October 18, 2013 
The idea of healthcare costs and the need for healthcare transparency has become a front page issue. With the shift to consumer driven healthcare and high deductible plans, the average consumer is increasingly aware of what things cost. And companies like Change Healthcare provide tools to help consumers navigate this maze.
But, what I don’t hear many people discuss is the issue of middlemen and how this adds cost to the system. I’ve worked for several middlemen so I think I understand the model well. Of course, these companies make good (and true) arguments which is that they lower costs due to scale based efficiencies. But, healthcare is big business so everyone has to get paid somehow. Some of the “non-profits” make the most money.
Let’s look at prescription drugs:
– This begins with the manufacturer who adds the marketing and sales costs to the actual ingredient and packaging and shipping costs.
– The drug is then shipped to a wholesaler who stocks the drugs and ships them to pharmacies.
– The drugs are then sold by the pharmacy to the consumer and the pharmacy bills the payer.
– Assuming the payer isn’t the actual employer, the payer will then bill the employer.
So who all gets paid in this process:
– The manufacturer of the drug
– The advertising companies (they name the drug, they create the packaging, they create the ads)
– The marketing companies (they set up the websites, they create the mobile apps)
– The law firms (trademarks, patents)
– The sales companies (they hire and manage the pharma reps)
– The data company (the manage the Rx data to help target the reps)
– The shipping companies (transportation)
– The wholesaler
– The pharmacy
– The marketing and communication companies (refill programs, on the bag messaging)
– The technology companies (switch company, adjudication company)
– The recruiters (hiring, staffing)
– The PBM (contracting, rebating, customer service)
– The payer (adjudication, customer service, risk management)
– The broker (commission)
Still wonder why healthcare is expensive?
I wish I had an easy answer. A lot of these services are needed and it would cost more if the employers all had to do this themselves. There would be no scale. There would be no efficiencies.
This is certainly one argument for the efficiencies of a single payer system but I don’t think that’s very efficient IMHO.
Enabling Healthy Decisions 
I believe PSAOs and GPOs should be added to this list of middlemen
This rapid growth of PSAO and GPOs has generated formidable controversy and animosity with in the Pharmacy community. GPOs and PSAOs are also being compensated by drug, device vendors, PBMs and wholesalers through administrative “fees” and spread pricing. The same problems pharmacists are having with the PBMs?
Lawsuits have arisen regarding “pay to play’’ practices. These lawsuits delve into the world of informal middlemen between client and vendor where the middleman is supposed to have a fiduciary relationship with the client but instead are being paid by the vendor to land the client contracts. PSAOs and GPOs use “Pay to Play” for both wholesalers and PBMs to land contracts.