“Is your PBM’s Prior Authorization – promise to perform – a myth, a fictional novel with a sad ending, entitled ‘Gone With The Wind’ or is it active, robust and effective? The answer may surprise you.” – Bill Rusteberg
SOURCE: Archimedes Rx
Nearly every employer is aware that skyrocketing specialty drug costs, if left unchecked, will threaten the financial viability of the entire health care benefit. However, most do not know that pharmacy benefit managers (PBMs), the organizations traditionally trusted by employers to make drug benefit decisions on their behalf, can be a major part of the problem of rising drug costs.
In this paper, we summarize one of the three key deficiencies of the traditional employer-PBM business model. We explain why it has become dysfunctional, especially for specialty drug management, and why public attention to the problem has not translated into better service for employers. For this deficiency, we present alternative ideals—best practices to help employers achieve a drug benefit that is sensible, sustainable, and provides specialty drugs for patients who need them.
Not surprisingly, PBM PA approval rates average about 90%, perhaps partly because PBM-owned specialty pharmacies make just as much money from filling inappropriate prescriptions as they do from filling appropriate ones. Our reviews of claims paid after undergoing PA review reveal numerous instances of uses that should not have been covered.
Most PA processes in the PBM industry today are ineffective, and published evaluations of these programs are rare:
- Often, PBMs rely on physician office attestations that a patient meets clinical criteria, rather than taking the extra necessary steps of reviewing the medical record and following up with the provider to obtain information necessary for in-depth clinical review. Without that necessary step, physician offices may use the PA form as a “decoder ring” that tells them how to “pass the PA test.”
- With few exceptions, PBMs generally do not conduct PA on a regular schedule tied to the clinical features of the drug. For example, if a drug should improve a patient’s ability to walk, the PBM should require periodic testing of walking ability, with medical record documentation of the results.47
- Most employer-PBM contracts fail to hold the PBM accountable for PA failures.
- In an era of high costs, overprescribing, and safety concerns, PA should be robust, but commonly, it is lax. Adding to the problem, PBM contracts typically do not give employers the audit rights they need to determine if clinical decision rules are being followed. The result is a great deal of wasted expense, as well as potential safety problems for patients.
- The PBM should provide regular, drug-level reporting of the outcomes of PA, especially whether PA was given and whether the patient’s medical record indicated the decision was warranted.
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