CPAP Module 26, Section 5: Reporting for Client Value
MODULE 26: DATA ANALYTICS & POPULATION HEALTH IN UTILIZATION MANAGEMENT

Section 5: Reporting for Client Value

Understand the business of managed care by learning how PBMs use sophisticated data reporting to demonstrate cost savings, clinical quality, and overall value to their clients.

SECTION 26.5

Reporting for Client Value

The Art and Science of Demonstrating Your Worth.

26.5.1 The “Why”: The Final Link in the Value Chain

This entire module has been a journey through the PBM data ecosystem, from understanding the raw materials of claims data to analyzing trends and measuring program effectiveness. We now arrive at the final, and perhaps most crucial, destination: the client report. All the sophisticated analytics, clinical programs, and strategic interventions a PBM performs are ultimately meaningless if their value cannot be clearly, concisely, and compellingly communicated to the client who pays for those services. The client value report—often delivered in a formal Quarterly Business Review (QBR)—is the ultimate accountability mechanism. It is the PBM’s “report card.”

For a health plan, a large employer, or a government entity, the pharmacy benefit is one of their largest and fastest-growing expenses. They entrust a PBM with the immense responsibility of managing this spend while ensuring their members receive high-quality care. The value report is the primary tool through which the PBM proves it is a worthy steward of that trust and a value-adding partner, not just another cost center. A well-crafted report does more than just present data; it tells a compelling story of partnership, problems solved, and value delivered. It demonstrates transparency, builds trust, and forms the foundation of a long-term business relationship.

As a managed care pharmacist, even if you are not the one presenting the final report to a client CEO, your work is the bedrock upon which these reports are built. The integrity of the clinical quality metrics rests on your diligent application of PA criteria. The credibility of the savings figures depends on your recommendations for cost-effective alternatives. The success of a clinical program is a direct result of your interventions with members and providers. Understanding how your daily tasks are aggregated, analyzed, and presented as “client value” is essential for grasping the big picture of your role. It connects your clinical expertise to the business of healthcare and empowers you to see your work not just as a series of individual cases, but as a vital contribution to a massive engine of cost and quality management.

Retail Pharmacist Analogy: The Annual Performance Review with Corporate

Imagine you’re the manager of a pharmacy that is part of a large national chain. At the end of the fiscal year, the regional vice president visits your store for your annual performance review. This meeting is your “Quarterly Business Review.” You know the VP isn’t just there to see if the shelves are clean. She’s there to determine if your pharmacy is a high-performing asset for the company.

You wouldn’t just tell her, “We were very busy this year.” You would come prepared with a comprehensive report—your “client value report”—that tells the story of your pharmacy’s performance, using data to prove your value.

Your Performance Report Would Include:

  • The Executive Dashboard: An opening slide with key metrics: Total Revenue, Gross Profit, Prescription Volume, and your store’s overall ranking within the district (e.g., “#2 out of 15”).
  • Financial Deep Dive: You’d show your Generic Dispensing Rate (GDR) was 92%, 3% above the corporate goal, which saved the company an estimated $150,000 in acquisition costs. You’d present a trend line showing your immunization revenue grew by 25% year-over-year.
  • Clinical & Quality Deep Dive: You’d present data from your MTM platform showing your pharmacy closed 95% of its assigned CMRs and TMRs. You’d show that your pharmacy’s PDC score for the local health plan’s diabetes patients was 88%, contributing to that health plan achieving a 5-Star rating (and thus, higher bonus payments for your company).
  • Strategic Initiatives & Future Outlook: You’d close by saying, “Based on our analysis of local prescribing trends, we see a major opportunity to launch a new point-of-care testing service for strep and flu next quarter, which we project will generate an additional $50,000 in revenue.”

By the end of the meeting, you have used data to prove that you are not just managing a pharmacy; you are running a high-performance business unit that is saving money, improving quality, and identifying new opportunities. This is exactly what a PBM’s account management team does in a QBR, using the clinical and financial data generated by you and your colleagues to prove their value to the client.

26.5.2 Anatomy of a Client Value Report (The “QBR Deck”)

While the specific format varies, most PBM client value reports, often presented as a PowerPoint “deck” in a Quarterly Business Review (QBR), follow a logical structure. They begin with a high-level overview and then drill down into specific areas of performance, always framing the data in the context of the client’s specific goals (e.g., cost savings, member health, predictability).

A Visual Blueprint of a Typical QBR Deck
1. Executive Summary

The “at-a-glance” dashboard. Key metrics, overall performance grade, and major successes. Answers: “How are we doing overall?”

2. Financial Performance Review

Deep dive into the numbers. Drug spend trends, PMPM analysis, savings from UM and formulary, rebate performance, GDR. Answers: “Are we saving money?”

3. Clinical Quality & Safety Review

Focus on health outcomes. Adherence rates (PDC), opioid safety metrics (MME), guideline concordance. Answers: “Are my members getting better, safer care?”

4. Utilization Management Program Deep Dive

Spotlight on PA. PA approval/denial rates, turnaround times, top denied drugs, appeal rates, savings specific to PA interventions. Answers: “Is the PA program working efficiently?”

5. Pipeline & Market Intelligence

A forward-looking view. Analysis of new drugs in the pipeline, upcoming patent expirations, and the PBM’s strategy to manage future costs. Answers: “What’s coming next and are you prepared?”

6. Strategic Recommendations & Action Plan

The “so what?” section. Based on the data, the PBM proposes new programs or adjustments for the next quarter. Answers: “Where do we go from here?”

26.5.3 Deep Dive: The Financial Performance Narrative

This is the heart of the report for the client’s Chief Financial Officer (CFO). The goal is to demonstrate effective cost control and financial stewardship. The key is to present data not as isolated numbers, but as evidence of a successful cost management strategy.

Masterclass Table: Presenting Financial Data for Impact
Metric Presented How It’s Visualized The Narrative (What the Account Manager Says) The Pharmacist’s Underlying Contribution
PMPM Drug Trend vs. Benchmark A bar chart comparing the client’s % PMPM increase over the last year to a national, book-of-business, or industry-specific benchmark. “As you can see, while the national drug trend was 8.5% this year, your plan’s trend was held to just 4.2%. This 4.3% difference, or ‘trend advantage,’ is a direct result of our proactive management strategies and saved you an estimated $5.2 million.” Your consistent application of step-therapy criteria, recommendations for lower-cost alternatives, and denials of medically unnecessary requests are the primary drivers that “bend the curve” and create this trend advantage.
Savings by Management Levers A stacked bar chart or pie chart breaking down the total savings figure by its source (e.g., PA, Step Therapy, Formulary Management, Rebates, GDR). “We achieved a total of $12 million in savings this quarter. As you can see, the largest contributor was our formulary management and rebate negotiations at $5 million, followed closely by $4 million in savings from our clinical utilization management programs.” The savings attributed to “UM Programs” is a direct quantification of the value of your work. Every time you redirect to a preferred drug or deny a non-covered indication, you are contributing to this part of the savings pie chart.
Generic Dispensing Rate (GDR) A simple gauge or line chart showing the client’s GDR over time, often compared to a contractual guarantee or a national average. “We are pleased to report that your plan’s Generic Dispensing Rate hit 91% this quarter, exceeding our contractual guarantee of 90%. This focus on generics is the single most effective tool for controlling traditional drug spend.” When you review a PA for a brand-name drug that has a generic alternative and deny it for “failure to trial generic,” you are directly contributing to a higher GDR. You are the clinical enforcer of the generic-first strategy.

26.5.4 Deep Dive: The Clinical Quality & Safety Narrative

This section demonstrates that the PBM’s cost-saving measures are not coming at the expense of patient health. For clients like health plans (especially Medicare plans), these metrics are just as important as the financial ones, as they directly impact quality ratings (like Medicare Stars) and member satisfaction. This is where the PBM proves it is a true healthcare company, not just a financial one.

The Power of “Green Checkmarks”: Visualizing Success

Clinical data can be complex. The most effective client reports use simple, intuitive visuals to communicate performance. A common and highly effective technique is the “stoplight” or “dashboard” approach, where metrics are color-coded (Green for meeting/exceeding goal, Yellow for approaching goal, Red for underperforming) and accompanied by a simple icon.

Q3 Clinical Quality Dashboard

Statin Adherence (PDC)

85%

Goal: >80%

Diabetes Adherence (PDC)

78%

Goal: >80%

Opioid/BZD Overlap Rate

1.2%

Goal: <2.0%

This simple visual instantly communicates that while Statin Adherence and Opioid Safety programs are performing well, the Diabetes Adherence program needs attention. This naturally leads to the “Strategic Recommendations” section, where the PBM might propose a new intervention for that specific measure.

26.5.5 The Pharmacist’s Role in the Reporting Ecosystem

It can be easy to feel disconnected from these high-level client presentations when your daily work is focused on individual PA cases. However, it is crucial to understand that the integrity, accuracy, and ultimate success of every client report are built upon the foundation of your daily clinical decisions. You are not just a user of the system; you are a primary generator of the data that the entire value proposition rests upon.

Masterclass Table: Connecting Your Daily Work to Client Value Metrics
Your Daily Action as a PA Pharmacist How It’s Aggregated into Data How It Appears in a Client Value Report
You review a PA for a non-preferred, high-cost biologic. The case does not document a trial of the preferred, lower-cost agent. You deny the case and recommend the preferred alternative. The case is coded as a “Denial – Step Therapy Not Met.” The system tracks the cost differential between the requested drug and the presumed alternative. This single action adds to the “Savings from UM Programs” bucket on the Financial Performance slide, contributing to the overall ROI.
You review a PA for OxyContin 80mg TID for chronic low back pain. You identify that the patient’s daily MME is over 200. You deny the request based on the plan’s safety limit of 90 MME. The denial is recorded. The member’s MME is calculated from claims data. The program tracks the number of members whose MMEs are successfully kept below the 90 MME threshold. This appears on the Clinical Quality dashboard as a high performance on the “Members >90 MME/day” metric, demonstrating improved patient safety.
You review a PA for a new oral oncology agent. You meticulously check that the patient’s specific cancer type, stage, and biomarker status match the NCCN compendium and your plan’s criteria before approving. The approval is recorded. Analytics later compares the pharmacy claims for this drug to medical claims data for that member to verify the diagnosis and line of therapy. This contributes to a high “Guideline Concordance Rate” for the oncology program, proving to the client that this extremely expensive drug is being used appropriately.
While reviewing cases, you notice a pattern: many providers are confused by the documentation requirement for a specific lab value in a new PA criterion. You escalate this feedback to your clinical manager. This qualitative feedback is combined with quantitative data showing a high denial rate for “Insufficient Clinical Information” for that drug. This insight becomes a “Strategic Recommendation” in the QBR to clarify the criterion and publish a provider FAQ, demonstrating that the PBM is a responsive partner.