Understanding the Critical Role of Pharmacy Benefit Managers
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Chapter 1: The Influence of Pharmacy Benefit Managers
The way you access medications and manage your health can significantly hinge on the three letters—PBM—that many patients are unaware of.
Most individuals are largely uninformed about the powerful role of Pharmacy Benefit Managers (PBMs) in shaping the availability and pricing of prescription medications and devices. As the landscape of health insurance and pharmacies shifts towards greater consolidation, PBMs are emerging as pivotal players, altering traditional processes and raising concerns about transparency. These relationships often complicate the clarity of practices within the healthcare system.
In response to growing concerns, the Centers for Medicare and Medicaid Services (CMS) has indicated a desire to scrutinize medication delivery practices. A recent communication from CMS to PBMs and healthcare plans emphasized, "We are hearing an increasing number of concerns about certain practices by some plans and pharmacy benefit managers (PBMs) that threaten the sustainability of many pharmacies, impede access to care, and put increased burden on health care providers. We are writing to share these concerns and to encourage you to work with providers and pharmacies to alleviate these issues and safeguard access to care. This is especially important for vaccines and treatments that can prevent and treat influenza, COVID-19, and RSV as we enter the winter respiratory virus season."
Section 1.1: The American Diabetes Association's Concerns
The American Diabetes Association has also raised alarms with Congress regarding the influence of PBMs on patient care. Representing the interests of 37 million Americans living with diabetes and another 100 million with prediabetes, their letter stressed the need for accountability across the commercial drug supply chain in reducing therapy costs. PBMs, which operate as intermediaries between insurers, drug manufacturers, and pharmacies, wield significant influence over drug pricing and accessibility.
Subsection 1.1.1: The Impact on Patients with Respiratory Disorders
This issue extends beyond diabetes; it also affects those with respiratory conditions. For instance, if you find your usual medication, such as Flovent, is suddenly unavailable, PBMs may be the reason behind this change. Numerous educational videos on platforms like YouTube elucidate the implications of PBMs on healthcare. Be mindful that some of these videos may be sponsored by PBM companies or affiliated pharmacies.
Section 1.2: The Growing Power of PBMs
Understanding what PBMs are and their evolution is crucial. If you discover that a medication you've relied upon is "no longer on our formulary," it’s likely due to PBM decisions that may not prioritize your medical needs.
Chapter 2: The Relationship Between PBMs and Health Insurers
PBMs are increasingly collaborating with health insurers. Major companies such as Aetna, Cigna, Elevance, Humana, United Healthcare, and many Blue Cross Blue Shield plans are either directly owning PBMs or are part of organizations that do. This consolidation has evolved relatively recently, with Express Scripts (merged with Cigna) and CVS Caremark (merged with Aetna) controlling nearly half of the market as of 2018.
The first video titled "Pharmacy Benefit Managers (PBMs) Explained - Learn How the Money Flows" provides an overview of how these entities operate within the healthcare system, highlighting their influence on medication pricing and availability.
The second video, "The Role of Pharmacy Benefit Managers," delves into the specific functions and implications of PBMs in managing prescription benefits, shedding light on their impact on patient care.
The American Medical Association has reported substantial shifts in healthcare dynamics due to PBM consolidation. According to an AMA study, such consolidation diminishes price competition, ultimately disadvantaging independent insurers, self-insured employers, and patients alike.
This article aims to provide insight into the complex and often opaque world of PBMs. It serves as a resource for both healthcare providers and patients, encouraging informed discussions and proactive measures regarding healthcare decisions. Our health is our most precious asset, and it cannot be dictated solely by corporations focused on profit. It is imperative that patients remain at the forefront of healthcare discussions.
Who should be making critical decisions about your health and medications? Undoubtedly, it should be the healthcare professionals directly involved in your care, along with the pharmacies that dispense your medications.
Consider the role of PBMs in your prescription journey: Are you receiving the medications your doctor prescribes, or are you being nudged toward alternatives that are not medically indicated?
Take the time to reflect on these issues and engage in meaningful conversations with your healthcare providers, insurance representatives, and congressional leaders. This is a matter that warrants serious attention and scrutiny.