In a rapidly changing health care system, pharmacy benefit managers (PBMs) are accelerating the cost savings and care management services consumers and payers need. As prescription drug spending is poised to reach as high as $5 trillion during the next decade, new data find that PBMs’ proven cost savings tools are expected to reduce prescription drug costs for health plan sponsors and consumers by an average of 20 percent, or more than $1 trillion.
While PBMs are widely recognized for taking on drug manufacturers to lower costs and deliver results, this success is only one part of the PBM story. Because the pharmacy benefit is typically the most heavily utilized part of a consumer’s health benefit, PBMs serve a crucial role as the hub connecting multiple aspects of the health care system that serves patients. As a result, PBMs’ care management programs play an outsized role in securing improved patient outcomes.
These care management programs are especially vital for the more than 130 million Americans managing chronic illnesses, including cancer, heart disease, hypertension, hyperlipidemia, and diabetes. Chronically ill patients can not only typically face high prices for their medications, especially breakthrough, first-in-class drugs, they often have to see multiple providers and have unique needs.
Novel therapies are changing lives for the better every day, but they require novel approaches to care coordination, delivery, and affordability. Gene therapy, including CAR-T, can easily cost seven figures and overwhelm benefit plans. These therapies require an intensive, highly personalized treatment regimen to be effective, and payers need the assurance that they are delivering value and outcomes for the patients they serve. Plans cover many specialty medications, which only adds to the urgency for more connected care programs that emphasize direct patient engagement linking the pharmacy, hospital, physician, and lab. This is where the PBM comes in.
PBMs’ care management role begins well before prescribing. On behalf of PBMs, independent clinicians carefully evaluate new drugs, review existing drugs, and apply sophisticated drug assessments that promote optimal use of complex medications and the appropriate use of mainstay drugs. PBMs use these assessments when establishing formularies, which creates more competition among drug manufacturers and helps keep overall prescription drug costs lower than they otherwise would be.
PBMs harness data and provide platforms to connect patients, medical professionals, and payers. Real-time prescription benefit technology, used at the point-of-prescribing, informs prescribers and patients about a medication’s formulary placement and cost sharing. Prescribers can include doctors, physician assistants, and nurse practitioners. Utilization management tools are embedded in this technology to help guide patients and their prescribers toward the safest, most cost-effective drugs, to help reduce waste and avoid negative drug interactions.
This real-time prescription benefit technology is linked to electronic prescribing, which enables the prescriber to send the prescription electronically to the pharmacy of the patient’s choice. By jumpstarting this discussion at the point-of-prescribing, PBMs help reduce the hassle factor at the pharmacy counter for all stakeholders and ensure patients get the medications they need at the right time and the expected cost.
PBMs also work closely with payers of all sizes to bring innovative solutions to market that help physicians and other prescribers to treat the whole patient. By connecting different parts of health care, PBMs help provide both clinicians and payers an unprecedented line of sight into individual patients, enabling clinicians and care managers to act in real time. Health benefit plans are now able to leverage the experience of literally billions of pharmacy and medical claims and enhance these experiences with predictive modeling to help prescribers know what patients are likely to need outreach to stay on their medications or might experience side effects. Together, these data help inform a highly customized, individual treatment plan across the care continuum, particularly for patients with chronic conditions.
Additional patient support can be provided with 24/7 access to nurses, clinicians, and pharmacists. PBMs are complementing this work with digital tools, including remote monitoring of drug therapy and syncing with diagnostic devices that monitor blood pressure or glucose levels. This intensive coordination allows care teams to continually evaluate a patient’s health and make any necessary mid-course corrections.
All this work reflects a shared goal: improved adherence that leads to better outcomes for patients. Despite our collective best efforts, too many patients still fail to take their medicine as directed. The reasons are complex but require a comprehensive approach. Non-adherence leads to unnecessary emergency department visits and hospitalizations and, tragically, more than 125,000 annual deaths. With improved adherence, as a nation, we could recoup billions of dollars annually in avoidable health care costs, reduce overall spending, and help people live fuller, healthier lives.
To realize these changes, we need every part of our health care system working at an optimal level. PBM cost savings and care management programs go hand-in-hand and help improve outcomes as patients navigate our complex health care system. And that’s the proven benefit of hiring a PBM.