Today's prescription drug landscape is complex. The FDA works constantly to review and approve new medications and expanded uses for existing medications. In 2018, the agency set a record for novel drug approvals–59, compared to a 10-year average of 33. That means more drugs to treat more ailments, each with its own risks and benefits. Physicians work hard to do what is best for their patients, but they cannot do it alone. Every medication they prescribe carries certain contraindications and risks. These can be challenging to identify when there are barriers to communication and coordination between each of a patient's health care providers.

Pharmacy benefit managers (PBMs) are sometimes viewed as one of these barriers, but they don't have to be. PBMs can support efficient coordination of care between prescribers, specialists and pharmacists. This coordination mitigates the risk of potentially harmful medication utilization, something that helps both patients and plan sponsors.

As health plans get larger through mergers and acquisitions, patients get smaller because they are no longer the priority. Health care must be a coordinated team effort to ensure each patient receives the most appropriate care. Doctors prescribe what they believe to be the best option, but may not have all of the information they need at hand. As a PBM, we often have access to information doctors may not.

PBMs have an obligation to use this information to work with prescribers and help patients achieve positive treatment outcomes. At BeneCard PBF, our pharmacists review the information we receive from prescribers to understand the disease, condition, and symptoms being treated, as well as additional facts that may impact treatment success.

We are all patients and have experienced or seen what happens when the health care system doesn't work the way it should. We must demand more for clients and drive the PBM industry to take ownership of advancing better health outcomes. The paradigm shift necessary to spur evolution in pharmacy benefit managers includes two key pillars: improving care coordination and infusing complete transparency into the system.

Improving care coordination

In an evolved PBM environment, the PBM's pharmacists help coordinate care across primary care providers (PCPs), retail pharmacists, and specialists to ensure that they are aware of all prescribing that is taking place. Evolved PBMs also consider the patient's health status to make recommendations for the most effective and lowest cost treatment.

Further improving prescribing practices, pharmacogenetics (also known as pharmacogenomics) can help PBMs and health care professionals determine the safest medication and most appropriate dose for a patient, based on how well the individual may be able to metabolize each medication. Having more data available related to each member before dispensing a drug—as well as facilitating better communication between the PBM pharmacist, the prescriber, and the retail pharmacist—can go a long way to support care coordination, improve health outcomes, and prevent fraud, waste, and abuse.

We a team of health care professionals who work to pinpoint the most effective treatment options. This approach considers factors such as dosing, length of treatment, the likelihood for compliance, whether the treatment requires other medications concurrently, and the cost–which impacts adherence (whether a member will fill or refill their prescription). PBM pharmacists conduct these reviews to ensure patient safety and to make certain the medication prescribed is the best option, taking into account an individual's health profile.

Infusing complete transparency

The ongoing conversation around PBMs and their role in controlling costs constantly circles back to transparency. However, it is time to stop looking at the theoretical concept of transparency and projected discounts. We must focus on the actual amount of money being spent and how proactive clinical care coordination can improve the bottom line.

Without a universal standard for transparency in PBM operations, pharmacy benefit managers can continue to play financial games and mask income streams, which makes accurately comparing PBMs via today's standard spreadsheets virtually impossible.

Some PBMs may not charge an administrative fee, but instead profit from spread–the difference between what the pharmacy benefit manager pays for a drug and what it charges your client. These expenses, along with other difficult-to-track fees and excessive or even dangerous drug utilization, can add up to significant expenses over time for plan sponsors and their members.

A truly transparent PBM is focused on clinical concerns and doing what's right for patients and plan sponsors. They should also immediately pass through improvements in drug pricing and embrace actual acquisition cost (AAC) pricing. With AAC, the plan sponsor pays exactly what the PBM pays for every drug–with no markup. This buy-side pricing model saves the plan money, which in turns helps your clients keep costs down for their members.

To help ensure brokers and plan sponsors know exactly what they are getting, pharmacy benefit managers need to provide clear, candid contracting that includes provisions for thorough plan audits that allow close monitoring of all prescription plan expenditures.

The effects of improved care coordination & complete transparency

Improved health outcomes: According to the CDC, adverse drug events are responsible for approximately 1.3 million emergency department visits each year, with roughly 350,000 of these patients hospitalized for further treatment. This presents a significant cost both economically and in terms of patient well-being.

Ironically, employee health, well-being, and productivity are rarely the focus in the PBM marketplace. This focus should be the mission of any quality pharmacy benefit manager. However, patients are getting lost in the equation, while PBM profits and stock prices are influencing care–or the lack thereof.

Improved health outcomes mean a better quality of life for employees, which can also contribute to improvements in job satisfaction and productivity, as well as less time spent at the doctor's office and less money spent on health care.

Lower costs: Drug utilization has increased dramatically over the past decade, and the number of high-cost specialty medications is growing at a brisk pace. Specialty drugs with rapidly growing price tags account for an increasing share of today's health care costs, which now add up to nearly $90,000 annually for some of the sickest patients. Approximately 40 percent of these patient's annual health care expenses come from prescription drugs.

The current fee-for-service model does not work and has led to out-of-control spending and a health care system that endangers patients through overprescribing to drive profits. It's time to focus on improving health outcomes with proactive, patient-focused clinical programs that save real dollars.

Unfortunately, there is currently no incentive for the system to support de-prescribing when warranted, so brokers should ask tough questions regarding clinical programs and financial transparency to effectively evaluate their PBM options.

One of the newest methods to support effective clinical utilization management and improve patient outcomes–leading to lower costs–is the pay-for-performance PBM business model. When performance standards are tied to clinical guarantees, the PBM has a vested interest in helping members achieve better health outcomes and preventing wasteful and unsafe drug utilization.

Michael A. Perry is president of BeneCard PBF. BeneCard PBF's "member first" approach centers on clinical programs that drive costs down while helping improve their member health outcomes.

Read more:

Instant Insights /

Creating meaningful change in the PBM marketplace

More From HR Executive

Related Stories

Recommended For You