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Future-Proofing the PBM and Pharmacy Business


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Companies in the pharmacy and PBM space need to optimize key business processes and operational health by embracing new and distinctive organizational designs that make them more agile.

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Future-Proofing the PBM and Pharmacy Business

  1. 1. • Cognizant 20-20 InsightsFuture-Proofing the PBM andPharmacy Business Executive Summary black-box earnings are a bigger threat. Getting there requires PBMs and pharmacies to rapidly Pharmacies and pharmacy benefit management build distinctive capabilities and optimize exist- firms (PBMs), large and small, are being forced to ing operations — two challenges that, if not done fundamentally remake their business models. This efficiently and in a timely fashion, could further is due to several factors, including a reduction in jeopardize their long-term existence. the number of blockbuster drugs, shorter product lifecycles and design cycles and quick-and-easy This white paper examines how companies in replication of efficient distribution models by the the pharmacy and PBM space can optimize key competition. Many of these companies are losing business processes and improve their overall their hard-earned competitive advantage and operational health by embracing new and distinc- are seeking the next big thing to revitalize their tive organizational designs that make pharmacies revenue streams. and the PBM more agile. The competitive landscape is changing rapidly, with competition coming from unexpected quarters. For example, Argus Health is pioneering Industry Trends Forcing a new approach for selling services to PBMs via Business Cycle Change a utility model. Walmart-Caterpillar’s direct-to- • Healthcare reform transparency regulations payer contract model is also causing a stir by dis- • Simplification of pharmacy benefits intermediating PBMs. This is not too dissimilar to • Generics replacing blockbuster drugs what is going on in other industries. For instance, who in the previous decade would have thought • Reduced emphasis on pharmacy benefits management that e-tailing behemoth Amazon would be among • Increased emphasis on patient-centric approach today’s cloud computing leaders? Or that music distribution or mobile communication would be • PBM disintermediation from retail giants revolutionized by a PC maker, Apple? • Rapidly emerging nontraditional PBM models: PBA, transparent PBMs Moreover, the unrelenting forces of regulation, • Questionable viability of standalone PBMs demographic changes, consumerism and techno- • Conflicts of interest for retail-owned PBMs logical advancements are challenging pharmacies • Concerns over increased payer costs in and PBMs. Additionally, shrinking margins in core self-dealing PBMs revenue streams, commoditization of services, and transparency regulations that undercut Figure 1 cognizant 20-20 insights | september 2011
  2. 2. Business Model Transformation demanding change is the Health Resources and Services Administration’s launch of the Patient Safety and Clinical Pharmacy Services Collabora- tive for evidence-based pharmacy services. Patient Management As the pharmacy space undergoes major business transformation, many players will need to re-invent Therapy Management themselves. At issue is whether pharmacy companies can leverage existing knowledge and Benefit Management capabilities to successfully transform. The Challenge for Business Model Distribution Transformation Business reinvention requires new distinc- tive capabilities and enhancements to existing operating models, which takes time and resources to build and let mature. According to Amazon’s Figure 2 Thursday, September 1, 2011 CEO Jeff Bezos,1 it takes five to seven years before the seeds of innovation planted at his company have a meaningful impact on the economics of Business Model Transformation the business. When it comes to transforming the The pharmacy industry has traditionally gener- business model, the commitment of resources — ated earnings by driving efficient delivery of combined with a high level of risk and uncertain- drugs from manufacturers to patients. A majority ty surrounding the ability to deliver effectively of the industry’s earnings have historically been and on time — is among the biggest decision driven by the sale of blockbuster drugs. Several barriers business leaders face. Sometimes, by bio-pharma challenges — including patent expira- the time decisions are made and the capabili- tion deadlines for many brand ties are developed, a new business cycle begins At issue is whether drugs, a dearth of blockbusterpharmacy companies drugs in the landscapea and a pipeline, highly competitive A Congruent Relationship can leverage low barrier for new entrants to existing knowledge replicate the current low-cost and capabilities drug delivery-based operating model — are rippling across STRATEGY to successfully the industry value chain, indi- transform. rectly impacting pharmacies and PBMs. These forces influ- BUSINESS MODEL ence rebate yields, average prescription price and simplification of pharmacy OPERATING MODEL Business Agility benefits design. As a result, pharmacy companies Capability Agility are looking to revitalize their revenue streams by adding new and innovative value-added ser- vices to their current distribution channels CAPABILITIES (see Figure 2). PROCESS Among the supporting trends is ongoing health- care reform. As reform slowly churns, the phar- PEOPLE macy segment is rightly positioned within the industry value chain to drive high-quality, lower- TECHNOLOGY cost healthcare for all. As evidence, pharmacies are already experimenting with in-store clinics, in-store inoculation, disease management and health services to foster reductions in patients’ out-of-pocket healthcare costs. Another force Figure 3 cognizant 20-20 insights 2
  3. 3. to emerge and the company ends up behind the Embracing the Future of Workcurve, needing to contend with the challenges of It takes a great amount of resources to buildthe next business cycle. distinctive capabilities within the organization,The pharmacy space is currently at this not to mention the time required to mature andjuncture. Major pharmacies have to make the scale them. As business cycles compress, phar-decision of whether to embark on adding clinical macy and PBM companies have to continually revitalizemanagement, therapy and disease management Increased competitionand benefits management services to their by frequently creating newcurrent product portfolio to improve the and distinctive capabilities. in the pharmacy andeconomics of the business. To build these new The reason: shorter planning PBM segment will cycles means they have littleproduct and services offerings, senior leadership force existing playersmust assess how quickly and efficiently their latitude to wait for returnsteams can build new and distinctive capabilities. on expensive Cap-Ex invest- to embrace a virtual ments. In the past, pharma- operating model, cies and PBM companiesTo achieve material increases in net margins, our where many non-coreexperience reveals that business leaders must could depreciate capitalassemble the right combination of processes, investments over five- to business functionsskills, knowledge, structure and tools. Moreover, 10-year horizons. However, and capabilities are given accelerating industrythey need a business operating model that is delivered as utility-agile enough to quickly integrate the new and changes, today they mustdistinctive capabilities required to support new plan and invest for returns based cloud services.products and services. Those companies that achieved three to four quar-can more swiftly revise their business operating ters down the road.models to accommodate new capabilities anddecouple current capabilities that no longer align To rapidly add or remove the capabilities towith business strategy will be better positioned to match tighter business cycles, PBMs mustrapidly adapt to changing business cycles. Those move from an integrated to a virtual operatingcompanies willing to embrace these new concepts model. This virtual operating model, wherewill be positioned to leave their rivals behind contextual business functions and capabili-(see Figure 3). ties are provided by more efficient partnerShifting Operating Models Virtual Operating Model • Core capabilities kept in-house. • Non-core capabilities, such as billing, distribution and manufacturing utility, obtained from third-party. • Flexible for business transformation. • Quickly available. • Requires business architecture to be able to couple with various cloud-based services. • Medium to high efficiency but highly agile. Integrated Operating Model • All capabilities built in-house. • Major new capabilities added through creation of new organizations. • Rigid to transformation. • High cultural change barriers. • Closed business architecture. • Drives very high efficiency. • Recommended for mature capabilities.Figure 4 cognizant 20-20 insights 3
  4. 4. companies, has already been adopted by some business functions and capabilities are delivered of the more successful companies in the high- as utility-based cloud services (see Figure 4). technology market, a sector where winning requires not only innovative products but also Pharmacies have been slow to embrace virtual dynamic business models and go-to-market collaboration models and externally delivered strategies.2 The virtual integration operating services for one primary reason: Their business model requires tight but flexible integration environment did not compel them to do so. But between companies with transparent processes with increasing volatility, pharmacy companies and information freely flowing and PBMs will have to shift from a completely between the partners. integrated operating model to a hybrid approach But with increasing before fully embracing a virtual operating model volatility, pharmacy This virtual model is evident — but only if warranted by business conditions. at companies such as Dell,companies and PBMs where almost all business For starters, pharmacies will have to open up will have to shift functions and capabilities their business architectures and identify loose couplings for seamless adoption of the emerging from a completely of product manufacturing, cloud-delivered services within their current delivery and support (other integrated operating than brand management) are operating models. The current spectrum of “as a model to a hybrid handled by third parties.3 service” utility-based offerings such as business process as a service (BPaaS), infrastructure as aapproach before fully For pharmacies and PBM service (IaaS), platform as a service (PaaS) and embracing a virtual organizations to migrate software as a service (SaaS) are examples ofoperating model – but from an integrated to a point solution-based capabilities that reliably and virtual operating model, they consistently deliver a specified outcome. only if warranted by must completely understand business conditions. current business processes Sanovia’s PA-Logic is a good example of a prior and fundamental perfor- authorization capability delivered as BPaaS. mance levels. They also need to instrument its ADP’s Payroll Services is another example of a demand forecasting process so output can be utility-based BPaaS to manage the employee shared by all the partners within the virtual payroll process, a function that is often not the model. core competency of the pharmacy or PBM. A key challenge to overcome is the decision of To swiftly derive distinctive business capability which business processes to turn over to a partner. relevant for the pharmacy business space, To answer this, the organization must acquire a businesses must optimally combine the dynamic strong understanding of the current process, its potential of these point solutions-based capabili- performance and its impact on the business. The ties from various vendors. The combined benefit decision to partner can be a challenging one given of a traditional operating model with the dynamic that these decisions may require the organiza- potential of cloud-based services will reduce the tion to partner for business processes in which it learning curve the organization must ascend already has significant investments. when building new and distinctive capabilities, and it will also reduce the capital investment Another impact of this model will be on the usually required. organizational structure. The organizational structure of the company adopting the virtual Pharmacies and PBMs that learn how to adopt operating model will undergo a major change “cloud services” will be better equipped to and will have to add the capabilities to manage transform themselves by embracing a more processes that can span multiple partner com- virtual business operating model. Taking this tack panies. In addition, the organization will have to will enable them to more efficiently and rapidly apply more mature decision-making processes respond to changing market dynamics and to harness the benefits of the virtual operating business cycle volatility. In fact, this approach will model. form the foundation for thoroughly transform- ing the business core across the enterprise for Increased competition in the pharmacy and PBM the future. Cloud-based services will be the key segment4 will force existing players to embrace attribute for next-generation operating models a virtual operating model, where many non-core that leave key rivals in the rear-view mirror. cognizant 20-20 insights 4
  5. 5. Footnotes1 Paul Nunes and Tim Breene, “Reinvent Your Business Before It’s Too Late,” Harvard Business Review, January 2011.2 This is evidenced by the fierce competition in the smartphone market, where Apple came from behind and captured market share through the introduction of innovative products such as the iPhone.3 Joan Magretta, “The Power of Virtual Integration: An Interview with Dell Computer’s Michael Dell,” Harvard Business Review, March 1998.4 Several events — including the recent entrance of Walmart in this market segment, the merger of ESI, Medco and Catalyst Rx, as well as the acquisition of Walgreens’ PBM business — are all indications of an increase in competition.About the AuthorUday Shah is PBM Practice Lead within Cognizant Business Consulting’s Healthcare Unit. He has over20 years of professional experience in the pharmaceutical manufacturing, supply chain management,retail pharmacy, hospital pharmacy, informatics and managed care pharmacy segments. Uday’s special-ties include aligning business and IT organizations with the corporate strategic layer; auditing businessand tactical architectural overlays for enterprise effectiveness; and pharmacy, PBM, specialty pharmacy,pharma sales and marketing. He completed an Executive Master’s in Technology Management degreefrom the University of Pennsylvania; graduate studies in Health Evaluation Sciences at Hershey MedicalSchool; and graduate studies in Pharmaceutical Sciences and a Bachelor of Pharmacy at M. S. Universityin India. He can be reached at Khanna is Senior Business and IT Strategy Consultant within Cognizant Business Consulting’sHealthcare Unit. He provides management, information technology and operations strategy consultingservices to customers in the healthcare space. Sanjay has over 17 years of experience impacting theenterprise bottom line and value performance through expert alignment of business and IT capabili-ties with the corporate vision, mission, goals and aspirations. He has a Master’s of Science (ExecutiveMaster’s in Technology Management) from University of Pennsylvania School of Engineering and AppliedSciences and Wharton School of Business, as well as a Bachelor of Engineering (Industrial Electronics)from University of Pune, India. Sanjay can be reached at CognizantCognizant (NASDAQ: CTSH) is a leading provider of information technology, consulting, and business process out-sourcing services, dedicated to helping the world’s leading companies build stronger businesses. Headquartered inTeaneck, New Jersey (U.S.), Cognizant combines a passion for client satisfaction, technology innovation, deep industryand business process expertise, and a global, collaborative workforce that embodies the future of work. With over 50delivery centers worldwide and approximately 118,000 employees as of June 30, 2011, Cognizant is a member of theNASDAQ-100, the S&P 500, the Forbes Global 2000, and the Fortune 500 and is ranked among the top performing andfastest growing companies in the world. Visit us online at or follow us on Twitter: Cognizant. World Headquarters UK Headquarters India Operations Headquarters 500 Frank W. Burr Blvd. 1 Kingdom Street #5/535, Old Mahabalipuram Road Teaneck, NJ 07666 USA Paddington Central Okkiyam Pettai, Thoraipakkam Phone: +1 201 801 0233 London W2 6BD Chennai, 600 096 India Fax: +1 201 801 0243 Phone: +44 (0) 20 7297 7600 Phone: +91 (0) 44 4209 6000 Toll Free: +1 888 937 3277 Fax: +44 (0) 20 7121 0102 Fax: +91 (0) 44 4209 6060 Email: Email: Email:© Copyright 2011, Cognizant. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, transmitted in any form or by anymeans, electronic, mechanical, photocopying, recording, or otherwise, without the express written permission from Cognizant. The information contained herein issubject to change without notice. All other trademarks mentioned herein are the property of their respective owners.