By Edmund J. Pezalla
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, or 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.
Though drugmakers continue to raise prices out of proportion to increases in value, PBMs are doing their job by keeping drug costs down. A recent report by QuintilesIMS Institute showed that discounts, rebates and other price concessions on brand-name drugs reduced overall drug spending by an estimated 28 percent in 2016.
The report also shows that net price growth – the price payers actually pay – for prescription drugs is likely to remain in the zero to 3 percent range, largely because of the work of payers and PBMs.
Having been involved as a clinician representing insurers and PBMs for more than 25 years, I know firsthand 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.
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.
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, M.D., M.Ph., is a consultant on payer strategy for pharmaceutical and device manufacturers.