A Doctors View of PBMs and Pharmacy Hassles

I was interviewed for a widely read publication in the Pharmacy world called Drug Benefit News. They kindly gave me permission to reprint it on my blog:

Volume 9, Number 21 October 31, 2008

The following interview is part of an occasional DBN series that examines hot-button pharmacy benefit issues though the words of the industry’s thought leaders. To suggest a topic and com- mentator, contact Neal Learner at nlearner@aispub.com. Toni Brayer, M.D., has practiced internal medicine in San Francisco for more 20 years, and is regional chief medical officer of a large hospital/physician network in California. She is a fellow in the American College of Physicians and has served as president of the San Francisco Medical Society and chief of staff at California Pacific Medical Center. Brayer is a well-known speaker and author of the popular blog EverythingHealth (www. everythinghealth.net). DBN caught up with Brayer to get her view of how well the pharmacy benefit works in the doctor’s office.

DBN: How would you assess the state of the pharmacy benefits industry from a physician’s perspective?

Brayer: The pharmacy benefit industry is confusing and overwhelming to physicians. There is a lack of understanding about how they operate and the difference between mail-order pharmacies and PBMs. Some are subsidiaries of health plans, some used to be owned by big pharma. There are perceived conflicts of interest. It is unclear if PBMs bring any value to health care, and if they do...who benefits? Pharmacy costs continue to increase by double digits, and PBMs are thought to be part of the problem, not the solution.

DBN: Do you see significant differences in the way that individual health plans and/or PBMs provide Rx drug coverage?

Brayer: Physicians deal with too many health plans and numerous PBMs, and from our view they have no consistency. We have no way of knowing the various protocols and regulations they operate with, and new product designs make it impossible to keep up. Formularies are cumbersome and change all the time, and it is unclear who controls the formulary. It appears that formularies are based on [achieving] optimal revenue, not evidence- based. The goal should be to reduce hassles for primary care physicians and lower costs to patients and purchasers of health care. Health plans and PBMs are seen as the problem, not the solution.

DBN: What are the biggest hassles that you face every day in getting patients the drugs that they need?

Brayer: Prior authorizations (PA) are exploding and require both staff and physician time to muddle through. A drug that is covered on one plan might need a PA on another. The protocols are different for each one, and some require the physician to list every drug the patient has previously tried and failed (with dates), which means an extensive chart review. It is unclear what is considered a generic, a brand or a preferred drug with each plan or PBM, and there is no transparency in pricing. Pharmacies do not automatically refill ongoing prescriptions and call or fax the doctor’s office for refills, even when it was clearly written on the Rx. Requiring tamper-proof prescriptions is a huge hassle, and it is unclear that they reduce drug abuse, but they certainly reduce physician efficiency. Pharmacies in 2008 are akin to the DMV [i.e., department of motor vehicles]. It is a nightmare to get a prescription filled. The cost of pharmaceuticals is obscene, and the waste we see within the pharmaceutical industry (which drives up cost) is infuriating.

DBN: To what extent do you consider the cost of a drug when writing a prescription?

Brayer: Always. But information is not clear, and I advise patients to use mail order or Costco or price shop. The variation in pricing is not rational, and the fact that patients can only get one month at a time for chronic medications is just plain gouging them for the dispensing fee and monthly copayments. Certain generic drugs should cost pennies a pill, but even generics have inflated pricing if the patient pays out of pocket. It is unusual for any medication to cost under $40, even if it is a generic that has been around for decades. That is a marketplace out of control.

DBN: What would you suggest to PBMs, health plans and others to improve the system?

Brayer: Initiate education for physicians and transparency for everyone. Who benefits from PBMs? Can you really be transparent about rebates, kickbacks and back-room deals? Make formularies evidence- based, and stop the onerous PA. Price non-generic drugs lower if there is no generic to offer as an alternative (example: transdermals, bisphosphenates, certain inhalers, certain antibiotics, once-daily dosing regimens).

DBN: What can or should physicians do to improve the operation of the pharmacy benefit?

Brayer: Physicians are at the bottom of the food chain and do not have the ability to improve this operation. As I see it, PBM customers are the health plans and the pharmaceutical industry. Health plan customers are the employers or purchasers. Employer customers are the stockholders or company owners. Physician customers are the patient. Physicians and patients are out of the loop except as the user of the services. Since we are no one’s customer, in a free market we are irrelevant.


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Nice interview, Dr. B.
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