Pharmacy Benefit Managers: Learn more about PBMs, scams and more

ncpa logoRecently, I was invited by West Glen to interview the National Community Pharmacists Association (NCPA) CEO, B. Douglas Hoey. The topic: Pharmacy Benefit Managers. Please read below to learn more.

What exactly are “Pharmacy Benefit Managers?”

Pharmacy Benefit Managers (PBM) are secretive, largely unregulated corporate drug middleman. They act as an intermediary between the health plan sponsoring entity such as employers  and others involved in the prescription drug benefit process such as a patient or  pharmacist. PBMs generally make money through service fees from large customer contracts for processing prescription claims, operating mail order pharmacies, and negotiating prices with drug makers.

Unfortunately, PBMs are largely unrecognized by most employees—and even by many employers and human resource managers who are making the decision to hire them and are those susceptible to not making the most informed decision. But they have a tremendous impact on U.S. health care decision-making because they influence more than 80 percent of drug coverage.

Is this a scam? Who is most at risk of being scammed here?

While PBMs contend their buying power and efficiency will reduce costs the numbers don’t support their claims. PBMs quarterly profits have grown enormously over the past decade, yet health care costs continue to soar for plan sponsors and patients, while pharmacy profits continue to shrink. As a result the PBM business model could be viewed as a scam since it doesn’t work as advertised.

In addition, there are certain PBM business tactics that clearly hurt patients financially and in some case could compromise their health. For example, PBMs contract with the brand name drug manufacturers to make sure their product is favored, and those arrangements are not shared with anybody but the two existing parties. So PBMs have a financial incentive to dispense expensive brand name drugs over their generic prescription drug alternatives.

PBMs also own mail order pharmacies and either get plan sponsors to mandate their usage or provide a series of incentives to attract patients to them. The problem with either scenario is that true patient choice is being stripped away.

Also America suffers from a medication adherence problem, where according to the New England Health Institute up to $290 billion a year is wasted on the improper use of medication. Going through mail order means any  pharmacists consultation occurs with someone over the phone, whereas if you go to a retail pharmacy, especially for an extended period of time, you can develop a relationship with a clinically-trained medication expert that can help you maximize your health outcomes.

What’s the best way for people to save money on prescription drugs/meds, while remaining safe?

If the cost of your medications has you trying to decide which one you can do without, talk to your pharmacist.  Monday and Friday are often very busy in the pharmacy so stop by mid-week or call ahead and ask for an appointment.  If your pharmacist knows ahead of time what your concerns are, he or she can prepare recommendations to discuss.

Few health conditions have only one brand name (expensive) treatment.  New drugs may be developed to address resistance to therapy, improve adherence, eliminate side effects or exert effect by a new mechanism of action.  What this means for you is there is a good chance there is an older therapy –  not currently being marketed by a drug manufacturer – that will treat your health condition and cost less.  Your pharmacist will tell you if the less-expensive drug has different side effects or needs to be taken more than once a day.

Finally, 10 of the top 15 most frequently filled prescriptions (Forbes) treat diseases that can be improved with a healthy lifestyle.  Exercise and healthy eating will lower your cholesterol, blood pressure and blood glucose (see HHS DASH diet).

Smaller meals and low-caffeine intake can improve acid reflux and insomnia.  Healthy eating may seem more expensive, but the payoff comes when you eliminate the need for a daily prescription drug, feel more energy and spend less time being sick.

What’s the statistic of people harmed or even killed? (Those who buy fake drugs, etc.)

I’m not sure we can answer this specific question. We believe the best way to get the statistical information you seek is to contact a federal agency such as the Food and Drug Administration (FDA), Office of National Drug Control Policy (ONDCP) or the Drug Enforcement Administration. There is also this website that has some of the answers you are seeking: buying medication online

Learn more: Who runs my drug plan?

join the mommy perks community


Click Here to Leave a Comment Below

Leave a Reply: