By Danny Sanchez, Chief Executive Officer, EmpiRx Health
If there is one thing that leaders from both sides of the political aisle in Washington, DC can agree on, it’s that pharmacy benefit management (PBM) reform is needed – and needed now. In 2024, nine federal legislative initiatives targeting PBM companies were introduced, culminating in a comprehensive package that was ultimately excluded from the year-end spending deal. Nonetheless, the bipartisan momentum to pass PBM reform measures persists. PBM reform is no longer an “if” but “when” – and the industry must prepare for a post-reform world.
Across the political spectrum, the consensus is that the opaque, predatory business practices of the largest PBM companies constitute self-dealing profit generation over what’s best for the American people. Meanwhile, prescription drug costs continue to soar, and patient health outcomes aren’t improving in any measurable way. The fact is that these large, traditional PBM companies – the three biggest PBMs control more than 80% of the market – operate more like financial trading firms than healthcare companies, negatively impacting patients, benefits plan sponsors, and community pharmacies.
As PBM reform moves from conversations to reality, now is the time to define what a post-reform pharmacy care model can – and should – look like. Breaking up monopolies, demanding more transparency, and requiring rebates to be passed on to patients and plan sponsors are meaningful first steps, but they are only the foundation of PBM reform. Here are four key elements that we believe PBMs should integrate into their operating models to be ahead of the curve when reform inevitably passes:
Put the pharmacist at the center of pharmacy care by empowering them to practice at the top of their license. When empowered to use their full knowledge and expertise, clinical pharmacists can be the catalyst for implementing a post-PBM reform operating model by ensuring that patients receive the most clinically appropriate care. These expert healthcare professionals can holistically evaluate a patient’s medication mix and conduct live, direct consultations with prescribing physicians to improve health outcomes and maximize cost efficiencies.
Leverage advanced data and analytics tools to better understand patient populations and guide recommendations. A critical component of empowering pharmacists is providing access to modern, advanced technologies that can facilitate the analysis of member populations to identify patients who may benefit from additional support. Ultimately, this tech-enabled approach ensures that patients get the right drug, in the right dosage, at a reasonable cost.
Partner with benefits plan sponsors to drive positive health outcomes. PBM providers should always put their plan sponsor clients first and treat them as true partners with a shared goal. You’d think this would be accepted practice in the PBM industry but ask any plan sponsor and they will recount horror stories about the dismissive ways that the dominant PBMs treat them. A PBM’s primary purpose is to serve its clients and their plan members. That requires actively managing the pharmacy benefits plan and creating a first-class pharmacy care experience that keeps members healthy while reducing costs.
Elevate pharmacies and help them play an even bigger role in improving healthcare. Data shows that nearly 90% of the overall U.S. population lives within 5 miles of a retail pharmacy. This proximity reinforces why pharmacies are the backbone of America’s health system, providing trusted, affordable, and accessible healthcare services to patients. PBMs can support community pharmacies by fostering innovative care approaches, like expanded vaccination access and enhanced medication adherence, especially in underserved areas where pharmacies are essential healthcare resources. Equally important, PBMs need to adopt network reimbursement rates that allow community pharmacies to thrive, not push them out of business.
EmpiRx Health pioneered the shift to a pharmacist-led PBM model that prioritizes patients’ health outcomes while helping organizations to sustain the long-term health and viability of their benefits plans. By entrusting clinical pharmacists with a central role in the PBM service ecosystem and prioritizing patient health outcomes over drug sales and rebate incentives, we have helped our clients to substantially improve the health outcomes of their members, as evidenced by our many member success stories. Our pharmacist-led PBM operating model also produces guaranteed cost savings for clients, typically achieving an 18% reduction in per-member/per-month costs during the first year and continuing to improve over time.
PBM reform is finally on the horizon. We need to make sure we don’t squander this historic opportunity. It’s time for the entire PBM industry – including the largest PBM companies – to commit to a more patient-focused, affordable, and transparent business model. Because doing right by patients, plan sponsors, and pharmacy partners is always the right thing to do.