Pharmacy benefit management, cost-effectiveness analysis and drug formulary decisions

Grabowski, Henry G.; Mullins, C. Daniel

doi:10.1016/s0277-9536(96)00394-2

Cited by 80 publications

(51 citation statements)

References 16 publications

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“…5 In addition, PBMs often monitor and attempt to alter physicians' prescribing habits among those who disproportionately prohibit generic substitution. Grabowski and Mullins (1997) found that these various incentive measures can save payers 10% or more of their total drug budget.…”

Section: Important Industry Developmentsmentioning

confidence: 99%

Generic Competition in the US Pharmaceutical Industry

Saha

Grabowski

Birnbaum

et al. 2006

International Journal of the Economics of Business

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118

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Section: Important Industry Developmentsmentioning

confidence: 99%

Generic Competition in the US Pharmaceutical Industry

Saha

Grabowski

Birnbaum

et al. 2006

International Journal of the Economics of Business

Self Cite

118

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“…It can be argued that, under these arrangements wherein the health plan directly contracts with the PBM, there is a moderate probability of aligning financial/clinical incentives across drug/medical services. Recent surveys and case studies reveal that an increasing percentage of HMOs are integrating pharmacy and medical databases (17,32,33).…”

Section: Pbm Services As a Continuummentioning

confidence: 99%

“…FORMULARY AND FORMULARY-RELATED ACTIVITIES Developing, maintaining, and changing formularies are major functions performed by PBMs (10,17,22,43). Formularies provide the overarching structure of the pharmacy benefit because they define which drugs are covered (paid for) by the health plan and thus can be prescribed and dispensed to patients.…”

Section: Pbm Drug Use Control Functionsmentioning

confidence: 99%

“…The primary goal of therapeutic interchange programs is to reduce drug costs and maintain rebates for PBMs and their clients, largely through formulary adherence (17,22,42). It is difficult to assess whether these programs have an impact-positive or negative-on patients' health outcomes and overall medical costs.…”

Section: Interchange Programsmentioning

confidence: 99%

“…Outcomes analysis is an essential component of disease management programs to demonstrate their effectiveness and cost savings (17). Outcome measurement is generally restricted to client populations enrolled in new disease management programs and is occurring on a limited basis.…”

Section: Drug Utilization Reviewmentioning

confidence: 99%

See 2 more Smart Citations

Pharmacy Benefit Management Companies: Dimensions of Performance

Lipton

Kreling²,

Collins³

et al. 1999

Annu. Rev. Public Health

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Research on pharmacy benefit management companies focuses on descriptive accounts of the organizations and the scope of their services. This review provides a critical analysis of publicly available research on contemporary issues surrounding the operations and effects of pharmacy benefit management companies. There has been very little systematic, empirical research on these issues; major questions concerning the impact of pharmacy benefit management companies on quality, costs, and patient outcomes remain unanswered. We analyze what is known and what needs to be known, and we explore major research challenges that lie ahead in the assessment of the pharmacy benefit management company's role in the health care system and in improving the public's health.

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Pharmacy Benefit Managers

Mattingly,

Hyman,

Bai

2023

JAMA Health Forum

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ImportancePharmacy benefit managers (PBMs) play a major role in the provision of pharmacy services by acting as intermediaries between pharmacies, plan sponsors (insurance companies and employers), pharmaceutical manufacturers, and drug wholesalers. As their role and visibility have increased, PBMs have come under increased scrutiny from policymakers. However, no prior literature has systematically described the history, business practices, and policymaking of PBMs.ObjectiveTo provide an overview of the PBM industry, including its history, the evolution of services provided by PBMs, an assessment of the current policy landscape, and analysis of how proposed policies could affect PBM practices and patient care.EvidenceThis work reviews historical events; previous and current industry practices and publications; prior academic literature, existing statutes, regulations, and court cases; and recent legislative reforms and agency actions regarding PBMs.FindingsPharmacy benefit managers evolved in parallel with the pharmaceutical manufacturing and health insurance industries. The evolution of the PBM industry has been characterized by horizontal and vertical integration and market concentration. The PBM provides 5 key functions: formulary design, utilization management, price negotiation, pharmacy network formation, and mail order pharmacy services. Criticism of the PBM industry centers around the lack of competition, pricing, agency problems, and lack of transparency. Legislation to address these concerns has been introduced at the state and federal levels, but the potential for these policies to address concerns about PBMs is unknown and may be eclipsed by private sector responses.Conclusions and RelevancePharmacy benefit managers are intermediaries in the pharmaceutical supply chain and perform multiple roles in the management and distribution of pharmaceuticals to patients. When regulating PBMs, it is important to adopt policies that address market failure problems by improving PBM competition as opposed to policies designed to serve the narrow financial interests of other market participants (eg, pharmacies, pharmaceutical manufacturers) without meeting the needs of consumers.

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Pharmacy benefit management, cost-effectiveness analysis and drug formulary decisions

Cited by 80 publications

References 16 publications

Generic Competition in the US Pharmaceutical Industry

Generic Competition in the US Pharmaceutical Industry

Pharmacy Benefit Management Companies: Dimensions of Performance

Pharmacy Benefit Managers

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