The Future of Pharmacy Benefits Management

Allan Zimmerman

The Pharmacy Benefits Management (PBM) industry will continue to grow — but we will continue to see an evolving focus and a greater emphasis on service capabilities. Growth and demand for PBM services will partly result from the fundamental increases in prescription utilization and the rise in the average cost per prescription as new drug and specialty products enter the marketplace.

As a result, MedMetrics Health Partners believes that PBMs that are strategically positioned to deliver truly optimized cost control — not merely benefit designs or cost-shifting strategies — will be in the best position to increase market share and gain the attention of organizations who are continually frustrated by rising costs, declining clinical and service excellence — and a noticeable indifference from their current PBM.

For too long, traditional PBMs have profited from revenue streams that inappropriately influence clinical decisions. Today, however, PBMs such as MedMetrics — that emphasize financial, clinical, and operational transparency — will make significant market inroads by providing both economic control and a greater focus on quality of care and service.

This crucial alignment of interests creates an increasing focus on prescription utilization review and intervention, integration with medical guidelines, disease management, wellness, and other clinical, evidence-based programs. MedMetrics believes that objective clinical pharmacy program management, integrated with medical delivery systems, provide the best opportunity to achieve effective cost control and superior quality.

Consequently, while some traditional PBMs continue to focus on distribution channels and discounts — mail service, in particular — as the primary mechanism to achieve cost savings for clients, MedMetrics and other transparent PBMs are focusing on total health care expenditures and quality of care. Ultimately, clients are increasingly recognizing the value proposition of cost savings combined with quality care — a value proposition that far exceeds what’s provided by traditional PBMs.

A focus on pharmacy and health care quality also paves the way for data integration initiatives to increase the efficiency of health care delivery. In the coming months and years, we will see renewed efforts in e-prescribing and electronic medical records. In addition, continued interest in health care consumerism will influence the capabilities of PBMs of tomorrow.

As a transparent PBM, MedMetrics believes that providing clients and members with complete operational, financial, and member transparency is a fundamental business requirement. Transparency and disclosure provide members with necessary information to make informed health care decisions. They also enable useful access to customized clinical and benefit information and allow members to access PBM policies and formulary resources.

In summary, MedMetrics sees continued growth for new-breed PBMs that are fully transparent and that focus on quality of care, cost management, and service. In addition, PBMs will continue to emphasize e-prescribing and consumer-driven technologies to empower individual members to better utilize limited heath care resources.Close