PBM GPO market share shifts as health plan enrollment continues to churn

Market share of pharmacy benefit manager-led group purchasing organization (PBM GPO) covered lives increased for Zinc Health Services, declined for Ascent Health Services and remained nearly flat for Emisar Pharma Services over the six months ending in July 2024, according to Pharmacy Benefit Evaluator data from Clarivate released this month.

Over the same period, the total number of PBM GPO lives in the U.S. remained relatively steady after undergoing strong growth the previous year.

Zinc, Ascent and Emisar are the nation’s three major group purchasing organizations used by PBMs to negotiate drug rebates for at least 88 million commercial lives, according to Clarivate estimates based on pharmacy benefit data reported by health insurers.

Zinc’s PBM members are CVS Caremark and CarelonRx. The largest members of Ascent are Express Scripts and Prime Therapeutics. Emisar is used by Optum Rx.

As these GPOs have emerged to play a key role in PBMs’ business strategy, federal government scrutiny of GPOs has followed suit under the Biden administration, although this dynamic could shift in 2025 under the incoming Trump administration.

Major enrollment shifts disrupt health insurance sector

Medicaid enrollment has continued its sharp decline even as pockets of growth persist, according to Clarivate’s latest Managed Market Surveyor data released this month.

The data shows that, as of July 2024, Medicaid enrollment declined by more than 4 million over the prior six months and more than 12 million over the prior year because of states redetermining eligibility following the end of the COVID public health emergency.

But some geographies, such as North Carolina, are seeing Medicaid growth where states have expanded eligibility. In Texas, where Medicaid eligibility has not been expanded, enrollment nonetheless marginally increased in the first half of 2024 after undergoing a precipitous decline at the end of 2023.

Coinciding with the Medicaid decline is continued enrollment growth for ACA exchange marketplace plans. However, exchange growth is not keeping pace with Medicaid declines, which could indicate millions of people are losing healthcare coverage altogether.

As of July 2024, exchange enrollment increased by more than 500,000 over the prior six months and more than 4.5 million over the previous year due in large part to people losing Medicaid eligibility.

A reduction in the enhanced subsidies for exchange plan premiums would likely trigger significant enrollment losses. These enhanced subsidies only run through 2025, but exchange plan popularity could cause the new administration to limit or avoid any reduction.

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Josh Kelley, Director, Product Management at Clarivate, contributed to this article.

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