Coordinated Versus Integrated PBM

I’ve long held what would appear to be conflicting positions:

A. I believe that a standalone PBM offers the unique ability to be laser focused on pharmacy and should therefore optimize your benefits from a carve-out perspective.

B. I also believe that ideally that focus could be achieved within an integrated benefit where you could leverage pharmacy strategically to drive down the bigger overall area of costs – medical.

So, my initial reaction when I heard about the study below Anthem was that this finally showed a clear savings from the integrated PBM model.

According to a separate analysis Anthem conducted of members in its affiliated health plans, enrollees with both medical and pharmacy benefits managed by Anthem have medical costs that are $8 to $16 lower per employee per month compared with those without Anthem’s pharmacy program. (from Drug Benefit News)

I haven’t seen the original study which I’d like to read in more depth, but on the surface, this is interesting.  After further retrospect, I wonder if the issue isn’t necessarily integrated versus coordinated.

Can a standalone PBM act as an integrated PBM?  What would need to happen for that to be true?

  • They would need to coordinate benefit design across both areas (pharmacy and medical) which is easier when the managed care company is the buyer of PBM services not the individual employers.
  • There would need to be integration of pharmacy and medical benefits into a predictive model and an outcomes model.
  • The PBM would need to be tied to outcomes in some type of P4P model.
I’m sure there’s lots of PBMs out there on both sides of the fence who could (and will) argue this story better.  I’m just thinking through my initial reaction to think about what this study really means.

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