Current issues and recommendations to manage prescription drug benefits for public health programs

Abstract

Higher scrutiny is befalling public payors regarding drug costs and patient access to medications. These issues exist in a complex contractual environment where minimal oversight of pharmacy claim adjudication and reimbursement practices can occur. The complexity of prescription benefits, and the lack of defined expectations or accountability in the system contribute to a sense of frustration by the public. Key areas of improvement for this sector of the health care industry include legislative and regulatory shifts requiring ongoing analyses, reporting, and accountability of pharmacy benefit managers (PBMs) in order to improve payment transparency. These improvements will enable plans to eliminate misaligned incentives in the industry and drive value. Changes in public sector programs should be comprehensive in their approach so that the policy will result in a reduction in costs, enhanced patient access, better patient safety, and improved health outcomes.

Keywords: Drug pricing; Health plan; Pharmacy benefit manager; Prescriptions.