Pharmacy benefits managers have evolved from claims processing to home delivery, managing formulary, specialty pharmacy, and negotiating with manufacturers.
With the ongoing backlash against them—complaints of lack of transparency and regulation, conflicts of interest created through owning specialty and mail order pharmacies, perverse incentives, and rising pharmacy costs—PBMs may decide to make some changes in how they operate.
Susan Pilch, JD, Vice President, Policy and Regulatory Affairs for the National Community Pharmacists Association (NCPA), believes that heightened demand from employers for information about where their pharmacy dollars are going and what their contracts mean could force PBMs to come to the table and address these concerns.
But can the industry live without PBMs, she wondered. “We will always need claims processors—a valid PBM activity—but we would like to move PBMs away from their role as gatekeeper of drugs and their costs,” she said. “We need oversight to hold PBMs accountable, but it’s hard to place demands when you don’t know what PBMs are doing.”
NCPA would like to see a fix for direct and indirect remuneration fees (DIR), pharmacy competition, patient choice, and transparency, she said.
A Future in High-Deductible Plans, Medicare B, and Data
Mark Merritt, President and CEO of the Pharmaceutical Care Management Association (PCMA), predicts that PBMs will assume a more clinical focus as drugs continue to be more complex. “PBMs have been at the forefront of utilization data and, as genomics leads to more personalized medicine, we can provide claims data,” he said.
He also foresees greater collaboration with health plans as more specialty drugs enter the marketplace and with physicians who require access to data about formularies—what specifically is on them and how many are generics versus brands.
Another area of interest is participation in Medicare Part B, an unmanaged space in which PBMs are currently not playing a role. Merritt believes that policy related to bringing down Part B costs would enable PBMs to get involved. “We could drive discounts and help manage the benefit,” he said.
In defense of what many stakeholders call a lack of transparency on the part of PBMs, Merritt noted that as plan sponsors become more sophisticated about benefits by consulting experts, more transparency will evolve. However, he believes that transparency has always existed, but that purchasers have failed to fully take advantage of it.
“As efficiencies and benefits improve, there will be more competition by PBMs to provide transparency and reach 100% pass-through of rebates,” Merritt said.
He added that some insurers and employer-sponsored plans are asking PBMs to include inflation protection products in their contracts and setting price inflation benchmarks including risk sharing for gains and losses.
Finally, in, light of the growth of high-deductible health plans, Merritt anticipates that PBMs will address some of the challenges presented by these plans by providing first-dollar payment for preventive drugs even if employees have not reached their deductibles and pass-through manufacturer rebates at the point of service.
Up next: Justifying PBM roles