Understanding the Role of Pharmacy Benefit Managers in Healthcare
Pharmacy benefit managers (PBMs) positively contribute to overall member health and fulfill a critical role in the healthcare system. PBMs increase access to safe and effective medications for individuals while simultaneously reducing drug spending and costs.
PBMs manage the prescription drug portion of the health benefit for more than 266 million Americans. This includes individuals who are enrolled in commercial, government-sponsored, and employer group health plans. PBMs add value in three primary ways: improving health outcomes using evidence-based clinical programs, designing effective pharmacy networks, and reducing prescription drug spending and costs.
Successful administration of the prescription drug benefit requires weaving together these strategies in a way that is customized for each population; this can include formulary management, digital tools, and value-based payment models. This paper explores how PBMs enhance member outcomes and deliver economic value to the healthcare system.
Related Public Policy Research
Medicaid Prescription Drug Management: Quality Scores Compared Across Different Approaches
Data show that states that employ managed care organizations (MCOs) to manage the Medicaid prescription drug benefit collectively exhibit higher scores on pharmacy-related clinical quality measures than states that rely on the fee-for-service (FFS) setting to administer the benefit.
PBM and Community Pharmacy Partnerships Can Improve Medicaid Outcomes
Individuals’ visits to community pharmacies outnumber visits to other healthcare provider types by nearly 2:1. Value-based care arrangements between pharmacy benefit managers (PBMs) and independent community pharmacies, where enhanced services are performed, can improve outcomes for individuals at higher risk for poor health outcomes.
Value-Based Payment Programs in Healthcare and Their Application to Pharmacies
There is a growing understanding of the clinical roles that pharmacies and pharmacists can play, beyond medication dispensing and adherence, such as medication adjustment, vaccination, and outcomes monitoring. Value-based payment (VBP) in pharmacy has the potential to recognize the contributions pharmacies and pharmacists can offer to improve patient outcomes and reduce costs.