A Middle Man of Value--Are Pharmacy Benefit Managers a Help or a Hindrance?

I recently found myself at a dinner table with a number of senior healthcare executives discussing whether pharmacy benefit managers (PBMs) bring value in the healthcare space. This is not the first time that I have had this conversation. In 2003-2005, prompted by the inception of Medicare Part D, the question being asked was whether PBMs were costing or saving the healthcare delivery system money. Interestingly, the US government did study the issue and found that cost savings did result from the use of PBM services. Not long after my dinner conversation, I read a healthcare blog that discussed a similar issue.1 This prompted

me to sit down and reconsider the issue once again.

I have had the opportunity to work for a PBM, to act as a vendor for a PBM, to consult with employers about their choice of a PBM, to provide medical care, and to utilize my pharmacy benefit as a patient. So as I ponder the issue of value, I first must ask, “Value for whom?”

As an idealistic pragmatist, I believe that it all starts and ends with the patient. So as the song “Do Re Mi” from The Sound of Music says, “Let’s start at the very beginning.” During one of my trips to Washington, DC, I had the opportunity to speak with a member of Congress with whom I had a previous working relationship. That representative shared with me that she thought that PBMs interfered in the patient-physician relationship. I told her that this was not the intention of the PBM industry. In fact, if utilized appropriately by patients and their physicians, the information provided by PBMs could supplement the relationship with greater knowledge, insights, and support to both.

PBMs have been shown to save healthcare consumers money, to act as a safety net for medication mishaps, and to support healthcare consumers in attaining the goals set by both them and their healthcare providers.

Next, let’s look at the value that a PBM may bring to the payer. When I utilize the term “payer” I am referring to health plans, employers, and governmental payers. The pharmacy benefit is the most utilized benefit within healthcare. Although it is not necessarily the most costly when it comes to unit price and utilization, over the last decade or so it has often been the area with the greatest increase in cost trend. Through the educational and communication tools available through most of the PBMs, payers increase the opportunity to gain maximal value for the healthcare cost investment associated with the pharmacy dollar.

In addition to cost savings, many PBMs run clinical programs that help support medication management. These programs often address issues of safety, efficacy, and issues such as medication adherence. These programs work to educate and support healthcare consumers in ways that can help to improve clinical outcomes, workplace productivity, and quality of life.

The pharmacy benefit (and by extension, the PBM) also tends to be highly visible due to its high utilization. Therefore, it has the propensity to be highly correlated to patient satisfaction. The satisfaction associated with a pharmacy benefit can lead to increased employer recruitment or retention of highly regarded employees, or improvement in patient satisfaction for health plans.

Although providers tend to be the most vocally negative about the concept and actions of the PBM, physicians and other healthcare providers can extract value from its services. Data aggregated from all physicians who may be caring for a healthcare consumer help to decrease redundancy in medications and decrease the chances of drug-drug interactions. More recently, several PBMs have begun to give feedback regarding patient medication adherence to physicians so that the physicians can have a more focused conversation with their patients.

This is not to say that the PBMs cannot improve their offerings and increase their value to all stakeholders. The American Journal of Pharmacy Benefits is meant to be a forum to share ideas and activities so that we can learn from one another and maximize the value that the PBMs can bring through the pharmacy benefit. Do you agree with my comments or not? I look forward to hearing from you all.