I wouldn’t want to be the Pharmaceutical Care Management Association (PCMA). That is the group tasked to represent pharmacy benefit managers (PBMs). Would you enjoy trying to make the PBM industry look good?
According to The San Antonio Business Journal, PCMA has released the results of a study they commissioned stating that preferred and limited pharmacy networks could save benefit providers over $100 billion in the next ten years. The best part of this report is PCMA’s CEO Mark Merritt declaring that restrictive pharmacy networks don’t undermine a patient’s access to care.
I guess this is the “new norm” we’ve been conditioned to accept in the modern era of healthcare. The fact that patients don’t have the freedom to choose their own pharmacy is somehow a good thing that will also save money.
Except there is one problem, drug prices continue to outpace inflation. Prescription drug benefit premiums are on the rise. And that cost savings PBMs infamously promise at every turn? We’re still waiting for those to arrive.
PBMs do make deals with manufacturers. They also set up “preferred provider” networks. This means patients must use Pharmacy X or Mail-Order Pharmacy Y for their prescription needs or pay a penalty. They have a choice of course, but that choice will cost them dearly.
What the PCMA is trying to sell with this report is the concept of utilization management (UM) restrictions. These tactics can include prior authorizations, step therapy requirements, quantity limits, and/or mandatory mail-order restrictions. Basically, PBMs write deals for insurers that restrict what patients can get and where they can get it.
But remember, this is all in the name of progress. Cost-savings is the carrot forever dangled by the PBM industry. Those savings might actually be true except for one little detail- any savings typically goes into the pockets of the PBMs instead of being passed on to the consumer.
Drug prices are still outpacing inflation by several percentage points. The only real headway being noticed in the arena of lowering average medication costs is the fact that more major branded products are losing patents. Generics are saving people money, not PBMs!
You’d never know that by listening to the PCMA. They praise PBMs for their efforts to “control healthcare costs” by all of the UM restrictions listed above. It is as if PBMs are the white knights that come to our collective rescue in the war against high prescription drug costs.
It bothers me to see the reality of what the PBM industry has created and then turn around and read a story about their own industry group praising their efforts. PBMs have created needless middlemen, countless hassles and delays for patients seeking treatment, and they don’t even capitalize on the cost savings they promise.
The number of medications covered under Medicare prescription drug plans that now require prior authorizations have more than doubled in the last five years according to a Kaiser report. I have seen prescription drug claims for $4 generics result in a claim rejection with the message “prior authorization required.” Is this kind of needless delay of therapy really necessary?
The PCMA did take a moment in the press release to compare the number of pharmacies in the U.S. to the number of fast food restaurants. Somehow the number of retail pharmacy outlets is justification for a restricted pharmacy network? Why is the fast food industry our new benchmark?
The reality of the healthcare system in 2013 is that PBMs control the prescription drug market. They do this to manipulate the system to their benefit. But according to their own funded report, PBMs are helpful to patients and cost effective to the system.
It’s time we face a hard reality. The insurance industry has consumed the healthcare system. And their primary goal is not cost-effective care. They dictate therapy and control the distribution of pharmaceuticals in ways that undermine prescribers and limit patient choice.
The PCMA and the PBM industry sure can make some pretty bold promises. It’s too bad they are based more in fiction than fact. We could all use real prescription cost savings right about now.
The Redheaded Pharmacist