Let’s Stop Bashing ALL PBMs, Please

**********DISCLAIMER: THESE ARE MY PERSONAL OPINIONS ONLY*** Not necessarily those of my employers or affiliations. I work with over 60 PBMs in my day job, but below these are my opinions.******************************************

I was never a cheerleader in high school; I was more of a band geek. But I feel like professionally I’ve turned into a cheerleader for….of all things….Pharmacy Benefit Managers (PBMs). And trust me, no one is more shocked than I am at this revelation.

Please — let’s stop bashing ALL PBMs en masse.

Hear me out.

In my day job, I work with over 60 PBMs. If you read the history of PBMs, you’ll understand very quickly that they arose out of real-time online pharmacy claims adjudication or payment processing, which is frankly and still to this day REVOLUTIONARY in healthcare.

Medical claims reimbursement STILL has a huge claims payment lag — but your pharmacy claims are adjudicated at the time your pharmacist fills your prescription in nearly every instance, which again is rare in healthcare. Friends, there is value in real-time claims processing and it’s NOWHERE else in healthcare right now in the US.

That (r)evolution aside, PBMs are getting trashed in the press right now. A. Lot. Things like:

* DIR fees,

* clawbacks,

* spread pricing -

you name it — are all evil practices, and the PBM middlemen are doing the devil’s work.

But, I respectfully disagree. At least in part.

Yes, the big 3 PBMs carry a big portion of the market, at least in my world of commercial pharmacy benefits overall in the US. Employers work (very) hard to get the best benefits for their employees, esp. right now in a super tight labor market. Do the big 3 PBMs employ the strategies above? Do others? Does the majority of PBMs employ these practices? That’s not for me to say in this blog post. I’m certainly not going to defend these practices listed above either.

What there IS for me to say in this blog post is that there are legitimate, administrative- fee-only, fully transparent PBMs out there doing honest work on behalf of their employer clients, and not dealing in the shenanigans listed above.

First off, I think we all can agree that pharmacy benefits are complicated — in some instances, too complicated. There are over 90,000 OTC/prescription drugs/and healthcare supplements on the market at any one time. There are drug rebates, discounts, coupons, advocacy programs, and foundation funding — just to name a few drug pricing items. That’s more than overwhelming for pharmacists and healthcare professionals, let alone employers — especially employers who are not in the healthcare space every day.

Employers STILL NEED legitimate PBMs to oversee their employees’ pharmacy claims. Otherwise, it’s a free for all on what reimbursement rates are (and I’ve seen this over in medical benefits — so trust me when I say it can quickly become the wild wild west without someone overseeing claims on a regular basis.)

Second, some of the 60+ PBMs we work with actually pride themselves on price transparency and walk the talk. One example: Instead of using the mystical average wholesale price (AWP) discount metrics on drug prices (AKA — ‘Ain’t What anybody’s Payin’), they use acquisition cost-based metrics for pharmacy benefits repricings and RFP responses (what in the industry are known as average acquisition cost (AAC) or other acquisition cost benchmarks already available freely and typically used for Medicaid.)

Third, some of the PBMs we work with actually bend over backwards for members and patients on employer-based plans. I’ve witnessed it every day at my day job with Apex Benefits. The good PBMs also employ many healthcare professionals (pharmacists, pharmacy technicians, nurses, and other allied healthcare professionals) who understand the case complexities that can occur with patients — and those are the great PBMs that are earning their fees, in my opinion. At the end of the day, healthcare is also a business — and that means that the people providing the access to care, and processing the claims while making sure the plans paying the bills not getting hosed SHOULD be paid something for their services. How much they should get paid is for another post at another time. The point here is that they should be paid fairly, but I argue, transparently.

Last, I need to be clear — I’m not here to cheer for all (or even most of) the PBMs. There are, just like Santa’s list, some that are naughty and some nice when it comes to being transparent, honest, and working in the best interest of payers and patients. There is a lot of bashing out there right now that has been rightfully earned by some of the PBMs.

Which ones are legit? Well, that comes down to knowing which ones are better, and avoiding the ones who don’t have the best interests at heart for patients and their employer plans. If you’re the one hiring a PBM at a company or a plan, you need to get an educated advisor/broker on board who has the naughty & nice list, based upon experience with a variety of PBMs, not just the big 3, and not just one or two PBMs, but many.

As I started this article — I’m certainly no cheerleader. However, I am 100% for reasonable, transparent oversight of healthcare and pharmacy claims. Without it — employer plans can go bankrupt, businesses can shutter their doors, and people can be left without healthcare insurance and jobs at all, in the very worst-case scenarios.

In conclusion — let’s be careful out there in lumping ALL PBMs in the same (bad) bucket. Some have earned their terrible reputations, I agree 100%. But some are honest, decent, and should not be bashed, and employer plans still need them.

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Erin L. Albert is Kinetiq Health Pharmacy Benefits Practice Leader at Apex Benefits. Opinions above, however, are her own.