This is an opinion article authored by Todd Brown of the Commonwealth Beacon. Todd lashes out at the common supply chain whipping boys, Health Plans and PBM's while ignoring the unsustainable rising costs of pharmaceuticals for employers and government agencies.
His comments on the PBM spread pricing model is "spot on", pointing out that in many cases the PBM makes more money on a prescription (adjudicated by the PBM) than the pharmacy does for supplying the medication to the patient. In fact, many pharmacies actually lose money on certain medications because of generic MAC reimbursement and deep brand discount contracts imposed by the PBM. The PBM retains the "spread" discussed in the article and both the Health Plan (and sometimes the PBM) retain the back end rebates paid by the manufacturer. The pharmacy reimbursement model certainly has to change as the supply chain is under tremendous pressure to provide care in a local (retail) setting while PBM's steer patients to their own mail order pharmacies.
On the subject of CoPay Accumulator Adjustment Programs, Mr. Brown is missing a couple of key points. He points out that patients are "harmed" and the PBM and Health Plans make money by collecting deductibles twice. With an accumulator adjustment model the patient doesn't pay the copayment, the manufacturer does. The same manufacturer that sets the price of their drugs (charged to the health plan or employer) and then masks that price from the patient by providing them a subsidy to their insurance deductible. Once that deductible is met, a majority of their medical care will be covered by the health plan, whether it's for the medication they are taking or an ER visit.
When a health plan implements an accumulator adjustor program, they remove this "subsidy" and once the manufacturer money is exhausted, the patient is required to pay their original deductible. In some cases, they will continue to allow the patient to receive the medication at no cost (maximizer programs) but the patient is still required to pay a deductible for other medical care.
Mr. Brown fails to address the tremendous conflict of interest with the manufacturer copay model, where a manufacturer sets the price (in some cases these medications are well over $100,000 per year) and allows them to provide a nominal subsidy to mask any outrage or scrutiny of value for their product. All while profiting tremendously.