Deception is at the root of all villainous ploys and Star Wars is no exception. During the Clone Wars (think episodes 2 & 3), the republic tasks the Jedi to fight Count Dooku and the Separatist Alliance in a galaxy wide war. Before long, the Jedi become more like warriors and less of the peace keepers they promised to be.

During the three year conflict, the Jedi are so focused battling who they believe to be the republic’s greatest threat, that they are oblivious to Emperor Palpatine (Darth Sidious) pulling strings on both sides. All the while, having his own agenda that benefits only himself and the Sith legacy.

This is not too dissimilar to the healthcare industry readily fighting against PBM practices but willingly accepting their services like step-therapy and prior authorization as being overtly beneficial for their clients. Perhaps our battle has blinded us to PBM profits and how their services are quite misaligned with their clients’ bottom line.

Understanding PBMs: Necessary Evil or Profit Machine?

PBMs play a crucial role in our healthcare system, negotiating prices, rebates, and managing drug formularies. However, some of their practices, like spread pricing and retaining manufacturer rebates, have raised eyebrows. Despite scrutiny, PBMs are quick to adapt, finding new avenues for profit, such as utilizing Group Purchasing Organizations (GPOs) to collect fees from manufacturers.

Show Me the Money: Where PBMs Profit

PBMs rake in profits primarily from specialty drugs, their mail-order pharmacies, and administration fees courtesy of drug manufacturers via GPOs. These incentives often lead to the promotion of high-cost medications, raising questions about their commitment to genuine cost reduction.

The Illusion of Cost-Saving Measures: Step Therapy and Prior Authorization

Step therapy and prior authorization are touted as cost-saving tools, but do they really deliver? Step therapy, while guideline-driven, can be easily manipulated and bypassed, while prior authorization merely checks boxes without addressing broader clinical concerns. These measures fulfill minimum obligations to clients without actively reducing costs.

Beyond Adherence: PBMs Clinical Services

PBMs offer clinical services aimed at ensuring medication adherence, but are they doing enough? While valuable, these services primarily focus on adherence rather than comprehensive cost reduction strategies.

Conclusion: Questioning the Status Quo

It’s time to challenge the status quo. PBMs’ profit motives may not align with cost-saving initiatives as commonly perceived, highlighting potential gaps in our healthcare system’s approach. Relying on PBMs services is like trusting the IRS to find tax savings, the incentives are misaligned. It’s time to find an alternative strategy to assist providers’ decision making, while keeping drug spend at bay.

Thanks for joining me on this journey of discovery. Don’t forget to connect with us on LinkedIn and subscribe for more insights.

Warm regards,

Ryan Garner PharmD.

Apothicor Wellness