Pharmacy Benefit Managers
Imagine opening your mail one morning and finding a letter from a
pharmaceutical company questioning a prescription you wrote for a
competitors drug and suggesting that your patient might benefit more from
their drug. Or how about a letter explaining that because you prescribed
an anti-depressant for a patient, the pharmacy benefit manager for your
patients employers health maintenance organization had enrolled the
patient in a depression support group - without even consulting you.
These are not made up scenarios. In fact, they are happening to your
colleagues here in Texas regularly, and its all being done under the
banner of controlling health care costs.
Prescription drug benefits are the fastest rising segment of health
care expenditures in America. To rein in these expenses, employers who
provide health benefits to their workers and the HMOs, which provide those
benefits, increasingly are turning to pharmacy benefit managers (PBMs).
PBMs are companies who track all prescriptions written by physicians in a
health plan theyve contracted with. They administer prescription drug
claims, establish formularies, track physician prescribing patterns and
provide education to improve their efficiency and cost effectiveness, and
provide disease management programs, such as the depression support
program mentioned earlier.
Unfortunately, Texas physicians report a number of PBM-related problems
that they believe are compromising patient care. Top among these is the
increasing intrusion of PBMs into patient privacy. The PBMs and the HMOs
they work for collect an enormous amount of patient-specific information
under the guise of properly processing benefit claims. Unfortunately, that
information often is finding its way back to patients employers, who
contend they have a right to the information since they ultimately pay the
bills. And, since some of the nations largest PBMs are owned by
pharmaceutical manufacturers, the information is being passed on to drug
makers who, in turn, are beginning to use it in the marketing efforts.
Texas physicians have raised the alarm about these practices. They fear
this breech of patient confidentiality will have a negative impact on
patient care, particularly among those suffering from mental illness,
sexually transmitted diseases or other sensitive medical conditions. The
concern is that some patients wont even seek desperately needed treatment
for fear their employer will find out about it.
But the PBM problems are not limited to privacy. Other concerns have
been raised about unauthorized drug substitution or "slamming," arbitrary
formulary restrictions that might favor drugs manufactured by the PBMs
parent company, and financial incentives to encourage physicians to
prescribe certain drugs.
While these are serious concerns, PBMs are largely unregulated in this
state. Texas Medical Association and some lawmakers believe that needs to
change and these problems need to be addressed now. Sen. Jane Nelson
(R-Flower Mound) and Rep. John Smithee (R-Amarillo) are considering
legislation to ensure that sensitive information is not turned over to
employers or drug manufacturers or sold to other third parties.
And, TMA is working with the PBMs to address these issues on a more
informal basis. TMA has asked Texas two largest PBMs to cooperate in
developing and codifying preferred industry standards that protect
patients rights and quality care.
We acknowledge that pharmaceutical costs are rising rapidly and need to
be controlled to ensure all our patients can afford health coverage and
pharmacy benefits. But as physicians, we must ensure that the health care
marketplace is not dominated by companies who lack our level of commitment
to the quality of our patients care or who would sacrifice patient needs
in favor of investor profits. We hope the pharmaceutical industry and
their PBMs will join us in putting patients first.
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Austin TX 78701
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