Join Eileen Murphy, Director of Pharmacy for Security Health Plan, and Bryan Schuessler, Director of Product Management for Rx Savings Solutions, as they discuss the evolving pharmacy landscape and strategies for 2025. We explore their key focuses for the upcoming year, strategies to manage rising drug costs, and insights on preparing for regulatory changes. Listen for expert perspectives on staying competitive and meeting member needs in a dynamic healthcare environment.
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LUCAS: Hi, everyone, and thank you for tuning in to the Becker’s Healthcare Podcast. I’m excited to be joined by Eileen Murphy, Director for Pharmacy for Security Health Plan, and Bryan Schuessler, Director of Product Management for Rx Savings Solutions, to discuss navigating the evolving pharmacy landscape into 2025. Thanks so much for joining us both.
I know in 2025 there’s a lot of things that we’re looking forward to, a lot of things, outlook wise, that we’re going to be addressing here in a little bit. Lots to talk about. Eileen and Bryan, I just want to start off with having you introduce yourself to the audience a little bit with what you do on a regular basis, and your roles. And, Eileen, we’ll start with you here.
EILEEN: Yes. Hi. I’m the Director of Pharmacy Services at Security Health Plan, which is based in Wisconsin. It serves primarily a rural population throughout the state of Wisconsin, and I oversee all aspects of the delivery of the pharmacy services to the members.
BRYAN: Yeah. Bryan Schuessler here. I am the Director of Product at Rx Savings Solutions. I am a pharmacist clinician by background, and my day to day consists a lot of doing some research, investigation to try to solve problems for our clients across the spectrum on pharmacy benefits, how we can help members find lower cost alternatives, help drive quality, and overall give a better medication experience for members.
Where Should Health Plans Focus in 2025?
LUCAS: Yeah. And I think that’s really the key piece that comes to mind, right? We want to improve things for folks. We want to find solutions that help patients, that help people looking for solutions that fit them. And Bryan, I want to come to you here. We certainly know that drug costs are going to rise. That’s a trend that’s going to continue into 2025. What are your main focuses for the upcoming year and beyond? What are you looking forward to?
Engaging High-Impact Member Populations to Drive Savings
BRYAN: Yeah. You’re exactly right. Drug prices are continuing to rise. There’s a lot more attention on that again and again. And for us, we have some core principles that we always follow. So we’re going to stick to those, but really that is helping our clients drive and execute on the benefit strategy that they have designed. So, a lot of clients and a lot of plans, they’re going be tweaking things. They’ll be looking at changing formularies, plan designs, UM edits, and PA criteria. Each plan and each design can be different, so we like to be very intentional about how we serve them and help them execute that in the year to come. Because, really, that helps drive affordability and ultimately access, as well as we want to educate the members on the pharmacy benefit options, right?
There that’s how you find out, “What do I have available to me? What access do I have?” And sometimes that can be confusing.
I’m a pharmacist. I’ve been in this world for 20 years. It can still be confusing, what is covered. What’s tier 1? What’s tier 2? So, we want to spend time really educating people on what the best move is for them. And then it goes even deeper to provide some very tailored and detailed messaging where there can be some big key spend drivers. So we can target maybe biosimilar populations or members that really have a chance to save, and bring that information to light. So those are the focuses for us. We need to make sure what our client’s design is and then let’s go execute that and really help them drive those savings.
Educating Members on Lower-cost Alternatives
LUCAS: Absolutely. Eileen, same for you as Director of Pharmacy. You’re very close to this issue as well. What are your main focuses? What are you interested in?
EILEEN: Yeah. I agree a 100% with what Bryan said. We absolutely try to focus on the member perspective. They have choices, so we try and engage the member making sure that they’re aware of all their options related to medications. We try to encourage utilization of generic drugs. We have restructured our formulary for the next plan year to offer two $0 tiers. So, we have a preferred generic tier and a select care tier, which encourages utilizations of a lot of maintenance medications for cholesterol, diabetes, hypertension—common disease states. Our goal there is really to promote access to low-cost medications for common chronic conditions that are shown to improve health outcomes.
So, we’re really trying to engage the member in those options. And one of the options that we do have is working with Rx Savings Solutions and making sure that members are notified when they have opportunities to lower their drug costs.
They’re notified of potential switches, and we’ve had some success with that with so far. We’ve had over $500,000 in member savings out of pocket.
How Do Health Plans Prepare for Regulatory Changes?
LUCAS: Yeah. And there’s certainly a lot of things as you both mentioned that you can control in terms of trying to drive some of these changes, making things easier through the advancements that that you’re driving.
Unfortunately, there’s also a lot of things where there’s not as much control, specifically regulatory changes with the IRA and Part D redesign. And, Eileen, if you could address that too in terms of how leaders can really prepare for those changes?
Encouraging Utilization with Formulary Strategies for 2025
EILEEN: Yeah. That’s a great question. I think we’re starting with basics here. We’re starting by making sure we’re educating our internal teams and our partners and our members about all those changes. Whenever we have significant changes, like we do for the upcoming plan year, we want to make sure that everyone understands those. From a member perspective, a lot of those are going to be big wins.
The removal of the coverage gap phase, no member coinsurance in the catastrophic phase, the reduction of the max out of pocket to $2,000, the option of the smoothing program for some members. So, a lot of great things happening next year for members. We want to make sure that they fully understand those, and make sure any of our teammates who are talking to our members can fully articulate those changes.
In addition to that, I think a lot of the work done to prepare for 2025 in terms of formulary to structure changes has already been done way earlier in the plan year. We have made a number of different formulary tweaks to help fine tune our formulary, if you will, removing some originator drugs where a generic is available. We worked with our PBM partner to make sure that we had the best solutions in place. We added the two $0 tiers and have over 500 products now at $0, helping to encourage again utilizations of those lower-cost drugs.
Using Data to Forecast Impact of Regulatory Changes
LUCAS: Yeah. Bryan, what’s that for you? What does that look what does that preparation look like for leaders for some of these shifts that are happening?
BRYAN: So we do in our position, right? Somewhat like Eileen and her team, we work with data all the time, and we try to get in front of it. So we look for, hey, “What are the impacts based on some of the regulatory changes?” The things we can’t control, but what we can control is we can maybe forecast and say, “Hey. This might be the impact based on this $2,000 cap,” or ”This might be the impact based on formulary change.” We can help get in front of those. But the key for us is we ask questions to our clients and then we listen, right?
What do you want to talk about with these changes? What’s your strategy? Each group can be different. What we do is we communicate clearly and transparently to the members about what’s happening and why, according to the clients and how they want that.
And then as the year progresses, we don’t just stop and say, “We’re going to set up a plan and then let it go.” We will continue to monitor data, and we’ll work back with the clients to ask, “What’s working? What’s not working? Are there areas that we could maybe enhance? Can we communicate strategically in certain places based on the data we’ve now received?”
So it’s an ongoing process. But you do really need to look into your data, see what’s going to happen, and then try to get in front of it as well as the year progresses.
How Can Health Plans Manage GLP-1 Costs?
LUCAS: And speaking of data and some of the progressions for next year too—one of the trends that we’ve seen, unfortunately, over the last couple of years and treatments have certainly improved, and like you said, data has improved, etc.—obesity, diabetes…
Those issues are most likely not going to go away and a lot of folks have to adjust to that across the industry.
Eileen, I want you to address some of the things that have been going on with GLP-1s. What are the headlines there and some of the strategies that you have implemented to manage those costs in that area?
GLP-1 Utilization and Pricing Reform
EILEEN: Sure. So at our plan at this time, we’re limiting GLP-1 utilization to diabetes diagnosis. So that’s been one of the primary financial strategies around GLP-1s. From a more strategic perspective, we’re also working closely with other community health plans to push forward additional drug pricing reform. I think the root cause of the problems that we’re seeing here is related to drug pricing. So right now we have, some patent thickets, drug reform, laws being proposed. So we’re hopeful that there’s additional movement on that that’ll help alleviate some of the root cause of the problems going forward.
LUCAS: Yeah. Bryan, same for you. Are you seeing that same strategy sort of evolve as well?
Clear Communication around GLP-1 Coverage
BRYAN: It is across the board. Eileen and I were talking earlier this week. This is just a very hot topic, but it’s a very impactful topic to the bottom line when you look at what it’s done. And so how do you manage patients and their care, but do it in a way that’s economically feasible? It’s a tough spot to be in. The first question is, are you going to cover it or are you not? If you’re not going to cover it you want to be able to communicate that and tell a very clear story. So we can help with that.
Or, say, “Hey, we’re going to cover it, but here’s the way that we’re going about it.” Now other people have tremendous amounts of processes that members will go through. So, a lot of it is clear communication. I still think it’s monitoring what is the bottom-line impact, the outcomes. So, we try to use all that and help, but it is a very unique decision based on each client.
So, I’m interested to see where the future goes in 2025 because I think there’s going to be unique changes that happen.
How Can Health Plans Adjust to Stay Competitive?
LUCAS: Yeah. Well, we’ll certainly keep an eye on it and probably we’ll talk about it in a different podcast again. You’ve mentioned the financial feasibility a little bit too, and it is the one of the important things is to stay competitive and being able to say, “How do we adjust to be able to stay on the market competitively?”
For you, Bryan, too, what strategies should health plans look for to be competitive and meet those evolving needs that we’ve talked about throughout our conversation here for 2025?
Leveraging Partners to Guide Data-Driven Decisions
BRYAN: Absolutely. First and foremost, you have to manage the headwinds. And that is easier said than done. And I do not sit in that seat, but there are a lot of changes
We talked about the Medicare changes, some of the changes in IRA. You’ve got GLP ones. How are you going to manage that? You still have specialty spend. You still have outcomes you need to look at. So really, what we try to look for and work on with clients is; what tools and resources do you need to have in order to remain efficient and still remain quality centric? What’s going to make you work more efficient? We can help you with that and understand, where do you partner versus where do you go alone?
And then what does that partnership give you from a value standpoint? Make sure you get value out of that and then use data to make critical decisions. Go get that data, get access to it, look at it, and don’t be shy to ask your partners and those vendors that are helping you and say, “Hey, we need to get to this spot very quickly. Can you help us get there? Because we need to be able to make decisions to go forward.”
And I think if you can kind of muster up that as part of your strategy, then you have a great opportunity to remain competitive and differentiate yourself because, people are wanting, and looking to, health plans to provide the best value they can for them.
Focusing on Medicare Member Surveys
LUCAS: Yeah. Absolutely. It’s all–at the end of the day–a lot of folks look at that value prop on things. And, Eileen, same for you here. What are you seeing as the linchpin, the most important piece to stay competitive and look at those evolving needs for next year?
EILEEN: Well, I think we’re trying to keep the member needs as a focus for us, particularly when we’re looking at our Medicare line of business. We’re looking at quality metrics such as, you know, Star Ratings that help us stay focused on where we need to be. So, we use a lot of the member survey data, such as CAHPS survey data to focus attention on areas for improvement.
Raising Awareness of Benefits Available to Medicare Members
EILEEN: We need to make sure our members are aware of all the benefits they are receiving with the plan. We know that members don’t always use all the benefits that are available to them. So, a lot of the work that we do is communicating and educating members about programs and services that are available that they may not be taking full advantage of. And then, as we continue to get new Part D measures, rather, new programs and additional work, we’re always trying to look for lower-value services we’re providing that members don’t want. So, trying to, again, just look at things from the member lens and keep that as our primary focus.
LUCAS: Absolutely. So many things to discuss. So many pieces to this, I think, that are going to be very important next year. That are going to be important for, for patients, for the industry, for a lot of folks. I’m really looking forward to that follow-up conversation that I think we will absolutely have at some point, Eileen and Bryan. Thanks so much for sharing your time and certainly your insights in this conversation.
