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Writer's pictureDr. John Hayes Jr.

How Pharmacy Benefit Managers Impact Patient Care


How Pharmacy Benefit Managers Impact Patient Care
How Pharmacy Benefit Managers Impact Patient Care

How Pharmacy Benefit Managers Impact Patient Care


Pharmacy Benefit Managers (PBMs) are intermediaries between insurers, pharmacies, and drug manufacturers, playing a critical role in managing prescription drug benefits. Their primary function is to negotiate prices, create formularies (lists of covered medications), and manage pharmacy networks. While they help insurers reduce costs, PBMs can significantly impact patient care in both positive and negative ways.


Positive Impact of PBMs:


  1. Cost Savings: PBMs negotiate lower prices with drug manufacturers, which can reduce prescription costs for insurers and potentially for patients.


  2. Formulary Management: By organizing drugs into tiers, PBMs encourage the use of lower-cost medications, such as generics, improving affordability.


  3. Pharmacy Networks: PBMs establish partnerships with pharmacies, giving patients access to a range of options and often discounted rates.


Negative Impact on Patient Care:


  1. Limited Drug Access: PBMs determine which medications are covered, potentially restricting patients from accessing certain drugs or pushing them to use less optimal alternatives.


  2. Higher Out-of-Pocket Costs: Some patients face high costs for non-preferred or excluded drugs, and rebate savings aren’t always passed directly to patients.


  3. Restricted Pharmacy Choice: PBMs may require patients to use specific pharmacies, limiting patient freedom to choose their preferred provider.


  4. Medication Switching: PBMs can force patients to switch drugs based on formulary changes, which can disrupt treatment and affect outcomes.


While PBMs can lower overall drug costs, their opaque pricing and rebate structures have drawn criticism. The focus on maximizing rebates can lead to higher prices for some drugs, and patients often bear the brunt of these costs.


Concerns over PBM practices have prompted calls for greater transparency and regulation to ensure that patient care isn’t compromised in favor of profits.


In summary, PBMs influence medication access and cost, sometimes benefiting patients but also creating barriers. Ongoing regulatory efforts aim to improve transparency and balance cost savings with quality care.


 

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