Question

who are the "middlemen" in the healthcare delivery system and discuss do we need them?

Answer 1

Many of us may wonder whether there is actually a middlemen in Healthcare System. The answer is a big YES. Let's find out what is trending in US Healthcare System.

Many of us noticed it as a common practice with which a doctor writes a prescription and the patient goes to the pharmacy to fill it. Guess what, some behind the scenes players are keen on changing things in a big way.

Group purchasing organizations (GPO) and Pharmacy Benefit Managers (PBM) those who were in the streamline purchasing of drugs and medical supplies for hospital and insurance companies are considered to be the MIDDLEMEN of Healthcare Delivery System.

PBMs are the middlemen between the drug makers and insurance companies. The role of middlemen is multidimensional in helping to bridge supply with demand and create adequate channel for drug delivery, proposal to curb their influence in price setting are gaining trading.

At the same time, increased consolidation on the part of pharmaceutical companies or hospitals will naturally curb intermediary market power.  

Until recently, filling a prescription was an easy process for many of us. Like many other health care transactions, you pay a small set copay for your medicine and a pharmacist provides you with your medication. But you may have noticed lately increased references to “specialty tier” medicines. These “special” medicines are often accompanied by a rather special price under the friendly sounding guise of “cost-sharing” or “co-insurance.”

Just to be clear, cost-sharing often means the patient gets to pay more. But that’s not all. Certain health plans and their partners are now trying to further limit patients’ access to these life-saving medicines by forcing them away from the expert care of the trusted local pharmacies in favor of required mail-order delivery.

So who is behind all these changes? The answer is secretive, unregulated middlemen known as pharmacy benefit managers, or PBMs.

PBMs are the middlemen between the drug makers and insurance companies. What most people do not know is that PBMs play a major role in determining which medicines are available to you and at what cost. Sadly, many PBMs profit via practices that are detrimental to both patients and the pharmacists who care for them.

When most people think of a pharmacy, they envision large chain store where someone takes your prescription, hands you a bag with your medication, and sends you on your way. But there are numerous independent pharmacies around us play a much larger role in providing care, particularly for those in rural areas.

In these settings, pharmacists are more than just someone behind a counter. In many ways, these mom-and-pop style businesses are the most immediate and accessible medical professionals in their area and are often cornerstones in their communities.

Yet these small pharmacies have been threatened for years by unfair PBM practices. It began with shadowy reimbursement methods that mean pharmacies often receive less than the actual cost of the medicine they dispensed. And now they’ve graduated to overt efforts to circumvent local pharmacies with required mail orders that could put trusted caregivers out of business.

This troubling new practice requires patients to forgo their face-to-face consultation with local pharmacists and only refill prescriptions for specialty medicines via mail. This removes access and consumer choice from the system and prevents another critical interaction between the patient and a well-trained health care provider.

This often impacts patient communities who least can afford a change in their treatment regimen, including those with cancer, mental and behavioral health issues and chronic pain.

Fortunately, lawmakers can address these problems with common sense legislation. For starters, lawmakers should finally make PBMs play by the rules and treat independent pharmacies fairly and correctly according to the law.

Under the current setup, pharmacists have no recourse to resolve unfair, inappropriate or even arbitrary actions of PBMs. By regulating PBMs, the state will have the ability to both sanction and fine those companies that engage in activities prohibited by state law.

In many communities, independent pharmacists are the backbone of local medical care, providing their patients with needed medications and a familiar expert face with whom to discuss their personal health and wellness. Instead of allowing shadowy PBMs to push them aside, we should be supporting local pharmacies and the services they provide to so many of us.

Correcting unfair PBM practices is critical to improving access to care for all.