AH053 - Selling Pharmacy Benefits: Relationships, Rebates, GLP-1s, and More, with Bridget Mulvenna

Transcript

Lightly edited for clarity.

[00:27] Justin Venneri: Hello and thank you for joining us for this episode of the Astonishing Healthcare Podcast. This is Justin Venneri, your host and director of communications at Capital Rx, and I have Bridget Mulvenna back in the studio with me today. For those of you who've been listening, she joined us for Episode 2, that was just over a year ago now, which is pretty hard to believe, and Episode 21, which was in June last year.  

And we talked about her experience as a pharmacy program director and plan sponsor and how she managed costs and then talked about how to tackle GLP-1s respectively, on those episodes, which we'll link in the show notes, of course. Bridget, thanks for coming on the show again.

[01:00] Bridget Mulvenna: Great to be back.

Previous AH episodes featuring Bridget:

• AH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy Costs
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna

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[01:02] Justin Venneri: So, what's your experience been like over the last year of quote unquote, selling PBM versus managing the pharmacy program and pharmacy benefit at a larger employer before that?

[01:11] Bridget Mulvenna: Well, it's been a lot more fun than I thought it was going to be. I still wake up every day excited, and I can't believe that I'm paid to talk about pharmacy all day, my favorite thing in the world. And anybody who's known me throughout my career knows that I could literally talk about pharmacy for 40 hours a week, every week for the rest of my life.  

It's a lot different, you know, than developing programs. When you're developing programs, you're rolling up your sleeves. You're getting deep into the operations. And sales, especially here at Capital Rx is more about building relationships, building relationships with consultants and brokers, building internal relationships so that I can actually get things done, and then taking our message, our value proposition, and then obviously melding that with my personal experience and going out and talking to the people: HR directors, CFOs, CEOs, in some cases, and then also, you know, kind of hitting the conference circuit. And a lot of that is more building relationships with others in the industry so that you can sort of make connections and develop some synergies too.  

So, it's been fun, it's been exciting. I'm glad that my children are all grown up because it's been a lot of travel. But I am having the time of my life. I could not be happier doing this. And hopefully that shows when I talk to people.

[02:30] Justin Venneri: That's great to hear. And I learned what a “boomerang trip” was last week. I'd never heard that term before, somehow, in this industry. And you were back and forth in one day from New York to Texas...

[02:41] Bridget Mulvenna: Yep.

[02:44] Justin Venneri: So how did your, how did the year overall, if you had expectations of coming into this, how did it compare to your expectations you mentioned? We just joked about travel, the value of in person meetings, being able to relate and share experience, and just the level of success you had.

[02:59] Bridget Mulvenna: Yeah, look, the travel was a little bit more than what was sold to me, but I think that's because I was able to get up to speed because of my prior pharmacy experience and the fact that I had been a plan sponsor, I was able to get up to speed a lot faster. And so I got more opportunities early on. Part of that was because of my innate abilities, but also part of it was because of the extreme growth curve that Capital Rx has been on for a while here. And another thing is that plan sponsors have become a lot more savvy. They're in tune with what's happening in the industry. They're seeing this, the regulatory stuff happening with the FTC investigating the big threes, the lawsuits. Even though the J&J lawsuit was recently dismissed, I still don't think that's dead. And so they're worried about fiduciary duty. Are they actually meeting those needs?  

And they're also tuned into the fact that their members, the folks that they service, and ultimately our, our customers too are getting more savvy and becoming more savvy prescription drug shoppers, which honestly couldn't ask for anything more than that. That's the reason I got into this, and I know we talked about this in Episode 2. I was attracted to Capital Rx because of the mission, because that mission so completely aligns with my personal mission in life.

So, I didn't come in with a ton of expectations and I honestly didn't expect to have the success that I had. First year salesperson has a lower sales quota and so I thought maybe if I could hit that, that would be awesome. But I far exceeded that by about 30,000 lives and that was really, really exciting. And hopefully it means that I get to stay and continue to do this job that I think is so fun.

[04:46] Justin Venneri: I think so. I think you'll be okay.

[04:48] Bridget Mulvenna: I hope so.

[04:50] Justin Venneri: And all of that makes sense. You know, it's kind of like a somewhat perfect storm for just information need and you can help with that. So it makes sense that you're on the road a lot and you're out there talking to people that have good questions. And on that note, what are some of the tougher questions that you had to deal with out in the field at conferences, et cetera, over the last year?

[05:09] Bridget Mulvenna: Yeah, not a lot of tough questions at conferences. Conferences are funny. Like, you have to be there. You need to show your face, you need to have, you know, have your name out. You've got to stand out in front of the booth and try to grab people to come and talk to you. But there's not a lot of hard questions there. Those folks are, you know, it's kind of like a mini vacation for some people.

[05:27] Justin Venneri: Okay, okay. All right. So during an RFP or a finalist meeting, did anything stump you?

[05:31] Bridget Mulvenna: No, but I had one of the prospects and I ultimately won this deal, but one of the prospects says stop. Like stopped me in the middle of the presentation and says, this sounds too good to be true. What's missing? And I just had to take a deep breath and say, “I agree with you.” I said, “It does. It sounds too good to be true.” Because it's hard for people to believe after years of getting fleeced - for the lack of better way of putting it - by the bigger PBMs in this space, that there is a company out there that has a model that is so clean that they're finally going to get what they've been promised all along. The transparency, the reporting, full pass through of manufacturer revenue. And notice that I didn't say rebates.

[06:26] Justin Venneri: Right.

[06:27] Bridget Mulvenna: Okay, so. And then obviously there were harder things that happened during implementation because we are a culture of yes and we say yes to everything, but sometimes we have to go, yes, we can do that, but we probably shouldn't and here's why. And so I think my experience has been helpful in that regard as well. So I feel like from when I first started in November of 2023 to where I am today, I'm almost a completely different person because I've learned so much not only from selling this product and this service, but from the implementation process and the internal teams and what the clients actually need.

[07:10] Justin Venneri: Got it. And what would you say was your biggest success over the last year and change?

[07:14] Bridget Mulvenna: There's a couple of things that I would say were really big success. I'm very terrible about patting myself on the back so much. And yes, what I did was great and closing my quota was great. But I think working with a consultant that I had never worked with before understanding that they didn't really do the best job of evaluating our model in their spreadsheet and relating that, building that tight relationship and literally winning a very large deal from basically last place because we were able to show our value in other ways.  

And I think a lot of that was about the strength of the knowledge of the buyer. And then the fact that this consultant really was able to see that maybe that spreadsheet model isn't the best way to evaluate Capital Rx, because you can't compare bananas to oranges.

[08:11] Justin Venneri: They're both fruit, but...

[08:13] Bridget Mulvenna: They're both fruit, but they taste vastly different. They're different shapes.

[08:19] Justin Venneri: On the point you made earlier, I'm just curious, manufacturer revenue versus rebates. Can you just unpack that a little bit for listeners?

[08:25] Bridget Mulvenna: Yeah, we talked about this a little bit, I think in our first podcast and episode two is that when a PBM puts a drug on their formulary, a high cost drug, especially a brand drug, that is rebate eligible, they go in with a guaranteed rebate from the manufacturer. Right? But that rebate is only a part of the picture. So if you sell a million units of something, for example, because your entire book of business is on this drug, then once you breach that threshold, you go into a new rebate area. And so that's called a performance bonus. Right. And then there are tax credits and other pieces of revenue that come back as a part of that total manufacturer revenue picture. So the rebate is only a portion of it now. It's a decently sized portion of it. The rebate is only a portion of it.  

And what happens. And even PBMs that say that they pass through the rebates, they're probably not lying. But we don't say, obviously we will use the term rebates because that's what people are used to hearing. But I don't like to use that term anymore. I like to say manufacturer revenue because Capital RX is very unique and that we pass through all manufacturer revenue and then that promise of. And oh, by the way, once you get your rebate payment, you're also going to get a report that shows what drugs you got rebates on. That really makes the light bulb go off too. Like, man, we're actually going to be able to track how much our drugs actually cost because that, and that helps people determine.  

You know, I'll pick on Humira. Humira is a high-cost anti-inflammatory drug. Right. And the cost has stayed high, but the rebate is pretty high. And so if you look at it from a net cost perspective, it's still in line with what the low WAC biosimilars on the market are. And so as biosimilars become more prevalent and biosimilars by nature are not the same as generic drugs, Some of them are interchangeable with the branded drug, some of them are therapeutically equivalent, meaning that you need a new prescription.  

And so I think as we see more of these drugs come out in the marketplace, you'll see, I think what we're going to see is a shift away from this dependence on rebates and a shift towards what I believe everyone should be doing and should have been doing this whole time, which is what is the lowest net cost across the whole, across the whole book of drugs that I'm getting, because it's ridiculous. 80+ percent of the drugs that are dispensed for any plan sponsor are generic, but it only attributes to 12 or 15% of their spend. So the other 12% of their use is 78 plus percent of their spend. That's where we really need to focus our efforts. You know, people have become so dependent on rebates. And so my hope is that we start to break that addiction.

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Related Content

• Pharmacy Benefits 101: Pharmaceutical Rebates
• Our Single-Ledger Model™ - Pharma Revenue Explained
• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan‍

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[11:21] Justin Venneri: And then I'm curious about a couple of other things. One, we've heard from prospects about technology and what that might mean to them. And two, I'd like to hear what you saw or think was most helpful to plan sponsors in wrestling with the cost of GLP-1s since we talked about that mid-year last year. So, the first part, the value of technology and claim processing speed, accuracy, efficiency, like modern tech. I know why we say it's important, but what does that mean to employer plan sponsors and how do you explain it?

[11:48] Bridget Mulvenna: Yeah, look, I think the best way to explain it, and I'm going to borrow from Hope and Hope's podcast a couple of episodes ago. If we make a mistake, we make a mistake on one claim, and it doesn't cost the plan sponsor a ton of money. Right? And that's because of our modern technology. It's because of the efficiency when we get a claim in half. We don't have to go to 10 different systems to address that claim to do a prior authorization, to figure out what is happening with the physician, what's happening with the patient. We're able to do it all under one roof in this modern infrastructure.  

The other thing plan sponsors love about JUDI^® and our technology, if they want to change something, and trust me, we've seen more benefit change forms come in in the first month, because once a plan goes active, you start to see how it acts and you're like, “Oh, we intended it to be this, but we really want it to be this way.” Is that instead of that taking weeks or months, up to a year, as soon as the plan sponsor sends back a signed form that says, yes, that's okay, because we need documentation that they want to change their plan. That change is made and tested within 24 hours and then it's live. And so they don't have any additional cost or any additional administrative burden. So there's financial burden and administrative burden to delay those changes over time. And that, that's been really, really a huge benefit.  

Plus, I think the more in tune, savvy plan sponsors out there are so excited about being able to access their claims data, not ours. We're just a claims administrator, right? We're a PBM and so we manage drug mix and we administer claims. That's what we do. We're also a tech company and we'll talk about that another day. But I think that it's really huge for them to have that visibility into those claims and to understand that instead of reconciling your claims in the aggregate and having to understand complex pharmacy pricing systems, you're able to see your claim in real time. And a description. This is the key. This is always the key. Because I'm a pharmacy person. I've been working in a pharmacy since I was 16 years old. So I know what all the reject codes and all the weird wonky language means that comes from the other systems. JUDI spells it out in plain language. This is what happened to your claim. This is how it processed. This is why it processed this way. This is what the member share was. This is why the member share was that way. And that type of clarity and visibility is hugely important to plan sponsors, especially as they grapple with am I meeting my fiduciary duty and doing what's right for my people?

[14:33] Justin Venneri: Got it. And GLP-1s?

[14:35] Bridget Mulvenna: When we talked last time, I talked about GLP-1s and how they are the largest growing drug class. And we are seeing, we have seen over time, a shift away from GLP-1s that have a lesser weight loss benefits to Ozempic and Mounjaro because they have such a high weight loss benefit. But let's remember that the FDA still only has approved Ozempic and Mounjaro for Type 2 diabetes.  

And so when we talk about weight loss, we've got plan sponsors who are considering coverage of Zepbound and Wegovy and as you know, last year when we talked, the only new indication was Wegovy getting the MACE indication - major acute cardiac events. Now there is additional indications for zepbound for OSA - obesity related sleep apnea, and there is talk about the chronic kidney disease indications and more and more applications for these existing drugs that are going before the FDA. And the impact of that is in the short term is it causes confusion for plan sponsors because they're like, we don't want to cover it for weight loss, but maybe we want to cover it for these other things. Understanding that when they cover it for these other things, there is going to be a weight loss benefit. And so it's push and pull right now.

I think we've got a really good model in place in the fact that we will allow coverage for the additional indications without weight loss. We can go all in on weight loss and whatever, and that we've got some of the lowest prior authorization rates in the country, meaning that we're following the FDA guidelines and we're making sure that these actually are the correct drugs to treat these indications and not just blanketly approving everything because it's on formulary and it's okay.  

I think plan sponsors are still really grappling with this. Most of the ones I talk to don't want to cover GLP-1s for weight loss. And if they are covering them for weight loss, they're looking for ways to control that cost. And they also want to know, if I pay for this now to the tune of, you know, $1,200 a month or whatever, it ends up being net of the rebate, am I going to see any downstream savings on my medical plan? And I think that's a really hard thing today to understand.  

I know because of what I know about what we're doing as an organization. And our CEO AJ Loiacono has talked about this. We're moving towards unified claims processing. So maybe sometime in the future we'll be able to see, hey, you paid for this WeGovy for five years. And here's the person that didn't take it, who's had all these other issues. Here's where the savings could be, but...

[17:17] Justin Venneri: That you see where the medical expenses related to other comorbidities, they go away over time. It's like, oh, this was your last year and now it's gone. And, “Whoa!”

[17:26] Bridget Mulvenna: Yeah. We've been here before with Harvoni, with, you know, with a drug that actually cures hepatitis C. And the marketing was, you know, pay for the cure today and you don't have all these downstream costs. Well, hepatitis C patients were really just maintenance patients. Their drug costs were relatively low because they were taking alpha interferon was expensive when it first came out, but today, compared to other drugs, it's not that expensive. And then they were taking antiretrovirals, which are largely generic now. And so it's kind of a balancing act and I think more will come. I will also warn you, here's another prediction. More GLP-1 indications are coming.

[18:05] Justin Venneri: Of course. Yeah. The joke is put it in the water, right?

[18:08] Bridget Mulvenna: Exactly. I still caution against like cosmetic use and stuff like that. I had somebody the other day go, “I should just get on a GLP-1. I need to lose 10 pounds.” I'm like, no, that’s not how you lose 10 pounds. There are other ways.

[18:22] Justin Venneri: So anyway, so out of curiosity, and it's kind of a follow up to the tech question, I really like the way you described all the. Instead of just the technology allows the patient to pick up the prescription on time at the pharmacy. There's all these other benefits of having a modern system and having all the information in one place.  

Have you had a chance to discuss Never Move Again™ with any prospects? What's the reception been like of having that core tech platform for adjudication plus the contact center and then being able to pick and choose amongst, you know, the other aspects of the pharmacy program that they could potentially go price individually?

[18:58] Bridget Mulvenna: Yeah, I absolutely have there. I strategically place this into conversations as I'm talking about PBM. As you know, Justin, I largely am responsible for PBM sales. So when I'm talking to a prospect in a capabilities meeting or a finalist meeting and they ask these questions about having a little bit more control because a lot of people watched AJ and Josh's Never Move Again™ webinar (Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™); definitely talking about the ability to parse things out, especially for PBM.  

For plan sponsors, they're probably less likely to plug in a different rebate aggregator just because they don't have the scale. But they are more likely to say, “We want to work with a different specialty provider.” And so plug that in. Maybe they have their own contact center. No big deal. Plug that in. And so we're talking about that with a couple of plan sponsors. And there's a large state that I think is a really good candidate for this because of how savvy their team is. I target Never Move Again™ conversations to plan sponsors that I think get it and are savvy and are ready for it.  

I think what's going to happen over time is we're going to have some of our larger PBM clients embrace never move again as they get more comfortable with the model. Again, kind of going back to what I said before, what we do is so clean and so unique in this space, especially because we have JUDI sort of running it all and that people need to see it to believe it. And so I actually am working with a fairly large health system and what I'm looking at for them is let's start you off with PBM and let's get you kind of tight and cleaned up and then let's move into more of a PBA or Never Move Again™ kind of model.  

And I think that kind of strategy with employers and plan sponsors and health systems is really resonating because it enables them to migrate over slowly. And in my opinion, and this is from my experience, the first year savings with Capital Rx can be significant for plan sponsors. And I've shared this before. In my case, moving from a large big three PBM to Capital Rx from 2020 to 2021, we saved over $5 million. And that was before GLP-1s were eating our lunch. And that's a weird pun, right?

[21:25] Justin Venneri: It is, but I appreciate it. Crystal ball question: what are you focused on or watching out for for the 1/1/26 plan year?

[21:34] Bridget Mulvenna: Yeah, talking to plan sponsors. I've had a lot of capabilities meetings this year, a lot more than I had last year. And so I've had a chance to kind of do the talk before the presentation. So what I'm doing is I'm selling against spreadsheet evaluations. I am literally saying to folks, we're not going to show up the best on the spreadsheet and here's why, but here are all the other things that we do to get you there. And then sharing my experience with doing that. And I'm also being a little bit more strategic.  

So, you know, I'm an old school pharmacy data nerd. So I'm doing a little bit more now that I've learned more and I kind of understand. I understand our wonderful underwriting team, their process, I understand the proposal process. I'm being a little bit more hands on and direct in the offers and then also in the presentations. And I'm going in with an individualized strategy for each one of these plan sponsors and these finalist meetings because they're all different. It's not one size fits all. You can't go in there with a script and expect to get your point across.  

You really need to go in with a specific strategy that's tailored to that plan sponsor, indicating to them that you have researched and you understand their business model. And then honestly doing what I've been doing for the last year, just leveraging the fact that not only am I a Capital Rx employee today and I understand the inner workings of the company, especially a year, 15 months in or however long it's been, but I was a client and I was a member. So I know how this product works from sort of a 360-degree view, better than the average person.

[23:16] Justin Venneri: So sounds like a much more consultative, individualized kind of PBM approach for next year?

[23:22] Bridget Mulvenna: Yeah, and fully authentic. And not that I'm performative anyway. I think anybody who listens to me talk knows it's extemporaneous all the time. I do make a plan, but I like for conversations with people to be as authentic as possible. And sometimes that means that my voice goes high and I get really passionate. But I think it works. At least it's been working so far. Go fix what's not broken.

[23:47] Justin Venneri: And I couldn't help but notice you didn't mention regulatory headwinds or tailwinds. Are you just kind of going about your business regardless of what happens in Washington D.C.?

[23:55] Bridget Mulvenna: i think that a year ago we might have been able to predict what's going to happen. I think right now in these first, first hundred days of the administration, while the balance of power gets established, whatever that's going to look like, I don't know that there's going to be a lot of legislative action because of sort of the chaos that's happening. And I'm trying to be very careful and not get too political here because everybody's got their own opinions and mine aren't that important in the grand scheme of things.  

But I do think that there will still be PBM reform. I think we'll probably see more of it at the state level. You've already seen states like Louisiana and Tennessee make serious reforms around dispensing fees and things like that and pricing and what PBMs can profit off of. I think the states are going to probably take the reins here and then perhaps there'll be some federal legislation that bolsters that, but I don't know that we'll see it in 25. I think that it's probably coming down the line when things stabilize, if they do.

[24:59] Justin Venneri: It's definitely, I would say, unpredictable is fair.

[25:02] Bridget Mulvenna: Yeah, unpredictable is fair. But crystal ball for Capital Rx is that we got tailwinds on us. We're doing pretty good.

[25:10] Justin Venneri: So, last question and thanks for sharing your thoughts with us and providing the update today. It's been great to hear. What's the most astonishing thing you've seen or heard out in the field that a prospect, client or channel partner is dealing with or that's still impacting plan sponsors? Well, that you can share, of course – that's compliant.

[25:26] Bridget Mulvenna: Yeah. So I think the most astonishing thing that I'm hearing, and it's coming from internal, from our underwriting team, is as we're doing these data and analytics and we're looking at drug spend, is that we're seeing some patients get two different GLP-1 prescriptions from two different pharmacies on the same day.  

And I think that there is, you know, obviously there's health risk there and there's also a great deal of financial risk there. And I just don't know that plan sponsors still have enough visibility into their data or pharmacy knowledge in house that is identifying that in real time. So I am concerned about obviously finances because I'm a pharmacy finance person, but I'm really concerned about people's health and just waste, especially because these are drugs that have been insured supply and there are people out there that look, I said this before, GLP-1s aren't bad. There are diabetics out there that really need these drugs. And so it's really important to make sure that there is not over dispensing of GLP1s for all of those reasons.

[26:38] Justin Venneri: Got it. Bridget, thank you so much for joining me today. I hope you have a great rest of your day.

[26:42] Bridget Mulvenna: Thank you. Talk to you soon.

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