Experiences with pharmacy benefit management programmes in the USA

摘要

As an increasing proportion of health care services in the US move from fee-for-service to managed care arrangements, drug prescribing is also moving toward more centralized, proactive management. Pharmacy benefits management (PBM) activities are being developed and implemented by payers such as self-funded employers and managed care organizations (MCOs) as well as provider organizations such as large medical groups and integrated delivery systems. These activities are aimed at controlling drug costs and improving the quality of health care, although critics charge that cost control goals play the dominant role.While pharmacy benefits management activities can and are performed within MCOs and integrated health care delivery systems such as Kaiser Foundation Health Plan, the main and growing locus of these activities is in dedicated companies, themselves generally known simply as PBMs. PBMs design, implement, and administer outpatient drug benefit programs for employers, MCOs, and other third-party payers. Currently, there are about 100 PBMs in the US [8], and they provide drug services for more than 100 million Americans [4]. As elsewhere in the world, the pressures to contain drug costs flow from the increases in those costs for both public and private MCOs [7,12,16,21,22]. Despite the dramatic increase in costs, very little is known about the nature and consequences of the strategies used by PBMs and their contractual partners to manage drug benefits.