PBM Leaders: A Conversation with Ken Paulus, CEO and President of Prime Therapeutics, Part 2

Second of four parts

As you mentioned you came to Prime from the provider side of healthcare— Allina, Vanguard, Partners in Boston. So could you just discuss the similarities and differences between running and being the CEO of a PBM and these nonprofit provider organizations? One difference is that you have to explain what a PBM is at a family gathering or a cocktail party, right?

I come from a family of caregivers. I'm one of six. There's a physician — my older brother is a primary care doc, my older sister is an occupational therapist, I was three, the fourth is a Ph.D., N.P. mental health clinician.The fifth is a psychologist and the last one is a counselor.

So I come from a provider family, if you will, and I tell you, when I moved from working in hospitals and clinics to working at a PBM, they were very concerned — to say the least.

The fact of the matter is, there's really an important role for both. The provider side, I always appreciated it, because you're right in the middle of the action. Are we doing the right thing for patients?

What we weren’t good at was, are we doing the right thing for patients in a way that is affordable?

And that’s where we come in. So we bring the affordability to the table, I think in some ways, and the providers bring the care and the quality to the table.

I am absolutely convinced that those two worlds need to come together.

It’s actually why I came to Prime. We were very frustrated on the provider side. Not in love with the PBM model. We mostly lost control of patients that were complicated specialty patients to big specialty pharmacies that we weren’t participating in. So we lost integration, and I think, in some cases, quality and adherence and really important outcomes.

By bringing those worlds back together, and having providers and caregivers be more involved in these pharmacy decisions — we must go there.

It just boggles my mind that we would separate pharmacy out and manage it off to the side and medical care be managed over here, and the two don’t meet. That absolutely makes no sense to anybody.

It’s almost the same conversation where we used to separate behavioral health and mental health from physical health. It makes no sense.

So I am driven to drive these two worlds back together. Bring the provider back into the equation, have he or she be part of the solution. All of us together in service of the patient. And if we do that, affordability will follow. I am convinced that we’ll get better outcomes. And we can do that at the same or a better price, and the quality and the care that we’re going toprovide will be far better.

It's kind of the kind of care that you would want for your mom if she was in specialty treatment. So I think these two worlds are going to come back together, and it’s time for us to do this.

That’s an interesting notion that the specialty pharmacy may sort of yank patients away from providers. So you’re kind of (proposing) kumbaya here — we’re going to bring it all together. But I going to challenge you on that. Whose interest is that in? The specialty pharmacies aren’t going to want to relinquish that control. I’m not sure how much power the providers have. So how does this occur? How does this actually happen?

First, starting with the providers — (they) would need to play ball. And having worked on that side for many, many years — decades — we didn’t take any responsibility for cost. (Under) th efee-for-service model, the more we did, the more we were paid. And we took no risk, we took no responsibility for cost of care. It’s a big reason why we are where we are as a nation. I would say that the chief reason our spending is 30% higher than it should be is that our (providers) aren’t aligned financially with the goal of trying to provide affordable health care. I had responsibility running Allina and working at Mass General and the Brigham and doing our part in managing costs, and we just didn’t do it. It just wasn't on our radar.

So we need to bring them into the equation, but they have to actually share some accountability with us. So if they want to keep the care integrated, which they do, they want to keep these specialty care patients in their control and they want to do the infusion and the dispensing and keep these two pieces together, I’m all for it, but they have to be with us financially. They have to share the risk — and the outcomes — together with us, so that we all are aligned.

So you're right, it's kumbaya, it sounds really good. Everybody’s going to have to come to the table and let go of a little bit and really do something different to significantly improve outcomes.

I have to tell you, adherence will be vastly improved. If a doctor tells you to stay on a medication, particularly specialty medications that are very costly, and there are lots of issues and challenges, if a doctor is behind it, you're going to adhere. If I'm telling a patient to adhere or if pharma t is telling a patient to adhere, or a health plan is telling a patient to adhere, they're not going to listen.

So if quality and outcomes like that are important, we need the doctor at the table. But we need the doctor at a table in a way that he or she is taking some responsibility for not just those outcomes but also financial outcomes.

So I'm with you. It sounds like kumbaya. It’s a heck of a lot more work than that. And we need everybody at the table, working together. We don't have it today. It's not aligned. It's not integrated. It's part of the reason healthcare costs so much in the United States.