By: Umair Malik
Every industry has its middlemen, but some industries have better examples than others. In the healthcare sector, Pharmacy Benefit Managers (PBMs) serve this role, operating between insurers, employers, drug manufacturers, and pharmacies. More specifically, PBMs are administrators of prescription drug programs and operate in conjunction with integrated healthcare systems and retail pharmacies, and sometimes as a part of insurance companies. Today, these companies manage pharmacy benefits for 275 million Americans and have established themselves as critical entities in the sector.
These companies perform a variety of functions, from negotiating rebates to processing pharmacy claims to assembling retail pharmacy networks, but the role of PBMs in modern healthcare has been hotly debated lately. This is largely due to concerns around how business incentives can lead to reduced competition, obscured business practices and pricing strategies, and questions about keeping up with evolving patient needs. It’s clear that the role of PBMs needs to evolve to meet the needs of today’s Americans, both functionally and institutionally.
AffirmedRx is a company leading the charge in the redefinition and evolution of pharmacy benefit managers in the American healthcare system. The biggest differentiating factor between AffirmedRx and other PBMs is that AffirmedRx is the only one in the United States to be structured as a Public Benefit Corporation (PBC), a for-profit corporate structure that enshrines making a positive social impact in its mission statement and goals. Their commitment to improving patient outcomes is built into their structure, and it’s backed by an operating philosophy that prioritizes full transparency, clinically driven, member-first approaches to pharmacy benefits, and full data access.
“At AffirmedRx, we don’t just provide services, we are leading a movement toward authenticity and humility, fostering a model focused on integrity and empowerment,” says AffirmedRx’s website. “Our mission is clear: to champion transparency, patient-centric care, and innovative solutions in an industry often plagued by opacity and complexity.”
Operating For The Public Good
AffirmedRx’s commitment to patient care and PBM reform is not just a promise, but a mission written into its legal corporate structure, which is a significant divergence from the industry standard. Structuring themselves as a public benefit corporation means AffirmedRx has added a pro-social layer that goes beyond (and may in fact mitigate) the mandate to increase shareholder value. In the context of the United States healthcare system, where soaring prices and impenetrable practices are common, this decision legally incentivizes AffirmedRx to operate in the public interest.
So what does this look like functionally? As for-profit entities, PBMs have developed a reputation for hidden revenue streams, poor transparency, and incentive structures that trade patient care quality for increased profits. Beyond the administration and service fees that are core to the PBM business model, many also benefit from manufacturer rebates, clawbacks, and spread pricing, obscure processes that most patients are blind to, and in some cases hurt by.
AffirmedRx rejects the obscurity and profit-first incentives in favor of a policy that is definitively more patient-focused. Firstly, and perhaps most importantly, AffirmedRx rejects the industry-standard revenue streams of other PBMs: no clawbacks, no spread pricing, and no rebate retention. AffirmedRx’s entire revenue stream is built upon a simple, fair, flat administrative fee model. This model supports pricing simplicity, radical data transparency, and unbiased clinical decision-making.
“By operating on a simple, flat administrative fee model, AffirmedRx ensures every dollar is accounted for, and employer groups have complete visibility and access to their data,” says an AffirmedRx representative. “We simplify the complexities of filling prescriptions so patients can confidently access the best care to get and stay healthy.”
AffirmedRx’s internal values drive their team as surely as they drive their corporate structure. Their HEART2 company values demand that both the company leadership and their team act from the highest level of integrity in all their business practices. Honesty and humility, Ethics and Empathy, Authenticity and Accountability, Respect and Responsibility, Tenacity and Transparency, these are the values that drive AffirmedRx.
Patient Care Advocacy
AffirmedRx operates from a patient-centric approach, which means putting the experiences and needs of the patient at the heart of every business decision. The beating heart of AffirmedRx’s patient-first methodology is their team of Patient Care Advocates (PCAs), the team that makes the company’s emphasis on human-to-human interaction a reality instead of just a promise. The PCAs have real-time access to claims and denials, which allows them to proactively resolve issues through coordination with providers and pharmacies, all before patients reach the pharmacy counter.
“Our growing team of Patient Care Advocates represents the plurality of our stewardship, ensuring that AffirmedRx can engage in high-touch customer service to identify savings opportunities, streamline prior authorizations, and problem-solve on behalf of our valued members,” says AffirmedRx spokesperson. “Where other PBMs initiate problem-solving after a frustrated member calls in to report a claim denial, our teams work to get those issues resolved before the member arrives at the pharmacy.”
AffirmedRx’s PCAs benefit from both modern training and modern technology to deliver the best care and service possible. Cloud technology lets these agents streamline the identification and resolution of member issues at the individual claim level. This lets PCAs reach out directly to members, providers, and pharmacies, track progress on issues, and escalate where necessary. When supported by their extensive and continuous training, AffirmedRx’s PCAs deliver consistently and transparently, such as helping identify cost-saving opportunities for members.
“AffirmedRx confirms the performance of the patient-first model through a number of metrics,” says AffirmedRx spokesperson. “We analyze out-of-pocket costs for members that can often be a barrier to access or continuity of care. We conduct surveys to assess the member experience both at the organizational and individual level.”
Today, AffirmedRx is redefining what it means to operate as a pharmacy benefit manager. Their patient-centric model, on its own, is less a radical innovation and more of a re-focusing on what truly matters in the industry: the health of plan members and their experience in achieving (and sustaining) healthy lives. As the industry shifts and AffirmedRx grows, the company plans on expanding the PCA team, with the goal of shielding patients from complexity by proactively identifying and resolving issues before members are burdened with them.
