AH076 - PBM 'Boogeymen' & Stopping the Madness Out There, with Jeff Hogan
Description
In this episode of the Astonishing Healthcare podcast, we discuss recent health policy news and how to bring greater transparency to health benefits programs with returning guest, Jeff Hogan, President of Upside Health Advisors. Building on our previous discussion with Jeff - How First-Movers are Taking Control of their Health Plans in 2025 - we shed more light on the “PBM boogeyman” narrative, explaining how opaque pricing structures and unhelpful provisions buried in contracts must be discovered. Jeff reviews attempts by states around the country to intervene and halt steering and other practices that negatively impact health plans and their members - from early medical reform efforts to recent PBM-focused legislation. He also notes Medicaid cuts are likely to have some "second-order effects" that impact commercial plans, and the mood in Washington, DC, overall is "dazed and confused," so we can't count on help at the federal level.
Highlighting the evolving role of PBMs and Capital Rx's expansion into medical benefit administration, it's apparent that the opportunity to reduce waste and take back control of benefits programs exists; however, "medical is worse," Hogan says. So, what is a plan sponsor or benefits consultant to do? Dig into those contracts - all of them (administrative services, broker, and stop-loss, to name a few) - and look at the provisions you're paying for! "This is where you discover the schemes that are occurring," he adds.
Lastly, Jeff notes an interesting trend with health systems and direct contracting that's worth a listen, especially if you liked AH075 - What Health Systems Need [From a PBM]: A Blend of Tech, Transparency, and Understanding, with Lindsey Butler, PharmD, and Chris England.
Related Content
- Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform
- Signs it is time to change your PBM vendor, and how to overcome common hesitations (BenefitsPRO)
- Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
To learn more about Upside Health Advisors, click here, or you can find Jeff on LinkedIn.
For more information about Capital Rx and this episode, please visit Capital Rx Insights.
United States
