By Bill Rusteberg
It’s clear no one likes PBMs…….. except hedge funds. There’s not a day goes by that we see yet another wash, rinse and repeat “PBMs are The Bad Guys” article along with an AI generated graphic to prove it.
If PBMs are bad then why do we still use them? Is it because…………-
- Pharmaceutical manufacture’s specialty drug net pricing gymnastics requires PBM intervention?
- Plan member point of sale financing is made convenient through PBM fronted money – plan members don’t have to pay and chase like in the old days?
- Getting something for nothing drives benefit decisions?
- Ignorance?
- Fear of the unknown paralyzes the weak
- All of the above?
Pharmacy spend averages 30-40% of a plan’s total spend whereas in the not too long ago past the average was 5-8%. Self-funded plans can be especially hard hit with expensive drugs costing hundreds of thousands of dollars for a handful of members, a risk factor exacerbated by runaway stop loss carriers seeking refuge in the world of lasers.
This can’t continue, it’s unsustainable.
It’s clear PBMs have failed to lower costs despite their protestations to the contrary. Can we do without them and save money and if so what would that look like?
That’s a question everyone should be asking but nobody is.
Can we do without PBMs? The answer is yes. But change is difficult for most, especially for human resource departments. The Department of No often controls benefit decisions while groggy CFOs assume the ostrich position.
What would a pharmacy benefit plan without a PBM look like? We asked a small rural Texas county in deep South Texas that question.
“We saved more money than we thought possible, plan members still get their needed medications and Commissioners Court gave the savings back to our employees in the form of a permanent pay raise.”
Ah……….so it IS POSSIBLE!
HOMEWORK READING ASSIGNMENT
8 Questions That Destroyed A PBM Relationship
Do PBMs Know The Exact Amount of Rebates Per Prescription?
