Posts Tagged ‘PBMs’

The Wizard Behind The Curtain – Part One

Friday, February 1st, 2019

Suddenly, everybody’s out to get Pharmacy Benefit Managers, or PBMs. CMS, state legislatures, state Medicaid officials, a boatload of experts and even Donald Trump, who appears to actually and sincerely believe PBMs have created a rigged system.

The issue, what you and I pay for medicine, is getting a lot of ink and airtime. As well it should. Drug prices in the US are nearly twice as high as other developed nations. How did it come to this, and are PBMs a big part of the problem or are they a modern Horatius at the Bridge holding back an invading army of even steeper costs?

The PBM industry was born in the late 1960s when Pharmaceutical Card System, Inc., (PCS) invented the plastic benefit card. By the mid-1970s, PCS was serving as a fiscal intermediary by adjudicating drug claims. In other words, it was a prescription Third Party Administrator (TPA). By working for insurers and health plans, PCS (later AdvancePCS) and others figured out that they could leverage the buying power of their clients to negotiate lower drug prices.  And until around 1992, that’s they did. During that approximately 20 year period, PBMs saved insurers, health plans and consumers money by driving physicians and patients to use lower cost generic drugs. This was a valuable service for all.

In 1992, however,  PBMs began to change their focus. As noted by the Wall Street Journal in August, 2002, from 1992 through 2002, PBMs had “quietly moved” into marketing expensive brand name drugs. Since then, two major problems have emerged.

First, there is an incestuous relationship between PBMs and pharmacy companies. This occurred over three periods.

From 1968 through 1994, pharmaceutical companies acquired PBMs. For example, in 1994 Eli Lilly bought PCS for $4 billion and SmithKline Beecham bought Diversified Pharmaceutical Services (from insurer UnitedHealth) for $2.3 billion. But the FTC saw anti trust implications these deals created and ordered the acquisitions to stop and the pharmaceutical firms to divest the PBMs.

So, Eli Lilly sold PCS Health Systems to Rite Aid for $1.5 billion,  SmithKline Beecham sold Diversified Pharmaceutical Services to Express Scripts for $700 million and Merck spun off Medco Health Solutions, the PBM for 68 million Americans at the time.

The third PBM evolutionary period, the one we’re now living in, has seen mergers between PBMs and PBMs with pharmacy chains. In 2000, Advance Paradigm bought PCS for $1 billion, and changed the name to AdvancePCS; in 2003 Caremark bought AdvancePCS for $5.6 billion; and in 2007, CVS bought Caremark for $26.5 billion. Similar long and winding roads have resulted in three PBMs, CVS Caremark, Express Scripts and OptumRX cornering 78% of the nation’s PBM business, serving 266 million Americans. Revenue for these three firms in 2017 was about $300 billion. And these costs are growing at an accelerated pace. According to the American Academy of Actuaries:

In some years, prescription drug spending growth has far exceeded the growth in other medical spending, while in others it has fallen below other medical spending growth. Over the next decade, however, the Centers for Medicare and Medicaid Services (CMS) projects that spending for retail prescription drugs will be the fastest growth health category and will consistently outpace that of other health spending.

Which brings us to the second big problem. The one everyone’s talking about.

More about that next week. After the Patriots win Super Bowl LIII!

Health Wonk Review, help for paraplegics, crane safety, PBM shakeups and more

Thursday, July 24th, 2008

Health Wonk Review – David Williams has a snappy new edition of Health Wonk Review posted over at Health Business Blog. Because HWR took a little summer hiatus last week, this issue is packed – and it’s all organized in a great format that allows for quick and easy scanning. David’s witty summaries are fun – check it out, it’s a good edition.
Cool development in assistive technology for paraplegics – Radi Kioff is a 40-year-old Israeli who spent the last 20 years in a wheelchair after being shot in the back while serving in the Israel Defense Forces. The video in this post shows him walking and climbing stairs with the help of a light wearable brace called ReWalk, a system designed to help paraplegics regain mobility. The system is undergoing clinical trials in Israel and scheduled to begin US trials in November. It’s great to see such a promising development for those who have suffered spinal chord injuries. (Thanks to Medgadget for the pointer.)
Crane fatalitiesrawblogXport points us to the story of an eyewitness account from one of the workers who escaped in last week’s LyondellBasell’s crane collapse that killed 4 workers and injured 7. The article’s sidebar recounts the number of crane accidents so far this year. Celeste Monforton posts more on this and other crane fatalities at The Pump Handle.
PBM shakeup – Joe Paduda has the skinny on PMSI’s recent sale to investment firm HIG. Find more detail in his post PMSI sale – the numbers.
Disgruntled claimant on trial for murder – When you’ve worked in insurance for awhile, you know that a lot of anger and tension can surface around money matters, even more so when things reach a litigation stage. And many a claims manager can cite a litany of stories about angry calls or threats from disgruntled claimants who feel they’d had a raw deal. A story from California today reports on the trial of a claimant who shot and killed his own attorney two years ago. Angus McIntyre was very angry at his workers compensation settlement. He had reportedly threatened and harassed his claims adjuster in e-mails and voice mails on numerous occasions and apparently also held his attorney responsible. One evening he walked into that attorneys office and shot him in the head. Terrible story, and a sad reminder that violent threats must never be taken lightly.
Provider jailed for fraud – It’s 12 months jail time for a New York social worker who double-billed insurance companies to the tune of $102,000 for health care services. A health care provider may bill two insurance companies for the same treatment, but is obligate to disclose the double billing and cannot keep amount beyond 100 percent of the cost of the service. The conviction is not surprising, but I can’t recall too many insurance fraud cases that result in jail time. It’s also a reminder that fraud comes in many flavors – it is not synonymous with “employee.”
Fall protection – Brooks Schuelke posts an overview of fall protection systems at InjuryBoard.com. Falls are one of the most common source of injury and death in construction work. (Related: our prior post on human fall traps)

Controlling the high cost of prescription drugs

Tuesday, August 24th, 2004

Industry trends point to a consistent decline in claims frequency, but a disturbing trend towards increased severity. In other words, the number of claims is trending down, but the cost of claims is trending up. Part of this is due to skyrocketing medical costs. Claims costs include both wage replacement and medical benefits. Historically, wage replacement has represented the larger share of the claims dollar, but recently, medical benefits has edged ahead as the leading cost. No surprise – health care has been rising at or near double-digit rates for a few years now.

Prescription drugs are an increasingly larger piece of the medical pie for workers compensation costs. According to Joseph Paduda of Health Strategy Associates, the costs for prescription drugs associated with workers compensation claims total approximately $2.5 billion a year, and are increasing at an annual rate of 13 to 17 percent. Despite this hefty price tag, it is interesting to note that workers comp expenditures represent less than 2% of the nation’s total drug costs, a fact that has significance in terms of the potential arsenal of cost-control strategies.

Joe discusses some of the reasons for this trend in an essay, Why Can’t We Control Drug Expenses?

Earlier this year, he also released the findings of a Comprehensive Prescription Drug Management Survey that Health Strategy Associates conducted among decision-makers at 21 of the largest workers compensation payer organizations to assess their perceptions, opinions, and attitudes about prescription drug cost management in workers compensation. Respondents cited Pharmacy Benefit Management (PBM) programs as a key tool for controlling costs. Next to PBMS, the most frequent cost control strategy cited was the treating physician:

Five respondents cited a desire to influence the treating physician, and four others specifically cited the ability of a “payer-side” pharmacist or physician to intervene with a treating physician, thereby influencing a specific prescription or the treating physician