Co-authors: Michell Zulu, PharmD; Kelli Brignac
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The pharmaceutical industry is at a crossroads, with Pharmacy Benefit Managers (PBMs) playing a central role in driving up prescription drug costs. As revealed in the New York Times article “How PBMs Are Driving Up Prescription Drug Costs,” these middlemen have become a fast-growing and profitable industry, often at the expense of patients and the overall health care system. This paper aims to empower patients, providers and payers with actionable strategies to combat corrupt PBM practices and work toward a more transparent, equitable and patient-centered pharmacy future.
As outlined in the article, PBMs present a variety of challenges well-known to those in health care. It’s common for PBMs to charge different rates to different plans; to demand rebates or hidden fees from drug makers (and thus cause retail prices to increase); to force patients to their own retail pharmacies; and to deny coverage for generic drugs to boost their own bottom lines. The three largest PBMs – CVS Health, Express Scripts and Optum RX – now control approximately 80% of prescriptions in the United States. But what can patients, providers, payers and independent pharmacies do about it?
Patients and Providers: Uniting for Change
In the pursuit of a patients-first pharmacy future, it’s crucial for both patients and health care providers to join forces in addressing the challenges posed by PBMs. By working together, they can create a powerful voice for change and drive meaningful improvements in the pharmaceutical landscape.
Advocacy and Transparency
- Providers can leverage their professional organizations and networks to advocate for increased transparency in PBM practices. This may include pushing for legislation that requires PBMs to disclose rebates, fees and other financial arrangements.
- Patients should feel empowered to contact their insurance providers, employers and legislators to demand greater transparency and fairness in prescription drug pricing. Sharing personal stories of financial hardship or treatment barriers can be particularly impactful.
- Health care providers can support patient advocacy efforts by documenting instances of harm or financial burden caused by PBM practices. This data can be used to build a compelling case for reform.
Exploring Alternatives and Optimizing Care
- Providers should familiarize themselves with alternative medication options, including generics and biosimilars, that may offer cost savings for patients without compromising care.
- Patients can also explore pharmacy discount programs, independent pharmacy prices or mail-order services that may offer more competitive pricing than traditional retail pharmacies bound by PBM contracts. A good place to start is to ask the pharmacist if the current price is the lowest available – there may be coupons or other opportunities to decrease the cost.
- Health care providers can also collaborate with pharmacists to conduct comprehensive medication reviews, identifying opportunities to optimize drug therapy regimens and reduce overall costs for patients.
Fostering Collaboration and Community
- Providers should actively engage in interdisciplinary care teams, working closely with pharmacists, specialists, and other health care professionals to ensure coordinated, cost-effective care for patients.
- Patients can participate in support groups or online communities to share experiences, exchange information about medication access and affordability, and collectively advocate for change.
- Health care organizations can host educational events or webinars to bring together patients, providers and payers, fostering a sense of community and shared purpose in addressing PBM-related challenges.
Payers: Driving Systemic Change
As the entities responsible for contracting with PBMs, payers have a unique opportunity and responsibility to drive systemic change in the pharmaceutical industry. Even better, they’ll have happier employees and – possibly – lower costs.
Rigorous Contract Assessment
- Payers should conduct thorough assessments of their PBM contracts, scrutinizing terms and conditions for potential conflicts of interest or hidden fees.
- Payers may also use data analytics to analyze drug utilization patterns, pricing trends and rebate structures, identifying areas where PBM practices may be inflating costs or limiting access to essential medications. They may also elect to survey covered employees to identify pain points with existing prescription coverage.
Negotiating for Transparency and Value
- Implement performance-based contracts with PBMs that incentivize transparency, cost savings and improved patient outcomes.
- Consider alternative arrangements, such as direct contracts with independently owned pharmacies or in-house pharmacy management, to bypass traditional PBM structures and reduce costs.
Advocating for Industry-Wide Reform
Collaborate with other payers, provider organizations and patient advocacy groups to present a united front in calling for PBM reform. By advocating for these specific actions, payers and patients can work together to create a more transparent, equitable, and patient-centered pharmaceutical system.
- Mandate transparency in PBM practices. Enact legislation requiring PBMs to disclose all financial arrangements, including rebates, fees and discounts received from drug manufacturers. Transparency will allow payers and patients to understand the true cost of medications and ensure that savings are passed on to consumers.
- Regulate PBM fees and rebates. Implement regulations to cap the fees and rebates that PBMs can collect and ensure that a significant portion of these savings are returned to patients and payers. This will prevent PBMs from artificially inflating drug prices and profiting excessively at the expense of patients and the health care system.
- Promote competition and choice. Pass laws that prevent PBMs from mandating the use of their own pharmacies and allow patients to choose where they fill their prescriptions, including independent and local pharmacies. Increasing competition will help lower drug prices and improve access to medications, especially in underserved communities.
- Strengthen oversight and accountability. Establish a regulatory body or strengthen existing agencies to oversee PBM practices, investigate complaints, and enforce compliance with transparency and pricing regulations. Enhanced oversight will ensure that PBMs operate fairly and ethically, while protecting patients and payers from exploitative practices.
- Support value-based pharmacy models. Encourage the adoption of value-based pharmacy programs that align PBM incentives with patient health outcomes, rather than volume-based rebates and fees just for filling prescriptions. Shifting the focus to patient outcomes helps promote better health care practices, reduce unnecessary costs and improve overall patient health.
Conclusion
Addressing corrupt PBM practices requires a concerted effort from patients, providers and payers alike. By uniting in pursuit of a patients-first pharmacy future, we can work toward a more transparent, equitable, and effective pharmaceutical system. As we continue to shine a light on PBM practices and advocate for meaningful change, we move closer to a future where all patients can access the medications they need, regardless of cost, and where the power to choose rests firmly in the hands of those who matter most – the patients themselves. Through education, advocacy, collaboration and innovation, we can transform the pharmaceutical landscape and create a healthier future for all. It’s time to heal the broken pharmaceutical industry and usher in an era of transparency, fairness and patient-centered care.
