peek: A game-changing prescription shopping solution that allows its members to view all their prescription cost options across cash discount programs and their insurance in one easy-to-use platform. Peek is currently being offered to organizations to help both employees and plan sponsors save money on their prescription spend. https://peekmeds.com/.

Institute for Integrated Health (IIH): Health care benefits, insurance coverage regulations, and doing business in the healthcare industry can be complicated. At IIH, Dr. Randy Vogenberg and his team understand these unique challenges and provides strategic guidance customized to every client. To help overcome your unique challenges, IIH delivers education, planning and advisory on market trends, and U.S. health care market intelligence. The firm’s decades of proven success are due to strategic collaboration with associates from the business, clinical, and scientific communities. https://iih-online.com/.

Music by:
Hanu Dixit, https://www.youtube.com/hanudixit

Transcript

So we've been asked a few questions, uh, about specific topics. And one of those topics was the Wells Fargo employer benefit lawsuit.  The question was, what are the implications of a major corporation being sued over the mishandling of their employee memberships policies?  And the answer is pretty simple. 

Employers who are self funding their benefit through their insurance fund is subject to the ERISA laws and the ERISA laws are there to protect the employees. And therefore they're the fiduciary that oversee the money coming out of that account. So their responsibility is to make sure they're getting the best prices and passing those prices through to their employees. 

Don't most employers use a third party subsidiary to manage their pharmaceutical management plans?  And if they are self funding, the answer of that is yes. About 165 million U. S. lives are self funded, and they're using a third party to administer their benefits. That could be a health plan who's acting as the administrator, or it could be a third party administrator and or a PBM. 

Why is the PBM not held accountable for selling or managing these types of plans? What people have to understand is the PBM is simply a processor of the claims and they promise rebates because of the purchasing power that they have. So as long as the PBM does what they're contracted to do, They're really not held accountable for overspending. 

And this has been a problem in the market, especially with the recent Johnson and Johnson lawsuit. And now you're seeing it with Wells Fargo. It has come to light that these PBMs lack transparency and do not pass through all of the cost savings, which are putting these employers at risks. So why are the employers the only ones being held accountable? 

That's because they are the fiduciary and ultimately the responsible party. And the really the only implication that the PBM will have in this case is they could possibly lose their contract, but there is no legal obligation for them in this case. Next question is how do these inflated prescription drug costs impact the healthcare choices and what measures can be taken to protect employees from similar situations in the future?  

First of all, the PBM has a high rebate for coverage is extortion. It's forcing the manufacturer to triple the introductory price of drugs just to be able to kick back a rebate that the PBM is willing to take. And as I mentioned before, it really lessens the money in the, in the healthcare funds overall by not having standards to pay appropriate prices for prescription drugs through the pension fund. 

And you are draining the future dollars meant to be there for healthcare spending. So in light of this case, what changes could be made to the industry standard? Well, in my opinion, it's a simple solution to a complex problem. Working with companies that provide cash discounts and integrate members insurance is paramount. 

This allows the patient to have a full picture of the cash options available to them and the insurance options available to them.  And this is why we founded Peak. Prescription marketplace to really empower employers and employees  and and really have more accurate.  Pricing and coverage information when they're choosing a prescription drug, it's a searchable platform 

So it allows the patient to have a comparison of cash discounts to the, or insurance. And we also think that the manufacturers will be happy to jump on board with peak. really to provide access to their medication, give another channel for patients to get access at better prices. We believe patients should know that they will decide this ultimately with their doctor,  uh, which prescription they need, but they'll know before they go. 

And that's the most important thing for us.