The Cold Hard Facts

According to BenefitsPRO, 93% of employers considered switching pharmacy benefit providers in the last year due to the rising cost of prescriptions and complicated PBM contracts; smaller employers are more likely to re-evaluate their pharmacy benefit plans than very large employers; and future company health plan designs greatly concern majority of employers (BenefitsPRO, 2023). 

Prescription spend continues to exponentially rise in the United States. Unfortunately, there is no end in sight to this problem significantly impacting company bottom lines and many employers are searching for new health benefits that will positively impact the trajectory of their company in the coming year(s).

Analyzing the Tool Belt

Healthcare is episodic, meaning there is a start and end date. Most medications, however, do not have an end date making them a reoccurring expense. Insurance is designed to cover the risk of unknown loss making this the wrong tool for this problem. Insurance makes services, including medications more expensive. Almost every medication is cheaper without insurance if you know where to look. That is the key!

Employers are Craving Change

The first step in making a change is recognizing that the tool employers have been using was never meant to take care of this problem. The next step is to acknowledge insurance is the wrong tool and seek out a better one. Just like any other expected expenses that companies plan for, procurement, not insurance, is critical for having confidence that those expenses are managed properly. 

Many employers crave the change that prescription procurement can provide. However, they may be unaware of the treasure. Prescription procurement is a high-value strategy utilized to effectively acquire a medication that a person needs. It allows employers to give their employees a better experience, not just have the option to access mediocre discounts on high-cost medications at the local pharmacy and deal with the bureaucracy of insurance.

A Financing Vehicle? More Like a Roadblock.

A self-funded employer acts like a traditional insurance company, collecting premiums from enrollees and taking on the responsibility of paying employees’ and dependents’ medical claims. It makes sense that they would hire PBMs and expect them to make sure that all expenses are essential and appropriate. The higher the cost of the drug, the more questions will be asked. To get answers to these questions, it puts patients in the middle. This often creates obstacles to care, causing frustrations with prior authorization protocols that, while necessary, are suffocating to a member just trying to take the medication their doctor prescribed.

It becomes an aggravating exercise with members and providers trying to prove that the medication they are trying to fill is needed. It frequently involves letters from the provider explaining why the member requires a specific medication while trying to steer the member to an alternative therapy, which is usually based on rebates to the PBM and not clinical outcomes.

It is assumed that if a patient does not use health insurance, it is impossible to afford the outrageous cost of the medications, but the reality is that insurance is the element patients cannot afford to use. This is where the illusive value of insurance comes into play.

A Fair Cash Price

No doubt, PBMs are incredibly smart and good at making money, so they put prohibitions on your local community pharmacies from offering patients fair cash prices. If there was value in having health insurance, then not having health insurance should make things harder. However, not having insurance has continued to prove that it actually makes things cheaper and simpler. From personal experience, I have learned when you stop asking for permission from insurance companies to attain what you need, the entire process becomes easier.

To further illustrate the point, cash only pharmacies, like Mark Cuban’s pharmacy, do not accept insurance and the prices are better than local retail pharmacies any day of the week. Why? Because not participating in insurance allows them to offer patients a fair cash price. The second a pharmacy benefit network enters the picture; a fair cash price is prohibited. This is what entangles most companies today.

Adjusting the Tool Belt

By implementing the right tool, (aka prescription procurement), a more predictable healthcare budgeting process is created. It allows employers to take control over what is being offered and how it is being offered.

Employers and employees alike despise the oversight and burden that using insurance creates, but they are not sure that they have any other choice. They do and SHARx is here to help. Trying to negotiate a better discount and rebate has never and will never solve this dilemma because that relies on the system that created the problem to also have the solution.  To truly solve this issue, you have to opt out of the system and only then can the answers be found.

SHARx exists to serve members that have been lost in this journey – the employer and the employee. Our passion is to give the ‘lost’ a voice and seat at the table. Unfortunately, other parties involved in our healthcare system profit on the problem, but that is not what we do or why we do it.

The SHARx Solution

SHARx navigates this messy healthcare issue with knowledge and expertise to lead our clients in a direction that benefits all parties involved. There is great value in the experience SHARx brings to the table when routing these debilitating problems that individual employers might greatly struggle to pilot on their own. SHARx is made up of trained individuals who have done the research and continue to do so. We know what to do and where to go for the members that need our help.

We believe people deserve to get what they need. With SHARx, employers can control one of the bigger variables in the game which are the medications that insurance was never meant to control anyway.

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The pharmaceutical industry has an ethics problem, but if you listen to many of the “talking heads” for Big Pharma, they will have you believe that it is the employers, looking for solutions so they can maintain/achieve financial solvency while doing right by their employees, that are being “unethical”.

Under the Insurance Umbrella

In the United States, pharmaceuticals are jammed under the insurance umbrella because most Americans need insurance coverage to help cover the cost of their prescriptions. However, many people paying for health insurance struggle to exist in a state of financial security. It is difficult for many individuals, but it is often even tougher for employers, tasked with carrying coverage for all or many of their employees, some of whom are taking high-cost medications.

Illusive Value

The insurance machine creates dependency on itself by making it seem like we need it to survive. Health insurance advertises itself as a method to protect individuals from health risks and businesses from financial ruin. Armed with the illusion of value and convenience, it leads many people to believe they have a network of support. 

The Network is Broken

The sad reality of the situation is that the insurance system/network is broken. Traditional Pharmacy Benefit Managers (PBMs) manage this network and the top seven PBMs have a 96% market share while all the other PBMs fight over the remaining 4%.

These popular PBMs have deals with thousands of pharmacies nationwide and patients can go to them for their needs. Additionally, they answer the phone calls and adjudicate claims, which can give the impression that they have the public’s best interest at heart. However, they also negotiate with the manufacturers. This negotiation is for a floor position on the formulary which is essentially a tiering system of bribery. If you are unfamiliar with the term “formulary”, it refers to a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. It is sometimes referred to as a “drug list”.

Playing the Game

If a drug is in the formulary, then a member can get their drug since someone will pay for it. The PBMs hold all the power and are on board with this set-up as long as the manufacturers continue to pay them. If that ever stops, the manufacturer believes they are out of the game. This is why the manufacturers continue to raise their prices, to satisfy the PBMs appetite for larger rebates and increase profit for shareholders when they can.  

While PBMs and drug manufacturers are playing power games with each other, employers and individuals are the ones coming out on the losing end. 

Whose Money Is It?

The user of the drug and the payer for the drug have no seat at the table whatsoever. Health insurance networks and carriers can play, but they are not playing with their own money. Whose money is it you might ask? The employer’s. The employer pays the premiums and claims. This is part of why we get the cluster that is the U.S. healthcare system. It is understood that the worse things get from a health perspective, the more profitable it is for Big Pharma. 

Stuck in the Cycle

Employers are stuck in the vicious cycle of what the United States healthcare system has become. If you ask yourself, “Why am I using insurance to pay for things that are routine and expected?”, the answer does not make much logical sense. Employers are forced to go outside of the system since they have limited options to escape the cycle. 

The Ethical Solution

Employers are forced to make tough decisions, such as to exclude certain drugs from their healthcare plan because they cannot afford the medications and sustain the nonsense. SHARx is the service that employers otherwise would not have to ensure their employees are taken care of.

Employers are making the choice to stop playing the insane game in a nonpainful way. It is about realizing that when health care budgets cannot be predicted or controlled, things suffer. Procurement and enhancing the experience of the member is the answer.

At SHARx, we have a passion to take care of the lost members in the system that was never designed to serve them and who are not being taken care of. We make sure that members get what they need in an affordable way. We strive to allow businesses to be sustainable and have solvency moving forward.

With SHARx, it is possible for employers to do what is right for the people who matter most – their employees.  

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A heartfelt thank you goes out to each and every one of you. Because you trust and believe in us, SHARx has significantly changed the lives of so many people in dire need!

To continue that momentum, I am excited to announce that I have chosen to move into the role of Chief Growth Officer (CGO) at SHARx. My focus now shifts fully to expanding our key partnerships and vendor programs, delivering more consistent communication to valued partners, building broker loyalty programs, and concentrated involvement on larger opportunities.

Yet, with the tremendous noise from social media platforms, it is possible you may experience doubt as to the impact you are having. Now more than ever, your clients need you and equally need SHARx.

My Story

In 2015, the trajectory of my life was dramatically altered. My first child was diagnosed with a rare disease known as Cystinosis while my wife was pregnant with our second child, who would also be born with the same disease.

While reeling from this new reality, we found hope through the existence of a specialty medication that treats the disease, only to be gut-punched with the $1.6 million annual price tag to treat both boys.

My personal roller coaster ride of learning to pilot the expensive world of high-cost prescriptions inspired me to invest time and energy into helping others that are experiencing similar challenges, of those feeling the strain and heartache while working out exactly how they will afford the life-saving drug(s) their loved ones need.

Out of my own need, my passion flourished.

An Unbearable Burden

According to Georgetown Health Policy Institute, more than 131 million people – 66 percent of all adults in the United States – use prescription drugs. Shockingly, drugs cost an average of 256% more in the United States than other countries (Rand Corporation).

The cost of these medications has led to financial, moral, and social dilemmas for both employers and individual Americans alike. As a consultant, you have shared in the anxiety of an employer telling you they can no longer afford to cover high-cost medications, while also feeling an overwhelming burden for the individual who no longer has insurance for these debilitating illnesses.

The Reality of the Anti-Prescription Procurement Industry and Manufacturers

Knowledge is power. This is particularly true in the prescription procurement world. Proponents of Big Pharma love to aim their arrows at organizations like SHARx in an effort to protect their financial interest. They espouse a plethora of inaccuracies and misconceptions about who we serve and why we do what we do, dismissing the fact that their own greed incubates the desperate situation in which individuals find themselves.

These ‘pharma bros’ want the public to believe they are altruistic. In reality, manufacturers produce medications and charge outrageous prices for three main reasons:

• There are third parties involved
• People will pay
• Very few people ask questions

The art of distraction allows manufacturers to rack up billions of dollars in profit while many Americans are forced to mortgage their future to save their lives. Currently, there are multiple ways to access medications, and Americans need the knowledge you have and the expertise SHARx provides them to help navigate the maze.

Our Service and Commitment

Your clients faced the proverbial fork in the road and now their team members need the help of experts. These members are living in a world without insurance for their medications and our team recognizes this. We support the employer’s need to financially adapt while remaining zealous in our pursuit of the members’ access to the medications. That is why SHARx is not designed around an egregious percentage of savings model and only partners with transparent PBMs with aligned incentives for all involved. Employers know their employees need assistance in sourcing medications given the plan exclusions and find it a fair solution to pay a per employee per month fee, so their team members get the guidance they desperately need.

A Healthy Future

What is your why?

SHARx helps individuals suffering in the silence source their high-cost medications. And that is our why. No person should have to make the choice between paying for medications or basic necessities.

My mantra: Empower the patient that takes the drug and the Employer trying to manage their company. Neither have a seat at the table, but we are giving them a voice. Your partnership with SHARx increases the likelihood of a healthy future.

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