Evolving Pharmacy Benefit Management

Pharmaceutical companies, insurers and pharmacists all played a role in pharmacy benefit management

Since their introduction in the late 1960s, pharmaceutical companies along with insurers and pharmacists all played a role in pharmacy benefit management. Their involvement ranged from drug pricing negotiations and distribution to managing formularies and developing a network of insurance covered pharmacists. Today, PBMs have assumed a role in which they align payers to negotiate access to pharmaceuticals and better pricing. Initially, PBMs did drive cost savings for payers – savings in the range of 15 to 20 percent. Today, however, PBMs are under heightened scrutiny and the specter of increased reform to address the main problem, which is that almost all of those stakeholders, except patients, benefit from drug price increases due to lack of incentive and transparency.

Lack of Incentive and Transparency

While some drug manufacturers have tried to lower prices, their efforts have failed as other stakeholders along the supply chain have been unreceptive due to the loss of revenue lower prices would cause. The fact that there are three major PBMs that control 80% of the market further impedes progress in this area which has employers/payers calling for more transparency. Some states have attempted to regulate transparency but find that many pharmacies cannot agree to drug price discounts.

The Role of the Pharmacists

Many insiders directly involved in solving the PBM problem believe that pharmacists can play a significant role. They believe there are opportunities to better utilize trained pharmacists, as well as other entities (e.g., specialty pharmacy management companies, medication dispensing and clinical operations, etc.) including in product development and in seeking programs and services that work to secure lower drug costs.

With more pharmacists, both those in practice for years and the new generation of pharmacists involved in the process, greater progress can be made. A broader effort in the education of all healthcare providers, administrators, employers, and insurers regarding pharmacy benefit management is also essential.