That’s the title of a current paper by Hernandez and Hung (2024). The article offers a wonderful overview of how medicine get reimbursed within the US and who the important thing gamers are. I present an abbreviated abstract under, however do learn the full article.
The gamers
- Producers analysis, develop, and produce new drug merchandise to market.
- Wholesalers act as distributors of drug merchandise. Wholesalers buy the drug product from producers and distribute it to pharmacies and well being care suppliers.
- Pharmacies dispense self-administered pharmaceuticals to sufferers. Forms of pharmacies embrace retail, mail order, on-line, specialty, and institutional.
- Well being care suppliers prescribe all pharmaceuticals and administer drug merchandise that must be offered below the supervision of a well being care skilled (e.g., infusions, some injections).
- Sufferers are customers of drug merchandise from well being care suppliers (physician-administered) or pharmacies (self-administered).
- Well being plans or insurers (aka payers) present protection for medical and pharmacy companies to their members. Non-public insurance coverage is funded by employers and workers; public insurance coverage (eg, Medicare, Medicaid) are funded with tax {dollars}. Medicine disbursed to sufferers at outpatient pharmacies are lined below the pharmacy good thing about an insurance coverage coverage, whereas provider-administered medicine are lined below the medical profit. Well being plans or insurers typically subcontract the administration of pharmacy advantages to pharmacy profit managers (PBMs). Well being plans or insurers are additionally known as payers.
- PBMs administer the pharmacy good thing about insurance coverage insurance policies and design formularies, negotiate reductions with producers, set up pharmacy networks, negotiate contracts with pharmacies or pharmacy companies administrative organizations, and course of and pay claims.
- Group buying organizations (GPO) are shopping for consortiums that combination buying energy amongst their members, permitting them to barter higher reductions than they might entry on their very own. GPOs embrace well being techniques, clinics, specialty pharmacies, retail pharmacies, and PBMs.
- Pharmacy companies administrative organizations handle and negotiate contracts with PBMs on behalf of unbiased pharmacies. Some pharmacy companies administrative organizations are affiliated or owned by wholesalers.
Circulation of funds for drug lined by the Pharmacy Profit
Funds between these gamers are summarized by the graphic under for medicine sufferers obtain by a pharmacy. The pharmacy might be an ordinary free standing pharmacy (e.g., CVS, Walgreens), a pharmacy inside a hospital, or perhaps a mail-order pharmacy.
Circulation of funds for drug lined by the Medical Profit
Right here, slightly than pharmacies delivering medicine to sufferers, medical suppliers provide the medicine. These suppliers obtain reimbursement each for the price of the drug administered and in addition the skilled companies rendered to manage this drug.
Wanting ahead
The article additionally identifies a lot of key themes:
- Drug costs have been rising lately, however rebates have been rising much more
- Federal authorities drug value negotiation is starting with the Inflation Discount Act (IRA)
- Elevated vertical integration with insurers buying PBMs and the creation of GPOs owned by PBMs
- Well being plans are more and more transferring specialty provider-administered medicine to the pharmacy profit, by “white bagging” (having a specialty pharmacy dispense the drug and ship it to the supplier) or “brown bagging” (having a specialty pharmacy dispense the drug to sufferers to deliver to the supplier for administration)
A primer on brand-name prescription drug reimbursement in the US
