Question in: Innovation in Biopharmaceuticals

PBMs accountability in total cost management for payers


Recent press has highlighted the synergistic profitability between PBMs and the Pharmaceutical industry (e.g., recent WSJ article on new eczema drug where Pharma said they agreed to lower price with big 3 PBMS for "loose PA criteria" - meaning rubber stamp yes). Do you believe that PBMs should be held financially accountable for payers total drug spend (drug mix and utilization) not just discounts and rebates?

Pharmaceutical Industry
Kristin Begley
1 month ago

4 answers


Your comment has a flavour of suspicion without offering any solid information. PBMs role has been defined very clearly: "PBMs are primarily responsible for developing and maintaining the formulary, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims. For the most part, they work with self-insured companies and government programs striving to maintain or reduce the pharmacy expenditures of the plan while concurrently trying to improve health care outcomes."
NEGOTIATION is a part of what PBM is supposed to do. It is defined as a "Bargaining (give and take) process between two or more parties (each with its own aims, needs, and viewpoints) seeking to discover a common ground and reach an agreement to settle a matter of mutual concern or resolve a conflict".
Your objection to "synergistic profitability" is quite off the mark. I think that is exactly what the process has been designed to achieve...

Karel Petrak
1 month ago

Yes Kristin, I think the evolution of pharmacy, and indeed all, benefit management should include accoutability for cost, utilization and Pt safety. Pharmaceuticals financially cripple too many Americans. Our industry is so siloed, that poly-pharm has been identified as a significant Pt risk. "Loose PA criteria" is probably just fine for a young, healthy individual taking few medications. It could be dangerous for elderly, medically complex or those taking multiple medications. The players gaining a profit should also accept some responsibility for overall cost, medication mix and utilization.

Karel, I agree with your definitiion of current roles. Isn't it time that we evolve to more integrated health care management?

Megan Hamilton
1 month ago

Of course transformation and disruption of PBM industry needed, but same for brokers/consultants who offer no value to purchaser of care.

Along with that, there needs to be cost transparency--not price transparency as that is meaningless in the current supply chain. Look at Amazon and soon to be others entering the space who see a segment ripe for innovation.

Randy Vogenberg, PhD
19 days ago

3rd part accountability remains unchecked as more and more examples find its way into the popular press. The situation reflects badly on how everyone has performed in healthcare over the past 30+ years to get us to where we are today.

Disruption is inevitable, but how fast will it occur or become more of an iterative transformation that may fall on its own weight of fiscal failure?

Randy Vogenberg, PhD
11 days ago

Have some input?