The Role of PBMs in Managing High-Cost Treatment Options

Stacey W. McCullough, DO, senior vice president of Pharmacy at Tennessee Oncology, PLLC; Bruce W. Sherman, MD, FCCP, FACOEM, medical director for Population Health Management for the RightOpt private exchange offering for Buck Consultants, A Xerox Company; and Glen D. Stettin, MD, senior vice president of clinical research and new solutions at Express Scripts, came together to discuss the role of pharmacy benefit managers (PBMs) as a means of helping to manage high-cost treatment options. The discussion, moderated by Bruce A. Feinberg, DO, vice president and chief medical officer of Cardinal Health Specialty Solutions, was held during The American Journal of Managed Care’s 4th Annual Patient-Centered Oncology Care Meeting.

Stettin explained that drug prices for cancer therapies are far more expensive in the United States than they are in Western Europe and other developed countries. While the tax rates in the US may have a part to play in this equation, he argued that American culture is also just as important to consider. Whike Europe works to negotiate prices and make decisions based on the betterment of its population, that’s not necessarily the case in the United States healthcare system, Stettin said. Regardless, the prices he said are unfair.

“We look at the issue of drug prices as one of an ethical issue—an ethical issue meaning that if you think about the value of health insurance, for some people it’s about access to care,” he said. “For some people, it’s about preventing financial catastrophe. And when you look at the cost of these cancer drugs to some of the other very expensive specialty drugs, very few people, if they didn’t have insurance, could afford it or have any access at all.”

It’s not just the drug prices in cancer care that are incredibly high, but the cost of insurance alone. Sherman explained that a study published by The Commonwealth Fund found that one-fourth of all individuals with insurance find their coverage unaffordable. Realizing that these are real people struggling with real healthcare dollars, he suggested that employers are leaning on PBM’s now more than ever.

“From that perspective, employers really don’t have the level of input from an individual perspective to substantially influence PBM or health plan activity,” Sherman said. “They can certainly make strong recommendations. Advocacy groups or business coalitions I should say are in a much better position to encourage or prompt a more conscious, rational value-based approach to care. But generally, employers are really relying on the PBM to be that hired gun to provide the level of control and management for healthcare service delivery such that those costs are not excessive for benefit enrollees.”