A new study from researchers at Weill Cornell Medicine sheds light on the role of pharmacy benefit managers (PBMs) in the U.S. healthcare system.
These entities are pivotal in negotiating medication access for patients, but their influence varies across different demographics, particularly among Medicare beneficiaries.
The study, published in JAMA Health Forum, finds that many patients are encouraged to use PBM-owned pharmacies.
However, these pharmacies appear less prevalent among Medicare recipients compared to their counterparts in other areas.
Financial Impact of PBMs
In 2021, approximately one-third of spending linked to Medicare Part D pharmacy services, along with nearly 40% of specialty drug costs, was channeled through the four major PBMs: CVS, UnitedHealth Group, Cigna, and Humana.
This is striking when you consider the nearly two-thirds market share reported in a 2024 Federal Trade Commission analysis.
Regulatory Environment
One factor contributing to the lower market penetration among Medicare beneficiaries is the “any willing pharmacy” regulations set forth by the Centers for Medicare and Medicaid Services.
These rules ensure that patients can fill prescriptions at any pharmacy that meets the Medicare Part D criteria.
Despite these regulations, PBMs still manage to steer a significant number of Medicare Part D patients towards their affiliated pharmacies.
Notably, for specific high-cost specialty drugs, these pharmacies reportedly capture over 60% of the Medicare market.
Future Research Directions
The ramifications of this study suggest that the prevalence of PBM-operated pharmacies could influence healthcare costs, limit options for independent pharmacies, and ultimately shape the patient experience.
Policymakers may need to explore extending rules similar to the “any willing pharmacy” regulations to the broader commercial sector.
Going forward, researchers plan to delve deeper into the quality of care provided by PBM-associated pharmacies, examining accessibility, prescription fulfillment speed, treatment adherence, and pricing practices.
Source: ScienceDaily