What exactly does PBM do?
Let's take a look at the background of the birth of this institution! In the United States, many third-party payment institutions, including federal medical insurance and commercial insurance, hope to control medical expenses on the premise of ensuring medical quality. For the medical expenses of hospitals and clinics, DRG and CPT can be used to control the expenses. However, due to the separation of medicines in the United States, drugs outside hospitalization need to be purchased at pharmacies, and 75% of these drugs are prescription drugs. Therefore, insurance companies need to use a method to control the price of drugs and advocate the use of low-cost and effective drugs.
The United States is a country that fully trusts the market, so the price of drugs mainly depends on market regulation, not government pricing. So how can insurance companies curb the exorbitant price of pharmaceutical companies? One of their important chips is the medical insurance catalogue. If an insurance company has enough insured people, then it has enough chips to negotiate: if your boy sells too expensive, I won't let you into our catalogue, and millions of people won't use your medicine! Of course, it is only useful for competitive drugs. If a medicine has a patent, you have no temper. In addition, since the retail pharmacy is the place where the actual transaction takes place, it is necessary for the insurance company to limit the price at the pharmacy port, and the way to limit the price is to negotiate and sign a contract with the pharmacy. In order to compete for customers, insurance companies let users pay the same price for a certain drug (co-payment), so it is more convenient for insured users to buy prescription drugs. For an insurance company, if its bargaining power is stronger, it will pay less money to pharmacies. Therefore, the core function of PBM institutions is to exist as a multi-interest coordinator, and its most suitable soil is the medical market dominated by the very scattered insurance institutions in the United States.
In 1970s, the prototype of PBM appeared. At first, they just helped the insurance company to handle the bills manually. Later, they began to manage the prescription drug data in an information-based way, then hired pharmacists and famous doctors to help the insurance company draw up the reimbursement catalogue, and began to negotiate with pharmaceutical companies and pharmacies. The above-mentioned business originally belonging to insurance companies has gradually moved to PBM institutions. Because PBM has the ability to bargain with pharmaceutical companies and get cheaper drugs, they have successively launched direct-to-user drug mailing services; At the same time, they have the ability to bargain with pharmaceutical companies, so they began to set foot in retail pharmacies themselves. Gradually, the tentacles of PBM organizations are getting more and more full and the rights are getting bigger and bigger. This institution, which should have stood on the side of the payer to help the employer save money, has achieved greater benefits than the employer. We can feel this from Express scripts 20 13, the largest PBM company in the United States at present:
The data clearly shows that the net profit of express script 20 13 is 4 1% higher than that of 20 12. In 20 12, Express scripts acquired another PBM company, Medco Health Solutions Inc, for $291100 million, becoming the largest PBM company in the United States, covering a population of 90 million. Followed by CVS caremark, covering a population of 85 million (drug retailer CVS acquired the then PBM company caremark Rx in 2006 and changed its name to CVS caremark). The top three companies with market share account for about 90% of the market share, as shown in the following figure:
Of course, in addition to the above functions, PBM also has business modules such as helping doctors to use drugs rationally, collecting drug feedback, and promoting health management. However, its core business is still dealing with the interests of insurance, pharmaceutical factories and pharmacies.
Why do the American people spit PBM?
Let's take a look at the profit model of PBM. In addition to the management fees paid by employers every year, mailing drugs is also one of their main incomes, among which the most questioned are "price difference and rebate", that is, premium and rebate. How exactly do these two things work? Look at the premium first. We know that PBM has a seemingly beautiful duty, that is, to negotiate with retail pharmacies on behalf of payers. For example, the final result of a drug negotiation is 80 yuan, and the user pays 20 yuan at his own expense, and then PBM advances 60 yuan to the pharmacy. But in the end, the crucial step is that PBM may write 100 yuan on the bill to the insurance company, so that they can earn 40 yuan (that is, premium). So the question is, are insurance companies stupid? A little silly, but not all. If the insurance company doesn't hire PBM to bargain with the pharmacy, then he may need to reimburse 1 10! So this is a very magical and tangled result.
Look at the discount again. We know that PBM can bargain with pharmaceutical companies. For example, there are four kinds of drugs with the same curative effect, and the prices are neck and neck. So who will PBM let into the medical insurance catalogue? Whoever gives them more discounts, let them in! This is the kickback that has been criticized. Regarding the operation mode of PBM, you can watch the video of a buddy on youtube, which is very detailed; In addition, an uncle named Phil also made several very cute short films to satirize PBM. These two videos are below, and I want to watch them directly. Therefore, when the China media praised PBM's various contributions in fee control, there were actually many questioning voices in the American media, so you can have a look at them when you have time.
Operation mode of PBM
Uncle Phil satirizes PBM
In addition, we can look at the essence of PBM from another angle, which will involve walgreens, an American drug retail giant. On 20 10, walgreen and PBM organized CVS caremark to publicly tear their faces and read an announcement to the effect that CVS retail pharmacies suppressed their competitor walgreen through CVS caremark. Looking at walgreen's announcement, I feel that they are helpless but have backbone, but CVS's response is completely "You are talking nonsense, but I can still tell you in good faith". Of course, walgreen ignored him. In the next 20 12 years, walgreens and Express scripts, the largest PBM organizations in the United States, were torn apart for similar reasons, and then ESI's attitude was probably "My boss, you can't get away". In fact, walgreen once had its own PBM business, but maybe people thought it should focus on drug retail, so it was cut off on 20 12. So walgreens is still very different from CVS and ESI.