Signal 4 is where this connects directly to the employer side. The same margin pressure pushing MA plans toward pharmacy cost management and adherence solutions is creating downstream effects for self-funded employers. As health plans tighten their Part D economics, PBMs adjust formulary strategy, rebate structures, and utilization management criteria across all books of business, not just Medicare. Employers often don’t realize that a CMS policy change affecting MA plans can shift the formulary their commercial members use within the same contract year. The structural pressure you’re describing doesn’t stay in Medicare. It flows through.
Great point on the downstream effects, Ginny! To your point, PBMs don't adjust in a vacuum, and many employers have little or no visibility into why their plan design shifted mid-year. Thanks for sharing! 🤝
Signal 4 is where this connects directly to the employer side. The same margin pressure pushing MA plans toward pharmacy cost management and adherence solutions is creating downstream effects for self-funded employers. As health plans tighten their Part D economics, PBMs adjust formulary strategy, rebate structures, and utilization management criteria across all books of business, not just Medicare. Employers often don’t realize that a CMS policy change affecting MA plans can shift the formulary their commercial members use within the same contract year. The structural pressure you’re describing doesn’t stay in Medicare. It flows through.
Great point on the downstream effects, Ginny! To your point, PBMs don't adjust in a vacuum, and many employers have little or no visibility into why their plan design shifted mid-year. Thanks for sharing! 🤝
This one sparked a great discussion on LinkedIn. Would love to hear your take too. Here's the thread:
https://www.linkedin.com/posts/ryan-peterson-1a20866_medicareadvantage-healthtech-riskadjustment-activity-7424503356678868993-9dV7