Four ways PBMs must change to thrive in the future


The days of the traditional, channel-focused and largely enshrouded PBM business model have come and gone. Here’s what’s next.

This year has already brought significant change and uncertainty as it relates to the future of U.S. healthcare.  For our nation’s PBMs, however, current industry dynamics are painting a very clear picture as to the transformation necessary for such companies to thrive.

Here are four of the most pressing areas of need.

1.    Enhance physician engagement

Future PBM programming must provide physicians with more enhanced and timely visibility into a patient’s overall care and opportunities for intervention.  It is also critical that such strategies be incorporated directly into the provider’s daily work flow so as to decrease administrative burden for already-overwhelmed physician practices.  With reimbursement models shifting more toward pay-for-quality, such innovation in PBM programming should be well-embraced amongst providers as a way to improved financial performance within these models.  

2.    Leverage touchpoints to drive education, engagement

Individuals utilize their pharmacy benefit more often than any other component of today’s healthcare system.  Consequently, PBMs must devise strategies that can capitalize upon each of these touchpoints to better educate and engage patients in their healthcare. At minimum, this should include providing all stakeholders who interact with patients on a routine basis with access to a continuously updated, robust view into a patient’s full profile of care and areas of opportunity. Opportunities should include advice for the patient regarding lower cost treatment alternatives; insights into condition management and/or wellness resources; and the ability to immediately connect with a pharmacist or nurse to discuss drug-related gaps in care; interactions; dosing issues; and possible adherence challenges. Such tools must also be complemented by IT advancements to connect today’s tech-savvy patients in ways much better aligned with their needs and today’s pace of living.

3.    Embrace the new age of alliance

PBMs must put aside “go-it-alone” approaches of the past and be more open to partnerships that can yield greater value to patients and providers. This will require greater connectivity with business partners; new and different contracting models; and bidirectional sharing of data and information with other key stakeholders such as medical carriers, behavioral health providers, pharmacies, lab vendors, care managers, and IT vendors. PBMs also need to find new ways to work with drug manufacturers to create improved pricing transparency, accountability, and aligned strategies that emphasize value over volume. 

4.    Deliver multidimensional trend management solutions

While demands for transformation abound, PBMs must still hold true to their core competencies in delivering effective control of bottom-line pharmacy expenditures. This will require unprecedented vigilance in monitoring factors, both large and small, that can impact drug trend. Consequently, this will require investment in the development of a consistently expanded, yet flexible, suite of tools and services that can proactively, and aggressively, mitigate negative trends without compromising quality of care for patients.

Today’s more sophisticated purchaser of PBM services is demanding a much more transparent, progressive and holistically-focused set of services to effectively tackle the challenges of today’s healthcare system.  Those with the foresight and resolve to embrace these changes and transform business models accordingly will clearly emerge as leaders in this future environment, while those who continue to stay the current course will likely fall by the wayside.

David Calabrese is chief pharmacy officer at OptumRx, and a Managed Healthcare Executive editorial advisor.

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