For Evernorth's Express Scripts pharmacy benefit management, should we prioritize cost savings for clients or broader medication access for members?

Introduction

The trade-off between prioritizing cost savings for clients or broader medication access for members in Evernorth's Express Scripts pharmacy benefit management presents a complex challenge. This scenario involves balancing financial considerations with healthcare accessibility, impacting various stakeholders. I'll analyze this trade-off by examining the product ecosystem, potential impacts, key metrics, and experimental approaches to inform a strategic recommendation.

Step 1

Clarifying Questions (3 minutes)

• Based on the current market dynamics, I'm thinking cost pressures might be particularly acute. Could you provide more context on the recent trends in client cost concerns versus member access issues?

Why it matters: Helps prioritize which aspect of the trade-off is more pressing currently. Expected answer: Cost pressures have increased significantly in the past year. Impact on approach: Would lean towards cost-saving solutions if confirmed.

• Considering our revenue model, I assume we have a mix of per-member-per-month fees and rebate sharing. How does our revenue breakdown look between these sources?

Why it matters: Influences the financial impact of prioritizing either option. Expected answer: Roughly 60% from fees, 40% from rebates. Impact on approach: Would affect how we balance cost savings vs. access in our solution.

• Looking at our member demographics, I'm curious about the distribution of chronic vs. acute medication needs. What percentage of our members rely on ongoing medication for chronic conditions?

Why it matters: Affects the long-term impact of access decisions on member health outcomes. Expected answer: About 40-50% have chronic medication needs. Impact on approach: Higher chronic needs would prioritize consistent access over short-term savings.

• Regarding our technology infrastructure, how flexible is our current system in implementing tiered access or dynamic pricing models?

Why it matters: Determines the feasibility of nuanced solutions that balance both priorities. Expected answer: Moderately flexible, but major changes require significant development time. Impact on approach: Would influence the complexity of proposed solutions and implementation timeline.

• Considering our team capacity, how are we currently resourced for potential changes in either direction - cost optimization or access expansion?

Why it matters: Affects the feasibility and timeline of implementing different strategies. Expected answer: Stronger resources in cost optimization, limited in access expansion. Impact on approach: Might need to factor in team expansion or training for access-focused initiatives.