Lyles Alan
Henry A. Rosenberg Professor of Government, Business, and Nonprofit Partnerships, College of Public Affairs, University of Baltimore, 1420 North Charles Street, Baltimore, MD, 21201, USA.
Pharmacoeconomics. 2017 May;35(5):493-500. doi: 10.1007/s40273-017-0489-1.
Pharmacy benefit management companies (PBMs) perform functions in the US market-based healthcare system that may be performed by public agencies or quasi-public institutions in other nations. By aggregating lives covered under their many individual contracts with payers, PBMs have formidable negotiating power. They influence pharmaceutical insurance coverage, design the terms of coverage in a plan's drug benefit, and create competition among providers for inclusion in a plan's network. PBMs have, through intermediation, the potential to secure lower drug prices and to improve rational prescribing. Whether these potential outcomes are realized within the relevant budget is a function of the healthcare system and the interaction of benefit design and clinical processes-not just individually vetted components. Efficiencies and values achieved in price discounts and cost sharing can be nullified if there is irrational prescribing (over-utilization, under-utilization and mis-utilization), variable patient adherence to medication regimens, ineffective formulary processes, or fraud, waste and abuse. Rising prescription drug costs and the increasing prevalence of 'high deductible health plans', which require much greater patient out-of-pocket costs, is creating a crisis for PBM efforts towards an affordable pharmacy benefit. Since PBM rebate and incentive contracts are opaque to the public, whether they add value by restraining higher drug prices or benefit from them is debatable.
药品福利管理公司（PBMs）在美国基于市场的医疗保健系统中履行职能，而在其他国家，这些职能可能由公共机构或准公共机构来执行。通过汇总与付款人签订的众多个人合同所涵盖的人群，PBMs拥有强大的谈判能力。它们影响药品保险范围，设计计划药品福利的承保条款，并促使供应商之间展开竞争以纳入计划网络。通过居间协调，PBMs有潜力确保更低的药品价格并改善合理用药。这些潜在结果是否能在相关预算范围内实现，取决于医疗保健系统以及福利设计与临床流程的相互作用，而不仅仅是经过个别审查的组成部分。如果存在不合理用药（过度使用、使用不足和误用）、患者对药物治疗方案的依从性不一、无效的药品目录流程，或欺诈、浪费和滥用现象，那么在价格折扣和成本分摊方面实现的效率和价值可能会被抵消。处方药成本不断上升，以及“高免赔额健康计划”的日益普及，这要求患者承担更高的自付费用，这给PBMs实现可负担药品福利的努力带来了危机。由于PBMs的回扣和激励合同对公众来说不透明，它们是通过抑制更高的药品价格来增加价值，还是从中受益，这存在争议。
