NEW YORK — Now more than ever, the media landscape is turning an increasingly critical eye towards pharmacy benefit managers — the health care system’s favorite scapegoats. As health care costs continue to rise at staggering rates, these organizations can help their clients save on drug costs. However, it’s a complicated and confusing minefield in which they operate. Phrases like “rebate negotiation” and countless fees and hidden costs contribute to making this industry uncomfortably opaque. It can also be a struggle to avoid financial conflicts of interest.
That’s why forward-thinking PBMs are choosing to adopt transparency in their dealings. Their clients and their consumers always know exactly what they are paying for, and how much it will factor into their budgets.
That’s good news for employee health plan sponsors, who are tired of seeing costs continue to rise every year, with little or no information about why it costs so much. It’s also a positive for consumers who are tired of paying more than they should for the drugs they need to survive. By being open and honest, transparent PBMs are taking the first step to address the underlying issues that are driving up the costs of care.
Supporting transparent pharmacy benefits reduces costs and even improves the chances of a quality outcome for patients. By being transparent about their highly complex revenue streams and any hidden fees, innovative PBMs are allowing purchasers to gain control of decision making by providing them with factual, accurate, fully disclosed information and statistics. Since PBMs are in charge of consumers’ access to certain drugs, it’s critical for them to negotiate costs with patients’ interests at heart. That means the chosen model should reward decisions that benefit the clients they serve.
Certain PBMs are bringing this idea to life. BeneCard is a purely transparent PBM that has significantly lowered fraud, waste and client costs related to opioids. After the Centers for Disease Control and Prevention found the chance for opioid addiction increases significantly after five days of use, the company joined the fight against opioid overuse by limiting starter painkiller prescriptions to five-day fills. With the opioid crisis at its height, BeneCard’s work to help curb overuse and addiction before it begins is incredibly valuable. Through a focus on patient safety and proactive practices, it has earned its clients measurable savings on prescription drug costs and improved patient outcomes. It offers employers flat, per-person fees and covering any pharmaceutical costs that exceed a predetermined rate.
Another company, Southern Scripts, helps employers understand the complexities and opportunities that exist in the self-insured market and guides them to make the most informed decision for their companies. The company had roughly 60,000 pharmacies nationwide as of 2016, and it processes an estimated 250,000 claims every year. Its work and pricing model have saved employees of Louisiana’s Terrebonne Parish Council $1.2 million on pharmacy costs by distributing the prescription savings it negotiated among policyholders rather than back to insurers (or itself).
PBMs like these are setting the bar for transparent tactics and cost savings, and they are inspiring a new model in the industry itself. These actions can create real systemic change in health care and address the root causes of some of the biggest issues the industry is facing.
A do-it-yourself health care reform movement is rising, and this is an opportunity for PBMs to take on a new role in the system — as drivers of cost savings that eventually transfer to the providers and the patients. If a focus is placed on transparent pharmacy benefits across the board, we can truly begin to shift the status quo.
Dave Chase is cofounder of Health Rosetta, which aims to accelerate the adoption of simple, practical, non-partisan fixes to our health care system. He is also the author of “The Opioid Crisis Wake-up Call” (Health Rosetta Media, September 2018).