By Mike Waterbury
It’s important to read beyond the headlines and understand the details of what’s really going on in healthcare. For example, recent news stories exclaimed that Optum is going to pay point-of-service rebates to the consumer for its fully insured business. At first blush, a reader might think this is a game changer, finally a big player is going to drive down cost by sharing all the discounts in a transparent way, paying pharmacy rebates to its members. In reality, this program could not be farther from a disruptive solution like that. Here’s what’s really happening to the members and employers who are paying very high premiums for healthcare and specifically pharmacy insurance:
- The change is that, when available, Optum is going to pay rebates to members in high-deductible plans who are PAYING FOR THE ENTIRE AMOUNT OF THE DRUG for their fully insured plans.
- Today, when a member pays for a drug out of pocket, Optum bills and collects a rebate from the manufacturer and keeps all the money. The pharmaceutical companies don’t want to pay for this utilization, but big PBMs bill them anyway with little transparency and expect payment.
- So, if you are a member and in your deductible as part of a fully insured plan with Optum and the drug costs $500, there is a 25% rebate. Today Optum collects $125 from the manufacturer and keeps your money. When they roll out this “new” program, they are going to give you your money back.
So the hoopla is over giving the consumer what is really theirs and no longer pocketing “hidden” rebates. Seems to me like it’s just the right thing to do. Bigger is not better.