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Once relatively obscure, PBMs are now front and center in debates over drug pricing and access. Their future role will have profound implications not only for how medications are priced but also for how pharmacies conduct their operations.
Pharmacy benefit managers (PBMs) have long played a significant role in the health care industry, acting as intermediaries between drug manufacturers, pharmacies, and insurers. However, the way PBMs operate is undergoing a significant transformation, influenced by growing regulatory scrutiny, demands for transparency, and shifts in health care models. Once relatively obscure, PBMs are now front and center in debates over drug pricing and access. Their future role will have profound implications not only for how medications are priced but also for how pharmacies conduct their operations.
Below are 5 key trends driving the evolution of PBMs and potential impact on the pharmaceutical landscape, especially retail and community pharmacies.
Drug pricing | Image credit: Oleg | stock.adobe.com
One of the most pressing issues in health care today is the lack of transparency around drug pricing, a problem to which PBMs have historically contributed. The secretive negotiation of rebates and fees between PBMs and drug manufacturers has made it difficult for patients and health care providers alike to understand the actual cost of medications. For years, PBMs have profited from the difference between what they charge insurance companies and what they pay pharmacies—a spread that many argue drives up drug prices.
For retail pharmacies, this lack of transparency has meant unpredictable reimbursement rates and an uphill battle to maintain profitability. However, regulatory efforts at both state and federal levels are pushing for more open pricing models. States such as Ohio and New York have introduced laws requiring PBMs to disclose rebate and pricing information,1,2 a move that will help pharmacies better plan their finances and potentially reduce reimbursement disputes.
Greater transparency will also empower pharmacies to negotiate more favorable contracts with PBMs. This could lead to more predictable and equitable reimbursement structures, allowing pharmacies to better manage costs and stay competitive. For retail pharmacies, these changes offer an opportunity to reclaim some of the power lost in negotiations with PBMs, as transparency becomes a focal point in the evolving regulatory landscape.
Health care is moving away from traditional fee-for-service models focused solely on cost reduction toward value-based care, which prioritizes patient outcomes. PBMs are slowly beginning to shift their strategies to align with this broader trend. Traditionally, PBMs have focused on cost-containment measures like prior authorizations and step therapy, which aim to reduce immediate expenses but can delay patient care. Now, PBMs are increasingly being asked to consider the long-term benefits of drug therapies, even if they come with a higher upfront cost.
This shift to value-based care presents an opportunity for retail pharmacies to play a more proactive role in patient management. Pharmacies that can demonstrate their ability to contribute to improved patient outcomes—through services like Medication Therapy Management (MTM), adherence programs, and personalized patient counseling—will be in a stronger position to collaborate with PBMs.
Pharmacies may also see increased reimbursement for their role in improving health outcomes. The ability to show value in patient care, rather than simply dispensing medications, could open the door to new revenue streams and strengthen partnerships with PBMs.
The health care industry has seen a trend toward vertical integration, in which organizations consolidate various parts of the supply chain to control costs and improve efficiency. Large health care conglomerates such as CVS Health have integrated PBM services with insurance and retail pharmacy operations. This consolidation allows for streamlined operations but also raises concerns about anticompetitive behavior, particularly regarding independent and retail pharmacies.
PBM-owned pharmacies, including mail-order services, are often given preferential treatment within PBM networks, leaving independent pharmacies at a disadvantage. Patients may be steered toward using these PBM-owned outlets, reducing foot traffic and revenue for smaller pharmacies.
For independent and retail pharmacies, this trend presents a significant challenge. To remain competitive, pharmacies will need to focus on offering personalized care and value-added services that PBM-owned operations may not provide. Superior customer service, strong patient relationships, and specialized health programs can help retail pharmacies differentiate themselves in an increasingly consolidated market.
In addition, pharmacies should explore opportunities to collaborate with health care providers on patient care initiatives, such as medication adherence programs or chronic disease management, where they can offer more personalized support than larger, vertically integrated competitors.
As PBMs strive to become more efficient and improve patient outcomes, they are increasingly turning to advanced technology and data analytics. Artificial intelligence (AI) and big data analytics are being used to improve formulary management, predict patient behavior, and streamline drug utilization reviews. For example, AI can be used to identify patients at risk of medication nonadherence, allowing PBMs to intervene before serious health issues arise.
Retail pharmacies can harness the same technological advancements to enhance their operations. By adopting AI-driven tools and data analytics, pharmacies can better track patient adherence, optimize their inventory, and identify potential drug interactions. This will not only improve patient outcomes but also make pharmacy operations more efficient.
For pharmacies, embracing these technologies can help them align more closely with PBMs’ evolving priorities, potentially leading to more collaborative partnerships and better positioning within PBM networks.
Increased scrutiny of PBM practices by legislators and regulators is another key trend reshaping the industry. PBMs have come under fire for their role in driving up drug prices, particularly through non-transparent rebate practices and restrictive formularies. In response, lawmakers are pushing for reforms that aim to make drug pricing more transparent and fairer, and to ensure that PBMs’ practices align more closely with patient care goals.
If successfully implemented, these reforms could bring significant relief to retail pharmacies. Regulatory changes may limit PBMs’ ability to impose restrictive formularies or under-reimburse pharmacies, leading to fairer terms in pharmacy contracts. In addition, greater transparency in pricing and rebate practices could give pharmacies more leverage in negotiations.
For retail pharmacies, these reforms could also mean more flexibility in offering a wider range of medications, helping them meet patient needs more effectively. This could improve not only patient care but also the financial stability of retail pharmacies, as they secure better reimbursement terms and reduce the risk of sudden reimbursement cuts.
Muhammad Cheema earned his Doctor of Pharmacy degree and is a current candidate in the University of Pittsburgh’s Master of Pharmacy Business Administration (MPBA) program. He has built his career as a pharmacy manager in the Greater Pittsburgh area, where he oversees a high-traffic pharmacy, balancing the demands of patient care and operational excellence.
The evolution of PBMs is shaping the future of drug pricing and pharmacy operations in profound ways. Key trends like increased transparency, value-based care, vertical integration, technological innovation, and regulatory scrutiny are creating both challenges and opportunities for retail pharmacies. To thrive in this rapidly changing landscape, pharmacies must adapt by embracing modern technologies, advocating for regulatory reforms, and focusing on personalized, value-driven care.
By staying informed about these trends and taking proactive steps to evolve alongside PBMs, retail pharmacies can not only survive but also position themselves for long-term success in an increasingly complex healthcare ecosystem.
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