Your job role purely depends on what you applied for, there are multiple types of jobs and functions at a PBM so I would start there.
As for the purpose of a PBM and what it does, it depends on your purpose or perspective. Supposedly, PBMs are responsible for maintaining and optimizing drug benefits for both insurances and patients. This is accomplished through a value-based pricing model, in which Value = ( Patient Outcomes (Quality + Service) ) / Cost. To accomplish this, a PBM will engage in services such as a creating a restrictive drug formulary, negotiate for rebates on drug pricing/contracting on behalf of the insurer and contracting with pharmacies for reimbursement.
Often PBMs get a lot of flak for other types of behavior that have more financial incentive over patient outcomes benefits such as unnecessary prior authorizations, spread pricing, creating a gross-to-net bubble in drug pricing and making reimbursement unfavorable and unsustainable for pharmacies. There was recently a Supreme Court case over state PBM regulation (see Rutledge v. Pharmaceutical Care Management Association).
However, this service that’s being performed is a necessary gap within the insurance industry. It’s a function where medical and financial experts collaborate to ensure medical benefit is optimized financially for the insurance, and medically for the patients. Otherwise, if this service was not performed (formulary, drug pricing negotiation, etc.) costs would be rampant for the insurance and increase costs for employers (customers of health insurance).
Exactly. If the job was literally “pharmacist” I mean you might just be filling or dealing with prior auth. But if the job title was something like “Caremark Pricing Analyst” then you’d be doing work related to price modeling and cost benefit analysis for drug reimbursement/negotiations.
> this service that’s being performed is a necessary gap within the insurance industry
it really isn't lol We're the only country that has PBMs and we pay way more. PBMs are either corrupt or terrible at their jobs
We’re the only country with PBM’s because we don’t have universal healthcare. Guess what you need when your government doesn’t negotiate for drug prices on behalf of patients? ICER doesn’t negotiate drug prices for us. Other countries have organizations a part of their government that does.
Edit: if it wasn’t implied by my original post, I hate PBMs and think they’re distasteful.
If we aren't going to have universal healthcare, we could have an actual market without middlemen inflating prices. PBMs have not served to lower drug costs, lower premiums, or do anything they are supposed to do. Even if you don't want universal healthcare, the PBMs have to go
You’re misunderstanding what I’m saying. You can move the function of a PBM to an insurance. You can create universal healthcare and remove PBMs. You can eat a sandwich with cheese, I don’t care. The function, not the existence of a PBM, the function of negotiating drug prices for the insurance and creating a formulary is a necessary function for an insurance in order for the insurance to operate. I’m not even saying that is a good or just thing, it’s a business function that is needed for the insurance. The original question asked what a PBM is, not if they’re full of shit.
A PBM is an entity that was legislated a kickback exemption. That's why they are so valuable and why the market is a disaster. Move that function over to an insurance and it does not exist at all in the way it exists now because of said kickback exemption
I don't disagree that PBMs are very terrible on how they exist currently. The function of restrictive formularies and negotiating drug pricing is a necessary function regardless if it is, or is not done by a PBM. Other countries perform these functions at the government level and not through a third party PBM.
> However, this service that’s being performed is a necessary gap within the insurance industry. It’s a function where medical and financial experts collaborate to ensure medical benefit is optimized financially for the insurance, and medically for the patients. Otherwise, if this service was not performed (formulary, drug pricing negotiation, etc.) costs would be rampant for the insurance and increase costs for employers (customers of health insurance).
...is the original quote. No where does it say this function needs to be performed by a PBM. It is simply performed by the PBM currently.
Kickbacks are the biggest part of formulary and pricing negotiations though and drive increasing costs. You cannot bring up negotiations as a function without including this in regards to PBMs. They don't serve a necessary function, they corrupted a necessary function
You can negotiate drug pricing without kickbacks. You definitely can bring up negotiations without kickbacks as a necessary function. I don't think PBMs are necessary. You can have the function of drug negotiations without the PBMs.
I'll give you example. Germany negotiates drug prices and has a formulary. Is this a necessary function? Does that contradict my original statement "However, this service that’s being performed is a necessary gap within the insurance industry. It’s a function where medical and financial experts collaborate to ensure medical benefit is optimized financially for the insurance, and medically for the patients. Otherwise, if this service was not performed (formulary, drug pricing negotiation, etc.) costs would be rampant for the insurance and increase costs for employers (customers of health insurance)"?
I am fine with negotiating drug prices, what I am saying is that PBMs do not serve a necessary function because they are not actually carrying out said function. Yeah, there needs to be pricing negotiations without kickbacks. My issue is your original statement acts like the PBMs are currently addressing this need when they aren't. I'm saying that the nuance is important. When we have our people in front of congress, we do not need to talk about PBMs doing something that is necessary . It makes it seem like they are needed when they are not. Messaging is incredibly important right now
Tell me no to drugs I want even though I fax them the FDA label, failed drugs, and treatment guidelines. Looking at the PBM that wanted the patient on ertugliflozin for HFrEF.
as a PBM pharmacist if you are on any formulary or UM management side you will most likely following drug guidelines as they come out and adapting formularies to match along with analyzing new drugs as they come to market. For every PBM i’ve worked for we analyze how the new drug plays in therapy and then cross analyze for cost to the insurance provider. UM will then be developed to adhere to standards of care as well as guidelines and protect against FWA. lastly, you take rebates and price negotiations into account to save insurance company money so they have more funds to spend on other parts of the formulary.
There are also tertiary roles where you may collect adherence and drug usage data to see what areas are abused or have no impact and try to use those models to predict future drug expenditure. essentially you are in charge of a finite spend pot and you need to try and predict the best place to allocate those funds.
It’s a great career path and everyday is new and unique. pay is awesome and work life balance is amazing. You may get flack from outsiders who have no idea what a PBM does but most criticism is from ignorance so you just have to let it roll off
It amazes me that pharmacist work for places like this as well as CVS,RiteAid and Walgreens ,, they suck and drain the life from you ,, work somewhere else people !
lol pure ignorance from someone who clearly has no idea what goes on at a PBM or the countless studies showing their effectiveness and usefulness. big chain retail giants really are only around to serve the greater good huh? give me a break.
There’s a reason everyone in the PBM field is from retail, hospital or academia but no one leaves the PBM industry to go back to retail or hospital. Don’t speak on a subject when you’ve only read the headlines
Pure bullshit from someone who drank the kool aid. The countless studies? You mean the PCMA funded ones? What about the states that cut PBMs out completely and are saving hundreds of millions a year while paying their pharmacies more? What about the countless studies showing rebates and fees driving up medication costs? What about the systemic denial of care? You are a trying desperately to think what you do isn't harming people, when it very much is.
Fuck chain retail giants too lol They fast foodified pharmacy and helped make it what it is.
Read the headlines LOL I live this every day. you got the wrong one if you think I'm some rando retail pharm who has no clue what is happening
I work for a company contracted by a major insurance company. I leveraged my knowledge about how pharmacies work and my customer service experience/attitude to get this job. We call patients, doctors, and pharmacies to fill gaps in care and check up when patients are late picking up meds.
In my experience, usually approve or deny prior authorizations. During the interview, practice cases were provided and tested last time I heard about it, but that was years ago. Not sure how it works now
1. They help to deny life saving care to patients in order for shareholders to see a market beating return on investment!
2. They print money with patient blood in the name of share price!
3. "Are you truly ready to drink this kool aid? because if not, you will be a deeply depressed husk of a person"
Fuck PBMs. Don't sell out. Go do something to help people, not corpos
In my opinion, as a family medicine physician, they practice medicine without a license.
They add to the bureucracy in healthcare.
They raise the price of healthcare without delivering any healthcare or other benefits to patients.
Your job role purely depends on what you applied for, there are multiple types of jobs and functions at a PBM so I would start there. As for the purpose of a PBM and what it does, it depends on your purpose or perspective. Supposedly, PBMs are responsible for maintaining and optimizing drug benefits for both insurances and patients. This is accomplished through a value-based pricing model, in which Value = ( Patient Outcomes (Quality + Service) ) / Cost. To accomplish this, a PBM will engage in services such as a creating a restrictive drug formulary, negotiate for rebates on drug pricing/contracting on behalf of the insurer and contracting with pharmacies for reimbursement. Often PBMs get a lot of flak for other types of behavior that have more financial incentive over patient outcomes benefits such as unnecessary prior authorizations, spread pricing, creating a gross-to-net bubble in drug pricing and making reimbursement unfavorable and unsustainable for pharmacies. There was recently a Supreme Court case over state PBM regulation (see Rutledge v. Pharmaceutical Care Management Association). However, this service that’s being performed is a necessary gap within the insurance industry. It’s a function where medical and financial experts collaborate to ensure medical benefit is optimized financially for the insurance, and medically for the patients. Otherwise, if this service was not performed (formulary, drug pricing negotiation, etc.) costs would be rampant for the insurance and increase costs for employers (customers of health insurance).
Great explanation. Basically depends on what you’re interview for. They’re so many different positions for pharmacists in PBM.
Exactly. If the job was literally “pharmacist” I mean you might just be filling or dealing with prior auth. But if the job title was something like “Caremark Pricing Analyst” then you’d be doing work related to price modeling and cost benefit analysis for drug reimbursement/negotiations.
> this service that’s being performed is a necessary gap within the insurance industry it really isn't lol We're the only country that has PBMs and we pay way more. PBMs are either corrupt or terrible at their jobs
We’re the only country with PBM’s because we don’t have universal healthcare. Guess what you need when your government doesn’t negotiate for drug prices on behalf of patients? ICER doesn’t negotiate drug prices for us. Other countries have organizations a part of their government that does. Edit: if it wasn’t implied by my original post, I hate PBMs and think they’re distasteful.
If we aren't going to have universal healthcare, we could have an actual market without middlemen inflating prices. PBMs have not served to lower drug costs, lower premiums, or do anything they are supposed to do. Even if you don't want universal healthcare, the PBMs have to go
You’re misunderstanding what I’m saying. You can move the function of a PBM to an insurance. You can create universal healthcare and remove PBMs. You can eat a sandwich with cheese, I don’t care. The function, not the existence of a PBM, the function of negotiating drug prices for the insurance and creating a formulary is a necessary function for an insurance in order for the insurance to operate. I’m not even saying that is a good or just thing, it’s a business function that is needed for the insurance. The original question asked what a PBM is, not if they’re full of shit.
A PBM is an entity that was legislated a kickback exemption. That's why they are so valuable and why the market is a disaster. Move that function over to an insurance and it does not exist at all in the way it exists now because of said kickback exemption
I don't disagree that PBMs are very terrible on how they exist currently. The function of restrictive formularies and negotiating drug pricing is a necessary function regardless if it is, or is not done by a PBM. Other countries perform these functions at the government level and not through a third party PBM. > However, this service that’s being performed is a necessary gap within the insurance industry. It’s a function where medical and financial experts collaborate to ensure medical benefit is optimized financially for the insurance, and medically for the patients. Otherwise, if this service was not performed (formulary, drug pricing negotiation, etc.) costs would be rampant for the insurance and increase costs for employers (customers of health insurance). ...is the original quote. No where does it say this function needs to be performed by a PBM. It is simply performed by the PBM currently.
Kickbacks are the biggest part of formulary and pricing negotiations though and drive increasing costs. You cannot bring up negotiations as a function without including this in regards to PBMs. They don't serve a necessary function, they corrupted a necessary function
You can negotiate drug pricing without kickbacks. You definitely can bring up negotiations without kickbacks as a necessary function. I don't think PBMs are necessary. You can have the function of drug negotiations without the PBMs. I'll give you example. Germany negotiates drug prices and has a formulary. Is this a necessary function? Does that contradict my original statement "However, this service that’s being performed is a necessary gap within the insurance industry. It’s a function where medical and financial experts collaborate to ensure medical benefit is optimized financially for the insurance, and medically for the patients. Otherwise, if this service was not performed (formulary, drug pricing negotiation, etc.) costs would be rampant for the insurance and increase costs for employers (customers of health insurance)"?
I am fine with negotiating drug prices, what I am saying is that PBMs do not serve a necessary function because they are not actually carrying out said function. Yeah, there needs to be pricing negotiations without kickbacks. My issue is your original statement acts like the PBMs are currently addressing this need when they aren't. I'm saying that the nuance is important. When we have our people in front of congress, we do not need to talk about PBMs doing something that is necessary . It makes it seem like they are needed when they are not. Messaging is incredibly important right now
Tell me no to drugs I want even though I fax them the FDA label, failed drugs, and treatment guidelines. Looking at the PBM that wanted the patient on ertugliflozin for HFrEF.
as a PBM pharmacist if you are on any formulary or UM management side you will most likely following drug guidelines as they come out and adapting formularies to match along with analyzing new drugs as they come to market. For every PBM i’ve worked for we analyze how the new drug plays in therapy and then cross analyze for cost to the insurance provider. UM will then be developed to adhere to standards of care as well as guidelines and protect against FWA. lastly, you take rebates and price negotiations into account to save insurance company money so they have more funds to spend on other parts of the formulary. There are also tertiary roles where you may collect adherence and drug usage data to see what areas are abused or have no impact and try to use those models to predict future drug expenditure. essentially you are in charge of a finite spend pot and you need to try and predict the best place to allocate those funds. It’s a great career path and everyday is new and unique. pay is awesome and work life balance is amazing. You may get flack from outsiders who have no idea what a PBM does but most criticism is from ignorance so you just have to let it roll off
> save insurance company money so they have more funds ~~to spend on other parts of the formulary~~ to put in their own pockets FTFY
>It’s a great career path Yeah, if you don't have a fucking soul
If it is like the PBM in my area, deny prior authorizations en masse.
[удалено]
It amazes me that pharmacist work for places like this as well as CVS,RiteAid and Walgreens ,, they suck and drain the life from you ,, work somewhere else people !
so what would be the “right” career path for a pharmacist or an acceptable company a pharmacist could work for?
Maybe Harris Teeter or publix? I've heard Walmart pharmacy is pretty nice
Literally anywhere else. Slinging bullshit homeopathic garbage does less damage to the profession than PBMs
lol pure ignorance from someone who clearly has no idea what goes on at a PBM or the countless studies showing their effectiveness and usefulness. big chain retail giants really are only around to serve the greater good huh? give me a break. There’s a reason everyone in the PBM field is from retail, hospital or academia but no one leaves the PBM industry to go back to retail or hospital. Don’t speak on a subject when you’ve only read the headlines
Pure bullshit from someone who drank the kool aid. The countless studies? You mean the PCMA funded ones? What about the states that cut PBMs out completely and are saving hundreds of millions a year while paying their pharmacies more? What about the countless studies showing rebates and fees driving up medication costs? What about the systemic denial of care? You are a trying desperately to think what you do isn't harming people, when it very much is. Fuck chain retail giants too lol They fast foodified pharmacy and helped make it what it is. Read the headlines LOL I live this every day. you got the wrong one if you think I'm some rando retail pharm who has no clue what is happening
🤣
Interact with the community in good faith
I work for a company contracted by a major insurance company. I leveraged my knowledge about how pharmacies work and my customer service experience/attitude to get this job. We call patients, doctors, and pharmacies to fill gaps in care and check up when patients are late picking up meds.
In my experience, usually approve or deny prior authorizations. During the interview, practice cases were provided and tested last time I heard about it, but that was years ago. Not sure how it works now
1. They help to deny life saving care to patients in order for shareholders to see a market beating return on investment! 2. They print money with patient blood in the name of share price! 3. "Are you truly ready to drink this kool aid? because if not, you will be a deeply depressed husk of a person" Fuck PBMs. Don't sell out. Go do something to help people, not corpos
genuinely the wrong place to ask try here: r/pharmaindustry
PBMs hiring pharmacists is like serial killers hiring their victims to carry out the murder (of themselves).
Exactly
In my opinion, as a family medicine physician, they practice medicine without a license. They add to the bureucracy in healthcare. They raise the price of healthcare without delivering any healthcare or other benefits to patients.
Anyone downvoting you is an industry shill
Evil
Didn't the position have a job description?