Spreadsheeting basic pricing terms (discounts, rebates, dispensing and administration fees) and claims utilization (generic substitution and drug interchange rates), and believing that the new PBM hybrids (Pharmacy Benefit Administrators or PBAs) are trustworthy because they say they are, Plan Sponsors are frustrated by the fact that they have neither the knowledge, data nor tools to evaluate, compare, negotiate and contract PBMs. Not surprisingly, this is very much by design.
PBMs and PBAs are very adept at operating pharmacy programs to benefit themselves at the expense of their clients while staying within the terms of their contract. Dealing with PBMs is like squeezing a balloon; a gain in one area is offset by a loss in another. At PNPS however, you can have it all. Like others, we wouldn’t hold ourselves out to be “transparent”, “full disclosure” or “pass-through” if we were not. We don’t miscategorize “brand” and “generic” drugs to suit our financial interests, conceal huge mail order spreads, or define a “claim” in such a way as to charge for the 20% of scripts that are reversed or denied. We don’t cherry-pick the highest price among multiple AWP indexes or retain “bulk purchase” savings that should be passed on (e.g., billing the 100-pill rate and not the 5,000-pill purchase rate). There are no contract ambiguities, lying by omission, fine print, self-dealing, double-dipping, etc. As we see it, practices like this not only run afoul of ERISA, they are just plain wrong.
But there is more to good pharmacy benefit program management than just managing costs: at PNPS our focus is just as much on quality of care issues……
Most PBMs still profit from financial incentives that improperly influence their clinical decision-making and their dealings with physicians and pharmacists. And intensified media campaigns and physician office promotions continue to greatly influence patient requests for expensive brand-name drugs when a lower-priced generic would yield an equivalent clinical outcome.
The dynamic nature of this environment requires a constant re-evaluation and re-tooling of plan designs, formularies, pricing and clinical utilization management strategies to balance the impact of these variables to achieve the optimal therapeutic trade-off between superior quality of care and total (medical and pharmacy) cost. This can only be accomplished by employing a global perspective and aligning and coordinating Rx plan protocols with those of the related medical care management, disease management, and wellness initiatives. Informed Plan Sponsors know that this value proposition far exceeds that offered by others.
