Purchaser Business Group on Health (PBGH)

One of the top issues employers and public purchasers are facing is how to manage the high cost of weight loss drugs. Most employers want their plan members to have access to weight-management medication options, such as GLP-1s, however, they also want to ensure that it’s clinically appropriate and accompanied by the medical and lifestyle modification supports to ensure long-term safety and efficacy for the individual. We’ve seen that PBMs and drug manufacturers have been reducing their rebates when employers are requiring a lifestyle management intervention as part of the drug criteria, so it has been challenging for employers to put in place the right programs to support their workers and family members. Self-insured organizations should have the opportunity to adjust their benefit plan design and coverage criteria without having a negative impact on a medication’s price.  https://lnkd.in/giqmjNQE  

Physicians Practice asked top health care leaders what they expect to see in 2025 – here’s what PBGH’s Raymond Tsai, MD MS had to say: “We expect a greater trend of employers moving towards direct contracting with healthcare providers for services. A 2024 survey showed 75% of health benefit managers are in discussions about direct contracting. The effort to do this in primary care by employers will also be bolstered by bi-partisan support for direct primary care for Medicaid. Overall direct contracting is a way for employers to respond to the need for greater transparency in healthcare to comply with being a prudent fiduciary and mental health parity regulations.” Read more: https://lnkd.in/eM8Z3b76 #DirectContracting #PrimaryCare #healthcareaffordability #healthcaretransparency #fiduciary #mentalhealth

HealthIT Answers asked health care industry experts what they think we will see in the business and finance of health care in 2025. PBGH COO Won Andersen explains: “In 2025, we expect to see more market-based reforms in health care price transparency as part of the Consolidated Appropriations Act of 2021. These laws build upon and emphasize the preexisting fiduciary responsibilities employers have, requiring them to seek, understand and use newly disclosed health care pricing and fee information to ultimately lower their health care costs.” Read the full article: https://lnkd.in/eqsUm3hJ #CAA #Fiduciary #transparency

⏰ REMINDER: The application deadline for the California Improvement Network (CIN) 2025-2027 cycle is approaching! CIN is now recruiting HCOs and CBOs for the upcoming two-year cycle (Mar. 2025 – Mar. 2027). Visit CIN's website to review eligibility requirements, commitment expectations, financial support and 📅 apply by Jan. 13: https://bit.ly/3OsDkae

PBGH’s Vice President, Advanced Primary Care, Raymond Tsai, MD MS was interviewed by Catlin Nalley for her article, “The Role of Primary Care Providers in Cancer Care” in Oncology Times. Read to learn about advancing primary care providers’ role in patient care, how it relates to cancer care and how partnerships can benefit providers and #patients: https://bit.ly/4gNypxq

STAT First Opinion posed two questions to leaders and readers, asking what story was underdiscussed last year and what our attention should be on in 2025. PBGH President & CEO Elizabeth Mitchell explained: “The 2024 presidential election hinged on affordability and costs, but much of the discussion centered on the price of eggs, bread, and housing. The skyrocketing cost of health care and its impact on the overall economy did not receive nearly the attention it deserves in 2024, and yet it has a greater and more pervasive impact on employers, employees, and their families. With 150 million Americans relying on employer-sponsored insurance (#ESI), the unsustainable cost of health care is baked into the price of nearly everything we buy, from cars and computers to groceries. These rising costs act as a hidden tax, ultimately affecting every corner of our economy. If Congress and the new administration are serious about strengthening the economy, they must first and foremost address the broken commercial health care marketplace and its massive impact on the future of ESI. Continued attention is needed on health care pricing transparency for #PBMs, #healthplans, and providers, as well as enforcing #antitrust laws, improving data accessibility, investing in #primarycare, and transitioning the U.S. health system from fee-for-service to outcomes-based payment models. For ESI to remain viable, a functional and fair health care market is essential.” Read the full article: https://lnkd.in/g57VAhrv

ICYMI: Read the Bloomberg Law article, “Employers Mourn Loss of Drug Data Transparency in Stopgap Bill” by Lauren Clason. Hear from PBGH CEO Elizabeth Mitchell and others for commentary about the bill, potential impact on #employers and #PBMs. https://lnkd.in/eTCZJUHe

Kickoff 2025 with behavioral health integration! Join CQC for our January 8 webinar as we highlight approaches to successfully spread behavioral health integration across practice sites and sustain quality, access and financial goals. Register for 'Behavioral Health Integration Spread and Sustain' today: https://bit.ly/4g4DYqV

The failings of the US health care system are widely known. We’ve talked about them for decades. Unfortunately awareness has not led to change and admiring the problem is its own pastime. But it doesn’t help the people paying for and receiving care. In my early career I had a boss who wouldn’t let anyone identify a problem without bringing at least one solution. Applying our best thinking to the hardest problems was what we were hired for. It was our job. Given the vast amount of money spent, the innumerable problems, and the legions of smart people involved I think that is a fair expectation of everyone in the industry- because the status quo is not an option. What I’m most excited about heading in to 2025 is the good company we are in not just identifying solutions but implementing them. At Purchaser Business Group on Health (PBGH) we do what people say can’t be done all the time - from multipayer alignment, patient outcomes measurement, new standards for maternal health and birth equity, and policy change. But this year we implemented something with our members that everyone said we couldn’t possibly pull off. We launched a directly contracted network for Advanaced Primary Care and top quality specialty care that is now live for over 70k people - and early results are great. Purchasers aligned on standards, created new payment models and methods, forged new partnerships and created access to great primary care with no cost sharing. It took 2+ years of work but rather than lamenting system failings we changed them. And if we can do this anyone can. What made this possible was incredible leadership from employer innovators like Linda Brady, and Rob Paczkowski, CEBS and others, provider leaders like Nate Murray and Kevin Wang, M.D. and deeply dedicated staff like Raymond Tsai, MD MS and countless others. It also required us to co-found an implementation partner where none existed and I’m thrilled that Dane Guarino and his team will be growing to help us scale in more markets this year. There has been a lot of noise about the role employers should play to fix health care. In my opinion it shouldn’t be the customers’ job to fix it but I’m glad they are not waiting. Last month over 25 jumbo purchasers joined us to chart a course to scale employer led innovation through direct contracting. The demand and readiness is real. This is just one innovation where many are needed but it’s one solution that is improving health outcomes and affordability. And many of our members are innovating for better care at lower cost -proving it can be done. Massive change is needed to reorient the system to serve patients. It will require change from all involved- employers included. But I am optimistic that collectively the innovators can start proving what’s possible and inspire others to join. And our pending partnerships are further proof we are on the right path. This is all wildly ambitious- but it’s worth the effort. And it’s our job. Here’s to 2025!

Thank you to the 20+ expert speakers who participated in our keynote presentations and four panel discussions at last week’s PBGH Annual Summit. These speakers tackled controversial topics, offering provocative viewpoints and inspiring an open dialogue amongst some of the most influential public and private purchasers in the U.S. Our shared goals: advancing #quality, driving #affordability and fostering #equity in health care. Here’s a highlight reel from the event: https://lnkd.in/ebYWAtby