Pharmacy Benefit Managers (or PBMs) are poorly understood by many...but are they at the center of the skyrocketing cost of prescription medications? incidentreport.co
So very true. PBMs are the horrific middlemen. If we could draw Sunday newspaper comic of the healthcare landscape, these guys would be painted with most intense of shifty eyes. "negotiate" means pointing a gun at pharmacists. That's not negotiating, that's robbing.
I am doing a youtube series on this issue. I patronize an indie pharmacy and my PBM, AetnaCVS has just made it 200 bucks more expensive per month for me to shop where I prefer. Where people know my name when I walk in the door. If you have ideas as how I can get my message out, please help. I've lodged grievances with CMS and CVS, but so far, am told, "I"m sorry that's just the way it is."
I'm in pharmacy and you've hit the nail on the head here. Everybody in healthcare wants a cut, the manufacturer, the supplier, the PBM, the insurer, the pharmacy, etc. In retail the majority of my conversations is attempting to explain the PBM's decisions, eg why medications are so expensive, why X or Y isn't covered, how deductibles and copays work. I totally get what you're saying about the nuke flattening the whole system. Our system is so inefficient and allocates value so poorly that I wish it would just collapse and we'd be forced into single payer or some other solution. We're at 18% of GDP and the return (in terms of better outcomes than other developed countries) on that cost is VERY inadequate.
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Thanks for putting this out. I've been a caped crusader and Miami Herald writer for 'indie' pharmacies down here in Florida, and have watched PBM's slowly choke the life out of small shops. Under the cover of Covid, they're hiking up prescription drug prices, cutting small pharmacies out of network, costing people like me hundreds of dollars more per month unless I patronize one of their stores (CVS) or their partners (Publix supermarket pharmacy Florida) and this is who we're trusting with the rollout of the vaccine, which hurts minorities, disabled, elderly and otherwise fragile folks who'd rather not go in these highly trafficked locations. I'm linking to you in a vlog.
PBM's create $3-5,000.00 per month in negative revenue for our small pharmacy. Paying dispensing fees of $0.25 or $0.00 and at or below cost of acquisition. Margins have declined from 20% where we need to be to keep the doors open to 2% or negative % in the past 4 years. rebates of 30-60% are being paid to PBM's and 25% discount pricing to the mail order pharmacies that are not given to retail pharmacies.
Every time I write a script for a medication that is also available OTC I remind the patients they can also pay cash and buy it OTC -- there is no difference so do whatever makes more sense for your pocketbook. And the last part about keeping the difference if the copay is greater than the cost does really cheese me off.
There is a slight difference between paying cash and using insurance in these situations: the copay counts toward your deductible and your annual out of pocket maximum. If you are going to reach your annual out of pocket max, then the prescriptions the rest of the year may have no copay, depending on your benefit design. Having your medications by prescription instead of OTC might push you over your OOP max earlier in the year, and COULD save you money in the long run. For most people who don't hit their OOP max, OTC is probably cheaper though.
PBMs are the Walmarts of the drug industry! I am referring to the way Walmart browbeats their Chinese manufacturer suppliers into lowering their fees in order for Walmart to carry their products on their shelves and make a profit.
I always 1st run my prescriptions through Costco 'without' Insurance. Most times they are cheaper than the co-pay. I only have 2 or 3 running prescriptions and can't even imagine how much the PBM's reap from their clients that don't 'shop'. It's a shameless rape off our backs to pay for basic healthcare. As an actively working RN for over 30 years, I'm a big supporter for a 'Single-Payer' system.
Last year Optum RX charged my credit card $400 for a 30 day supply of Pepcid for my son with a kidney transplant without our permission. It was an absolute nightmare getting a refund and it almost went to small claims court when we stopped payment on our card which would have prevented him from getting the rest of his immune suppression meds. We have also had antibiotics prescribed to him that conflict with his immune suppression and have made his levels go toxic nearly losing his transplant. These companies are a nightmare in continuity of care causing more issues for a plethora of patients with chronic illnesses.
Read the "Hi-Lex v. BCBS of Michigan" appeals court case. A lot of the insurers banded together to support BCBS to defend the "disputed fees" (read "spread pricing" from your talk today). In the case, BCBS association and Pharmaceutical Care Management Association filed a joint Amicus brief in support of BCBS.
To me it's telling that so few recognize AMZNs health benefits. Preventative & curative, not proprietary & proscriptive. Internally then externally. Root cause of the AMZN effect. Seems to me. ( Nice video. The middlemen will be eliminated with health. )
Seems it would be good to know how to avoid and prevent diabetes. Seems that body inputs affect body inputs. We didn't used to have so much diabetes. Why do we have so much now. Seems sickness benefits is quite crowded and health benefits is quite an opportunity.
