Health and Fitness

What is the difference between a PBM and a payer?

To develop the optimal pharmacy benefits plan for self-funded clients. You must first understand the payers and their influences and then determine how to best position your customers to prosper in the environment in which we live. This debate is meant to assist you in determining where payers fit about other parties and the instruments available to them to participate in the discussion.

The Critical Factors That Influence Prescription Decisions

Most prescriptions are chosen between the patient and the clinician, with the provider’s professional knowledge probably leading the debate. Those two individuals truly determine which prescriptions are issued, which are filled, and which are finally paid for. You’ll see the drugstore listed in this representation. Years ago, I would have replied that the pharmacy had minimal power since a decision had already been made when an item reached the pharmacy. Still, specialty pharmacies now wield a great deal more influence. They currently account for 50% of costs. Thus I would argue that the pharmacy has an increasing influence over what is distributed, when, and how.

Attempting to Influence the Decision vs. Paying the Bil

Outside of the immediate surroundings of the point of care and dispensing. Other parties have a say in what is prescribed and when. Pharmaceutical producers have direct-to-consumer advertising contact with patients and a very strong relationship with prescribers. They are there from the time they enter medical school until they hang up their stethoscope, assisting them in obtaining information regarding their goods’ clinical utility. Additionally, they work with pharmacy benefit managers (PBMs). They collaborate with PBMs to gain access to formularies and to pay rebates. The PBM retains a portion of the rebate revenue stream, while the remainder is distributed to the payer. Additionally, they have a relationship with the pharmacy, especially when those pharmacies are specialty pharmacies, via procurement discounts. They have a major influence on their market position and how they might enhance their market share.

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Through the point of dispensing, PBMs interact with the immediate circle. They have a claim payment system, which is ultimately responsible for determining what is paid or not paid, depending on formulary and clinical standards. As you can see, neither the payer nor the manufacturer nor the PBM are represented at the immediate point of care or dispensing. How does a payer get the ability to influence what occurs?

Balancing Clinical and Economic Value

Their only admission ticket is through the PBM. If you’re a smaller employer – or even a larger organization – navigating the PBM world to ensure you’re obtaining the best pricing, rebates, and utilization is critical. Are you capable of doing so? Are you capable of managing that on your own?

The wonderful thing about SpectrumPS is that, as a pharmacy benefits optimizer (PBO), we can harness the purchasing power of all our clients to negotiate better rebate contracts and network discount rates and improve clinical program management. We can influence the removal of low-value medications or separate PAs from the PBM, allowing them to operate independently and transparently. We may do numerous things to assist that employer in achieving goal alignment with some of the inner circle parties. A more accurate statement would ensure that others in that primary circle and secondary circle are more aligned with the employer.
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Medication producers are neither good nor evil. PBMs are neither good nor evil. Their objective is to promote therapeutically appropriate medications. Patients and physicians are, on the whole, kind individuals. Again, their stated objective is to prioritize clinical efficacy. However, none of those parties is always concerned with the economics of a decision. Manufacturers do not visit physicians to discuss their products in-depth or discuss the cost of their treatments; they discuss clinical efficacy. Often, physicians are uninformed of the relative cost of a prescription. Thus a treatment like Duexis may appear enticing to a physician because they have coupons, and their membership will not be required to pay a copay. Duexis can cost up to $2,600, while over-the-counter equivalents can cost as little as $20.

This type of discrepancy occurs in today’s society, and it most certainly does not fit with the employer’s objective. Our objective is to ensure that we can be inserted to help neutralize it and meaningfully involve the employer in the decision-making process to assist save expenses.

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