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PBMs: An Unexpected Ally in Patient Care

Brian K. Solow, MD, July 30, 2009

As physicians strive every day to provide the best healthcare to their patients, they may be overlooking a strong ally in this process: the pharmacy benefit management (PBM) company that manages their patients' prescription drug benefit.

As a practicing physician, I know that busy doctors often see PBMs as one more layer in the bureaucracy of patient care. Yet if that's our perspective, we're overlooking a resource that can be a significant help to us in our common goal: getting the right medication to the right patient at the right time, and at an affordable price.

My own experience is unique in that I see both sides of the picture. I now work for a PBM, and I still practice medicine. In many ways, it's never been more challenging to be in private practice. We can all benefit from assistance that helps us deliver the best care we can.

For decades, we've relied on pharmaceutical companies and their representatives to be an important conduit for information on effective use of prescription drugs. PBMs are another major resource to practicing physicians, not only for information on prescription drugs, but on how our patients are taking them, on potential adverse drug interactions that can be avoided, and on how to obtain the most affordable medications. This latter point is especially important in today's economy, when we know that many patients are compromising their care by skimping on or not taking their prescription medications because they can't afford them.

With these common goals in mind, let's take a look at how your patients' PBMs can be a resource to you and your practice, for the benefit of your patients.

The Role of the PBM: Adversary or Ally?
Pharmacy benefit management companies exist to manage the pharmacy benefit program that is funded by plan sponsors. While their original value was primarily in purchasing drugs in bulk and in processing claims, the role of PBMs today encompasses numerous programs and initiatives to help patients use drugs safely, to stay compliant with their prescription drug regimen, and to obtain drugs conveniently and as affordably as possible.

A significant asset that PBMs bring to these initiatives is the knowledge within their claims data base. They see the overall picture of a patient's prescription drug use across multiple physicians, facilities, and geographic areas—knowledge that the individual physician does not have in today's medical world. This information provides practical value to physicians to help provide their patients with the best healthcare.

Still, in the day-to-day practice of medicine, it's easy to view the interactions with the PBM as another administrative chore and even as interference in the physician-patient relationship. Another perspective is to see beyond the interruption of routine and to recognize the value of the information that the PBM brings to the physician that is otherwise unavailable.

Getting Value from PBM Interactions
Value from Basic PBM Practices
PBM “best practices” with which physicians are most familiar—such as prior authorization, step therapy, and programs that look at drug interactions and polypharmacy—are designed to work to the benefit of everyone: physician, patient, and plan sponsor. They are a checkpoint that brings together a wide range of information that the physician does not have available at the point of prescribing, to help make the best choice for a particular patient.

Here are some examples:

  • Prior authorization—the practice of requiring approval for a specific drug—is used to ensure that the right medication gets to the right patient for the right length of time. It is a good strategy to ensure that patients who need high-cost drugs receive them, while helping plan sponsors manage costs. Often, the physician is not familiar with the plan design and does not know all the drugs that may be covered in the formulary that may be options. Similarly, prior authorization is often required for new drugs on the market, to ensure that there is a full understanding of the drug's appropriate usage.
  • The goal of step therapy—prescribing the least expensive, equivalent drug first before proceeding to more costly medications—ensures that high-cost medications are the last, not the first, choice for treatment. It is a tried and true practice that works to ensure that patients are treated with the best medication at the best price for their disease or illness. If a generic drug is available and appropriate, it should almost always be the first-line therapy. If the outcome achieved is not as desired, then the next step would be to move up to another medication until the desired outcome is reached.
  • Avoiding drug-drug interactions and managing the dangers of polypharmacy is a critical health challenge as baby boomers age and chronic illness across all age groups increases. PBMs can help because they are in a position to identify at-risk patients, providing physicians with feedback on whether or not the patient is filling their medications and taking them correctly, and if there is the potential for a dangerous drug interaction, which can often happen when patients see multiple physicians. By contacting physicians and providing them with educational materials to use as a discussion point with their patients, a PBM's intervention can be very effective in preventing these interactions.

The communication in these touchpoints should always be two-way. Often the physician has important information on the patient's situation that impacts the decision. My PBM work includes many hours of such discussions each week, to reach the best choice for each patient.

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