Peanut butter and molasses sandwiches it ain't.
Are you thinking what I'm thinking? With a single-payer system, we could have one PBM for the entire country and all 300 million of us could participate.
That second column, "Utilization," it should more properly be labelled "Rationing of Care." Here's the Wisconsin Medicaid protocol for DURs [drug utilization reviews], which is supposed to limit waste, fraud, and abuse, but they look more like ways to abuse poor people's privacy and limit their medical care. Patient profiling and physician profiling are just what they sound like, tracking which drugs patients take too much of and which drugs doctors prescribe too much of.
Just an aside, the same people who profile patients and physicians will audit your PBM for you too. How many layers of bureaucracy do you need?
Fourth column. Formularies are lists of "preferred drugs" which surprise! surprise! turn out to be the drugs that the PBM negotiates the best prices on. If the best drug for what ails you isn't in the formulary, it'll cost ya. Disease management programs are a bit of a HIPAA nightmare [HIPAA being a nightmare in its own right too].
A finger in every pie...
How PBMs get paid: administrative fees and sharing in manufacturer rebates. Switching to a single-payer system would cut out this particular layer of administrative costs and secure the manufacturer rebates/discounts directly for the consumer, not one of the many middlepersons.
Political tensions have resulted. That should improve health care, when the pharmacy benefits manager causes tensions at the pharmacy.
If you think a 25% rebate is high, California Health Care Foundation says it may be as high as 35%.
Increased scrutiny by the Inspector General for Medicaid participation? The headline at the bottom right reads Medicaid AMPs: PBMs out, mail order in.
The Pink Sheet website, if you have $1775 to spare.
Sure, you and your doctor together make the decisions on which drugs you get, but with significant interference from people whose interest in their wallets is greater than their interest in your health.
Potential legal, political, and resulting PR threats. I'm doing what I can to give them bad PR.
Competition in the Healthcare Marketplace Hearings, 2003