‍How brokerages and insurtech are shaping the future of healthcare

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A growing demand for new, brand name medications is a major contributor to the high cost of health care. According to the American Health Insurance Association (AHIP), prescription drugs make up around 22% of commercial health plan premiums. In 2023, overall pharmaceutical expenditures in the U.S. grew 13.6 percent compared to 2022, for a total of $722.5 billion.

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Understandably, pharmacy costs are a chief concern for employers who want to offer their employees a robust benefit package while containing costs. That’s why industry leaders are collaborating with specialty consulting firms and insurtech companies to explore strategies and creative solutions to improve patient outcomes and reduce costs.

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Here, two leaders discuss their role in innovating pharmaceutical care, and how insurtech and specialized consultants are playing a future-forward role:

• Connie Perry, PharmD, Managing Director of Ethica Pharmacy Advisors
• Brand Newland, PharmD, MBA, CEO and Cofounder of Goldfinch Health

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Ethica Pharmacy Advisors: Leveraging technology to optimize benefits for employers

Ethica Pharmacy Advisors is a pharmacy consulting firm housed under the umbrella of M3 Insurance, a privately owned, independent insurance broker. Recognizing the need for specialized expertise for pharmacy benefits, M3 created Ethica Pharmacy Advisors in 2024 to help employer groups manage drug costs.

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“There’s a lot of concern about pharmacy benefit managers (PBMs) being opaque, focused on revenue, driving up costs, and overall, having misaligned incentives, which leads to unaffordability,” says Perry. “So, someone with diabetes can no longer afford their insulin, for example. There’s so much negativity to it. We aim to provide transparent and strategic advice.”

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Ethica works with primarily self-insured groups of any size, says Perry, adding that their sweet spot is small- to mid-sized employers. In order to optimize pharmacy benefits for employers, Ethica conducts a thorough review of PBM contracts and the structure of pharmacy coverage, helping clients understand areas for improvement and potential cost savings. 

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“We're intermixing the value of technology on the contract integrity side with clinical oversight,” she adds. “We distinguish ourselves from competitors who may still rely on manually processing data.” 

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Ethica’s platform is able to identify and categorize pharmacy claims, such as brand, generic, or specialty drugs, and assess PBM pricing strategies or tactics. “This enables precise repricing that inclusions actual claim exclusions without relying on assumptions, helping to eliminate tactics used by PBMs to obscure discounts and rebates,” say Perry. 

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The goal of Ethica Pharmacy Advisors is not only to reduce prescription drug spending but also to improve the care and management of chronic diseases, adds Perry. “This approach may sometimes increase prescription costs by ensuring patients receive the right medications and adhere to their treatments. However, these efforts can lead to significant savings on the medical side by preventing long-term complications and reducing emergency room visits, although these savings are harder to measure directly.”

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Goldfinch Health: How The Billion Pill Pledge uses tech to tackle the opioid crisis

Over the past two decades, a significant long-term complication of prescription drug use has been opioid addiction. Prescribed as safe and non-addictive for chronic pain management in the late 1990s and early 2000s, we now know that long-term use of opioids carries a high risk of addiction, dependence, and overdose.

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To combat opioid use after surgery, Brand Newland co-founded Goldfinch Health in 2018. As a 2020 BTV Accelerator participant, Goldfinch spearheaded The Billion Pill Pledge, an initiative that aims to erase 1 billion unnecessary prescription opioid pills from homes and communities.

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Newland, a PharmD who holds a certification in pain management, was inspired by personal experiences with the pitfalls of surgery and a lack of proactive solutions to the opioid crisis. “The frequency was staggering. It seemed everyone has a connection or a story to tell.”

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The pledge addresses the alarming statistics showing that even a single opioid prescription in a household can increase the risk of overdose by 60%. Two prescriptions can raise the risk by 600%. 

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“There are 3 billion leftover opioids each year after surgery in the U.S. The drugs are dangerous not only for the person who had the surgery or procedure, they are also a danger to the people around them,” says Newland. 

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The pledge began as a concept in 2020, gaining momentum with the opioid settlements in 2022. The program partners with states such as Iowa, Nebraska, Tennessee, and South Carolina, helping healthcare providers reduce opioid prescriptions through training and implementation of evidence-based, non-opioid pain management strategies.

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Goldfinch's approach includes tech-enabled healthcare services with nurse navigators supporting patients before and after surgery, aiming to reduce opioid use and improve recovery outcomes. Their approach addresses personalized pain management, education, implementation, support to providers, and proper disposal of opioid prescriptions. 

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In addition to working with employers and brokers, Goldfinch also leverages funds from opioid settlements to implement programs in multiple states, helping healthcare providers update their pain management practices. “The goal is to create sustainable changes in opioid prescribing and pain management, with employers and brokers playing a critical role in sustaining these practices once settlement funds run out,” says Newland. 

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“We’re seeing 60% fewer opioid pills, 92% fewer opioid refills, and we’re also decreasing readmissions,” says Newland. “So, patients go home with fewer opioids and they do better, not worse. But that's a little counterintuitive in the U.S., because it's been so ingrained over the last 25 years that opioids are state-of-the-art health care. It’s simply not true.”

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Goldfinch’s message resonates strongly with a certain segment of employers, especially public entities, school districts, manufacturing, and labor unions. “Sadly, many of these people can think immediately of someone who has been impacted by opioids,” says Newland. “They want to prevent it from happening to someone else.” 

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Goldfinch continues to sell their program through brokers and consultants around the country. According to Newland, “Much of the time, we're working with brokers we met through BTV, who has been so impactful to our cause.”

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Overall, companies like Ethica and Goldfinch Health demonstrate how innovation in pharmaceutical care by brokerages and insurtech is crucial in addressing the needs of modern health care. Their ability to embrace cutting-edge technology and adopt creative solutions have the potential to significantly enhance access to appropriate medications, decrease costs, improve outcomes, and streamline healthcare.

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