National Alliance President and CEO Shawn Gremminger Discusses 2024 Initiatives, PBMs, and Health Equity

Newly appointed National Alliance of Healthcare Purchaser Coalitions (National Alliance) President and CEO Shawn Gremminger steps into the role during a tumultuous time in US health care. With a growing national focus on issues like drug pricing, pharmacy benefit managers (PBMs), and care inequities, there is no shortage of areas where change is needed.

From past roles, Gremminger brings extensive expertise in health policy and government relations to the National Alliance. In this interview with The American Journal of Managed Care^®, Gremminger discussed his initiatives as president and CEO, as well as his thoughts on persistent issues in health care.

Transcript

As incoming president and CEO at the National Alliance, what will be some of your initial areas of focus?

When I was first hired by the board of directors of the National Alliance, the first thing they asked me to do was focus on establishing a new strategic plan for the organization, and we're going to be going through a process over the course of about a year. The big question that we're going to be focusing on at the outset is: what do we think the future of the health care system looks like—particularly in the commercial sector, and for large- and medium-sized, self-insured employers? I think there's pretty significant changes coming to the health care sector in the marketplace. The role of [artificial intelligence], in the way that health plans and employers can do better purchasing and be more thoughtful about the way that they do their purchasing is going to, I think, make a huge difference over the next 10 years.

Overall, I think the perspective always starts with, "What are the drivers that employers and purchasers are thinking about when they create their health care networks and are doing purchasing?" Always, it's sort of a dual challenge of keeping costs in line with projected growth targets, and continuing to meet the needs of employees and their families. And that's often in tension with one another, but that's usually the starting point for where we think about where we want to focus as the National Alliance on behalf of our coalitions, and ultimately on behalf of employers and purchasers.

Pharmacy benefit managers have been a major topic of discussion in recent months. Where do you see potential for policy changes in the near future?

It's really exciting, actually, to see some real attention at the congressional level and the state level focused on on dealing with PBMs and the entire drug supply chain. One of the things that I've encouraged employers and purchasers not to do is to fall into the kind of stale debate between pharmaceutical manufacturers and PBMs as to who's at fault. I think in the end, that's what where they want to keep the conversation is, you know, "it's all the fault of the PBMs" or "it's all the fault of the manufacturers."

I think we recognize that it's not a simple solution, and it's not a simple question as to what's driving higher health care costs. But looking at what's possible this year on PBMs, I think the the really good news is that that price transparency is making a big difference in terms of people understanding the nature of the problem. We've seen a rise of new kind of innovative, smaller PBMs that are trying to disrupt the marketplace. I think employers and purchasers are excited about that. But moving from you know, some of the large, sort of. big 3 PBMs to a smaller group is not easy. There's a lot of reasons and a lot of ways in which the big PBMs try to keep their market share by the way that they conduct business.

We're definitely supporting policy that would require substantial new reporting requirements on PBMs, and that would help employers and purchasers better understand the value of what they're getting. So understanding what the initial purchase price was when the PBM or its GPO first purchased the drug, all the way through all of the fees, all of the rebate structures, etc, so that when employers are finally cutting the check—when they're actually finally purchasing the drug from the PBM—they have a good sense of how much of that dollar has is being passed back to the employer and purchaser and ultimately, to consumers, and how much has been held on to by the PBM. Until we have that information, it's very difficult for employers and purchasers to know, frankly, whether they're getting a good deal or not.

Another topic gaining increased attention has been health equity. What are your thoughts on the role of employers in mitigating health disparities in the US?

To me, this is a really interesting area, and obviously a really important one. I think employers—as the people who ultimately are cutting the checks and are really invested in the the life and quality of life for their employees and their families—I think have a major role to play in ensuring health equity. There's a lot that employers can and should be doing on their own to make sure that they're structuring benefits in a way that are equitable, and are ensuring access for all of their covered lives. Whether they are located in higher income areas, lower income areas, medically underserved areas, we need to make sure that the way that we're actually conducting our business is is equitable, and is making sure that people are having real access to high quality.

That being said, we also have to be holding others accountable. So, all of the people that we are contracting with, whether that be our insurance plans, ultimately with providers, we have a responsibility to ensure that they are actually upholding, you know, a real value toward and pushing toward better equity.

An area where I feel like we may have sort of gone a little bit potentially too far—or at least there's some concern—is this idea that the health care system should be uniquely responsible for social determinants of health. I understand why people have gone there. The concern that I have, frankly, is that if you think about what social determinants of health are, they are a whole bunch of underlying things that that impact health. But most of those underlying things don't actually have a lot to do with the health care system. They have a lot to do with economics, transportation, poverty, physical health, diet, all of that kind of stuff. I worry about the health care system—the most sort of inefficient and challenged system in the country—being uniquely responsible for solving social determinants of health.

When you start getting a system that is so focused all too often on high prices, increased utilization, economic distortions, and saying, "Well, we want to pay you more to solve problems that are sort of outside of your bailiwick," I worry that we're going down a path in which we're not actually going to end up solving a lot of problems, but we are going to end up spending a lot of money.