There is so much rancor and finger pointing these days over prescription drug prices that consumers are often left to wonder: Who is fighting on their behalf? The answer: Pharmacy Benefit Managers (PBMs).
Companies and public programs providing prescription drug coverage hire PBMs for their expertise, and ability to reduce drug costs by negotiating for rebates and discounts from big drug companies and drugstores. It would be too expensive and complicated for employers, or other payers, to match PBMs’ ability to reduce drug costs, while providing access.
Having been involved as a clinician representing insurers and PBMs for more than 25 years, I know first hand the importance of leveraging savings while ensuring that patients have the medications they need.
One patient-friendly and cost-saving option that PBMs provide to consumers is home delivery of chronic medications. As more and more people move to a “home-delivery economy” for many of their needs, mail-service pharmacies are a natural extension that adds convenience and lowers costs.
By using home delivery, consumers can avoid multiple (and unnecessary) trips to the drugstore while receiving private counseling from trained pharmacists seven days a week, 24-hours a day.
Mail-service pharmacies feature cutting-edge technology that can track and improve patient's adherence to prescribed medications. Research shows that better adherence to prescribed drug regimens means that patients would not need as many trips to the doctor or hospital, lowering overall health-care costs for everyone.
It is easy to see that PBMs reduce drug costs, but often overlooked is the clinical value that they provide payers and patients. PBMs work in coordination with their clients to carefully evaluate new drugs, review existing drugs, and apply sophisticated drug assessments that promote the best use of complex medications, and the appropriate use of mainstay drugs.
Pharmacists, doctors and other professionals employed by PBMs review the medical evidence for every drug approved by the FDA, assist in managing drug-related side effects and provide support to create formularies so that patients stay on their drug regimens and out of the hospital. That in turn lowers costs for patients and the entire health care system.
These formularies often organize medications according to their therapeutic effects and create logical sequences for their use based on clinical effectiveness, place in therapy according to national guidelines, and safety. Generic and lower cost brand medications can be incentivized before more expensive medicines because they work well for the majority of patients and have lower copays.
As the health care sector moves toward payment for value rather than volume, PBMs are providing expertise in developing and executing on these types of outcomes-based contracts that are intended to ensure that our pharmaceutical dollars are spent on drugs that provide the best outcomes.
These agreements require a high level of sophistication about drug use patterns and patient outcomes, as well as the ability to monitor and improve patient compliance and measure relevant outcomes.
As the public debate continues to unfold on health care and lawmakers are even more hungry to hear from better-informed voters, PBMs are part of the solution that lowers drug costs and improves quality.
Edmund J. Pezalla, MD, MPH is a consultant on payer strategy for pharmaceutical and device manufacturers. He works with a variety of policy and industry groups on cutting edge coverage policy, innovations in value-based payments, and adaptive regulatory and market entry pathways. He is currently a scholar-in-residence at the Duke-Margolis Center for Health Policy in Washington.