Plan Sponsors Are Asking for Alignment & Change. Capital Rx Is Delivering Both
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Every year, organizations around the country release reports about the state of pharmacy benefits. These annual reports are often surveys that offer deep insights into industry trends and the challenges Commercial, Medicare, and Medicaid plan sponsors are facing.
Thanks to the combination of our award-winning team and our cutting-edge enterprise health platform, JUDI®, Capital Rx is uniquely positioned to solve the pain points mentioned in these report and deliver on the things plan sponsors are asking for.
So, let’s break down some of the highlights from four such reports and further explain how Capital Rx can help.
Insight #1: PBM Satisfaction Remains at an All-Time Low
It’s no surprise that plan sponsors are not fond of their PBMs right now. Pharmaceutical Strategies Group’s (PSG) PBM Satisfaction Report revealed that overall PBM satisfaction currently sits at 7.6 out of 10 -- unchanged from 2023 and the lowest it’s been since 2015. More significantly, this metric has fallen from 8.1 back in 2021.1
Net Promoter Score (NPS) tells a similar story. PSG’s report shows that NPS has fallen for both employers and health plans alike: 13 and –15, respectively (NPS is judged on a scale of –100 to 100). The same page shows that the “likelihood to recommend” metric has also fallen and stands at a five-year low (7.5 for employers; 6.3 for health plans).2
How Capital Rx Is Helping
These metrics are not sustainable. That’s why Capital Rx has focused on building a call center that is available 24/7, is multilingual, and is staffed with pharmacists that are available to help advanced situations that require clinical insight. As our co-founder & CEO has said on occasion, we aim to “delight” our customers, and we have done the hard work to ensure you never get trapped in an endless phone tree (trust us; we’ve been there, too).
As a result of our efforts, Capital Rx boasts the best NPS scores in the industry: 90 Client NPS and 83 Member NPS. On top of that, we retain 99.5% of clients and have a 100% implementation satisfaction rate. Plus, when members call with questions or concerns, we are proud to say we solve it during the first call 97% of the time, so members don’t have to call back repeatedly to get their issue fixed.
Bottom line: your satisfaction, and your members’ happiness, is paramount to us, and we walk the walk.
Insight #2: Plan Sponsors Want an Aligned Partner Prepared to Help with GLP-1s
Two common themes came up in these annual reports: one is that plan sponsors are increasingly concerned about GLP-1s. The other is that they are looking for an aligned, collaborative PBM partner.
Both of these points were raised in PSG’s report as factors respondents believe would help with their overall PBM satisfaction. Additionally, International Foundation of Benefits Employee Benefit Plans’ (IFEBP) reported that employers were projecting an 8% increase in healthcare costs. Specifically, 20% of employers specified that specialty and costly drugs – specifically GLP-1s – would be the primary factor associated with that cost increase.3
Similarly, KFF’s 2024 Employer Health Benefits Survey4 found that 33% of all firms expected GLP-1s will be a significant cost driver, including:
- 28% of firms with 200-999 workers
- 42% of firms with 1,000 – 4,999 workers
- 58% of firms with 5,000+ workers
At the same time, plan sponsors have solutions in mind that can help manage these cost increases. For example, in IFEBP’s report5, when respondents were asked what strategies would make the most impact on managing costs in 2025:
- 27% said utilization control initiatives, like prior authorization
- 21% said cost-sharing initiatives, like deductibles, coinsurance, and copays
- 15% said plan design initiatives, like high-deductible health plans, formulary changes, and dependent eligibility audits
- 9% said purchasing/provider initiatives, like telemedicine, price transparency tools, centers of excellence, and quality initiatives
The point is clear: plan sponsors want an aligned PBM who is going to partner with them to manage costs, especially those related to GLP-1s. In fact, Business Group on Health’s Survey found employers are prepared to reassess the quality and effectiveness of their vendor partnerships. Specifically, respondents said they were prepared to leverage the request for proposal (RFP) process to secure better vendor pricing and end partnerships with underperformers, with an eye specifically on transparent PBMs.6
How Capital Rx Is Helping
Cost continues to be a significant pain point for plan sponsors, and the influx of expensive GLP-1s has significantly exacerbated it. It should come as no surprise that plans are looking for a PBM partner that prioritizes cost containment while still maintaining focus on members’ health outcomes. That’s why Capital Rx is proud to partner with our clients to find a solution that best works for them and their members.
For example, by leveraging JUDI’s Prior Authorization Tool (PAT) we have helped stabilize and reduce GLP-1 related costs per member per month (PMPM) for current clients.
We also have consistently helped clients cut costs. In July 2024, CDPHP sat down with Modern Healthcare and revealed they have seen costs drop 9% for commercial members under the contract. Similarly, The Teamsters Health and Welfare Trust Fund of Philadelphia and Vicinity revealed in an article with The Wall Street Journal that switching to Capital Rx has helped them save more on drug spending each year than initially projected, including 17% the first year.
One solution does not fit every plan, though; that’s why we proudly partner with our clients to identify the strategy that will work best for them. Our VP of Commercial Markets, Nick Van Hook, said it best on a recent episode of our podcast, Astonishing Healthcare: “We are here to administer your plan. The data is yours. We have a fair acquisition cost pricing model, and at the end of the day, we're going to give you the information you need to make a more informed decision. We'll provide recommendations, but it is ultimately your plan...You get to ultimately make that decision and we'll give you recommendations and information that you need to do so.”
This looks simple on our end: we pass through all rebates, don’t make a penny on drug spend, and collaborate with clients on ways to manage costs. Furthermore, through JUDI, we are able to provide plan sponsors with the insight they’re asking for: easy reporting capabilities, greater transparency, and more interoperability. You can read more about JUDI’s open-API design and how that helps drive innovation and efficiency in pharmacy benefits here.
Insight #3: There is Increased Interest in Unbundling Pharmacy Benefits
For years, pharmacy benefit management (PBM) commodity functions, like mail order and specialty dispensing, have been tied to claims processing. This has resulted in a situation where plan sponsors feel tied to their incumbent PBM due to how onerous and disruptive it can be to implement a new PBM.
But plan sponsors aren’t satisfied with that status quo. As PSG’s report revealed7, many are interested in carving out specific services, including:
- Specialty Pharmacy: 68% interested (22% very, 22% moderately, 24% slightly)
- Rebate Management: 58% interested (13% very, 19% moderately, 24% slightly)
- Mail-Order Pharmacy: 49% interested (11% very, 16% moderately, 22% slightly)
- Retail Network Management: 44% interested (6% very, 15% moderately, 23% slightly)
- Claims Adjudication: 37% interested (9% very, 9% moderately, 19% slightly)
The trend here is clear: while plan sponsors have greater interest in carving out some services over others, there is interest in untethering some commodity services from claims adjudication.
How Capital Rx is Helping
PBMs used to be unbiased administrators, offering advice and guidance that was in the plan’s best interest. Obviously, that’s not where the industry is today. But, as our co-founder and CEO, AJ Loiacono, likes to say, “Let’s go back to the future.” And, at least when it comes to that philosophy, Capital Rx has done so.
This is the driving force behind our Never Move Again™ solution, which unbundles pharmacy benefits for large plan sponsors (10,000+ lives) and choose the fulfillment or clinical services they want within an ERISA-compliant framework. This meets large plan sponsors where they are, providing them with the flexibility they want to best serve their members.
JUDI’s interoperability makes all of this possible. We securely push and pull data every day with 600+ unique entities (carriers, health systems, point solutions, etc.). This interoperability makes it very easy for plan sponsors to plug in their preferred mail-order or specialty pharmacy partner while retaining a foundation of electronic infrastructure that’s future proof and offers unlimited data storage. Plus, our industry-leading customer care center is included with Never Move Again™, which means that members won’t have to worry about changing ID cards, websites, portals, or apps ever again.
That is what we mean by going back to the future – returning to the unbiased, conflict-free approach to pharmacy benefit administration and bolstering it with a platform designed to meet modern healthcare needs.
To learn more about Never Move Again™, click here to check out the full webinar replay.
Insight #4: Plan Sponsors Are Willing to Affect Change – and They Want a PBM Who Will Help
Not only are plan sponsors unhappy with the status quo, but they are willing to affect change. It makes sense, too – after all, plan sponsors have had a front-row seat to a lot of the pain points affecting the pharmacy benefit industry.
PSG’s survey found, unsurprisingly, that healthcare payers’ desire for change in pharmacy benefit management has only increased over the years – with 54% of respondents rating their desire for change at 7 or above on a scale from 1-10.8
On top of that, 75% of respondents agreed that payers must make changes, and only 16% of respondents said they were “not at all willing” to be part of disruptive change to the PBM industry.9
It’s clear that the issue is not that payers want to stick with the status quo – it's that they both want and need a PBM partner who’s willing to effectuate that disruptive change with them.
How Capital Rx is Helping
We are no stranger to the “disruptor” label. When asked why he co-founded Capital Rx, AJ almost always says, “To fix the problem, we had to become the problem - a PBM.” But we’ve been focused on returning to the roots of plan administration, doing what’s right for plan sponsors and their members, not our bottom line.
That’s why we refuse to profit from drug spend, instead charging a flat fee. That’s why we pass through all rebates. We built JUDI because we recognized the industry lacked a modern enterprise health platform capable of delivering the efficiency, interoperability, security, and scalability plan sponsors and members expect. In fact, JUDI’s interoperability is what makes our Never Move Again™ solution possible.
But we’re not stopping there. JUDI’s scalability and data storage capabilities make it possible to pursue unified claims processing, where pharmacy, medical, dental, and vision claims are housed and processed on one platform.
In short, Capital Rx is proud to be a PBM that drives change in the industry.
The Future of Pharmacy Benefit Administration is Now
If these reports reveal one thing, it’s this: things need to change within the pharmacy benefits industry. At Capital Rx, we’re driving that change – being an unbiased administrator that refuses to make money on drug spend, unbundling pharmacy benefits for large plan sponsors so they can better serve their member base, helping plans reduce drug spend, and deploying the electronic infrastructure our nation needs to deliver the healthcare we deserve. It's through this approach that Capital Rx has become a "one of one" organization and is setting a new standard for the future of pharmacy benefit administration.
Click here if you want to learn more about JUDI, our enterprise health platform. And if you want to hear in-depth breakdowns of important topics in the pharmacy benefit industry, subscribe to our podcast, Astonishing Healthcare!
Sources
1, 2, 7, 8. 2024 PBM Customer Satisfaction Report. Pharmaceutical Strategies Group (PSG). https://www.psgconsults.com/industry-report/2024-pbm-customer-satisfaction-report
3, 5. Employers project 8% rise in health care costs for 2025. IFEBP. https://www.ifebp.org/detail-pages/news/2024/08/15/employers-project-8--rise-in-health-care-costs-for-2025
4. 2024 Employer Health Benefits Survey. KFF. https://www.kff.org/report-section/ehbs-2024-summary-of-findings/
6. Business Group on Health Survey reveals almost 8% in projected health care trend for 2025. Business Group on Health. https://www.businessgrouphealth.org/newsroom/news-and-press-releases/press-releases/2025-employer-health-care-strategy-survey
