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Pharmacy Benefit Managers are under pressure: The industry is a lightning rod for America’s healthcare system at its worst

Pharmacy Benefit Managers are under pressure: The industry is a lightning rod for America’s healthcare system at its worst

Summary

By 2019, the Pharmacy Benefit Management market is forecast to grow to $283bn. Acting as the ‘middle men’ of America’s healthcare system, PBMs process and coordinate the delivery of prescription drugs, and act as intermediaries between payers and other value chain constituents. It is one of the least regulated sectors of the health care system, lacking transparency, choice, and ripe with conflicts of interest.

It is known that PBMs actively engage in conduct that harms the American consumer. Yet, there is increasing pressure on the industry both from healthcare buyers and politicians. A recent scandal surrounding the use of ‘gag clauses’ between PBMs and pharmacies has tapped into the deeply rooted American believe in the free market, and made PBMs the scapegoat of the ongoing political debate on high drug prices. The industry has consolidated, and is set to defend itself against pressure on all sides, including the entrance of a large corporate new entrant with an agenda to reduce the skyrocketing prices of drugs in America’s healthcare market.

Key Highlights

  • Pharmacy Benefit Management is a lucrative $283bn industry that has outgrown its value.
  • Pharmacy Benefit Management exploits informational asymmetries at the heart of a complex healthcare system, lowering the quality and increasing the cost of American healthcare.
  • Pharmacy Benefit Management Industry is set to be shaken-up by the entry of an Amazon/JP Morgan/Berkshire Hathaway joint venture. This will change the structure of the industry.
Scope
  • Examines the Pharmaceutical Benefit Management Industry
  • Evaluates future of Pharmaceutical Benefit Managers within America's healthcare
  • Assesses reasons behind the ballooning cost of America's healthcare
  • Looks at consolidation within the Pharmacy Benefit Management Industry.
Reasons to buy
  • What is the future of American Healthcare?
  • What is at the heart of healthcare inefficiency in the USA?
  • How will the PBM industry evolve?
  • How do PBMs make money?
  • How will PBM consolidation affect patient healthcare?


Overview
Catalyst
Summary
PBMs: the tapeworm in American Healthcare
Lucrative $283bn Pharmacy Benefit Management industry is hot topic
50% of the United States drug budget spent on specialty drugs
Historically, PBMs were a countervailing power
Expansion through the value chain towards the formulary
Today, PBMs benefit from rebates, payments, and informational asymmetry
Market opacity has led to rent-seeking by PBMs
Drug rebates retained
Algorithmic assistance
Cream skimming
Overpaying in confidence
Your auditor, my auditor
Attention is shifting to the ‘ballooning costs’ of healthcare
Amazon’s entry into the market intensifies consolidation
Conclusions
Appendix
Sources
Further Reading
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Disclaimer
List of Figures
Figure 1: PBM Market share by total equivalent prescription claims managed, 2017
Figure 2: Nominal and inflation-adjusted per capita spending on retail prescription drugs, 1960-2017
Figure 3: Express scripts drug trend by therapy class, 2006-2017
Figure 4: PBMs are at the center of a complex healthcare market
Figure 5: Generic prices have declined while branded drug prices tripled between 2008-2016
Figure 6: Payer-Aligned medical-pharmacy future

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