How We Move Forward

Dec 18, 2023

Earlier this year, we convened some of the brightest luminaries in the industry to collaborate, debate, and discuss one of Abarca’s biggest priorities: finding a better way in healthcare.

Here are just a few of our takeaways from the event:

  • We’re left with more (refined) questions. Sometimes, a serious discussion with experts leaves participants with new questions. But, at Abarca, we consider that to be a successful outcome because it challenges us to refine our thinking. A few points that we’ve been left to explore further:

    • The absence of a widely recognized ROI for pharmacogenomic access is giving payers pause in covering these tests, and therefore slowing the progress of the next generation of personalized medicine. What can we do to close this gap?
    • When it comes to applying alternative payment models to high-cost specialty drugs, there are four components that are critical to a successful implementation: data, alignment, timing, and trust. How can PBMs make this a reality?
    • Can we reimagine adherence by taking into account social determinants of health (SDOH), such as literacy, mobility and transportation needs, income, housing, education, and food security status? Other countries are using SDOH to determine what gets prescribed to improve member health. For example, in Canada you can get a referral for time you spend in nature. Does the US need to make greater use of SDOH?
  • The one thing politicians agree on. To state the obvious, the political climate in the US is starkly divided. But there is one thing that both sides of the aisle seem to agree on: drug benefits need to be reimagined. Abarca agrees, as well–and we are doing our part to lead the industry in this transformation.

At the same time, many non-traditional players, like Amazon, and already deeply entrenched entities, like CVS and Walgreens, are further challenging the traditional approach to prescription benefits by tying medications to consumer goods. For example, low-cost medications for Prime members.

This trend is bringing up new questions in the industry about the appropriateness of these approaches.

  • Progress is happening. Stakeholders across the industry are working to address what needs to be done to fix healthcare. However, we also need to recognize the progress that has been made thus far and proceed accordingly.

For example, it wasn’t too long ago that prescriptions and prior authorizations (PAs) were all written by hand. Those manual processes are becoming increasingly rare. However, we need to keep pushing for the widespread adoption of technology that can take the industry even further, and make healthcare seamless and personalized for all.

For example, while we work to move towards 90% approval for PAs, how can the system be reimagined so that 90% of members are not inconvenienced in an effort to identify the 10% of prescriptions that do not meet the prior authorization criteria and should not be filled?

  • What’s stopping virtual PBM? The industry is increasingly recognizing the benefits of a virtual PBM model. In particular, payers are open to separately outsourcing and/or insourcing claims administration, network, and rebates, and seeking out the best-in-class partners and technology to manage each area.

However, a virtual PBM cannot succeed without transparency or an infrastructure that effectively gathers and processes the necessary data.

We’re looking forward to continuing to dig into each of these areas, among others, as we work to deliver a healthcare experience that is seamless and personalized for everyone.

This blog was written by Safa Elshanshory, Chief of Staff at Abarca.