Pharmacy Benefit Managers (PBMs) play a crucial role in the healthcare industry. To this end, the PBM sector is evolving rapidly in the healthcare domain. Ever-changing regulatory guidelines focus on reducing drug costs which result in delivering best- in- class prescription products to better manage patient conditions.
The role of PBMs
Whether the need is for delivery of high-quality or cost-effective healthcare, PBMs are critical for helping patients achieve better health outcomes through greater access to appropriate medications. These include:
- Processing and paying prescription drug claims
- Developing and maintaining the formulary,
- Contracting with pharmacies to negotiating discounts and rebates with drug manufacturers
In a nutshell, PBMs are responsible for administering prescription drug plans for more than 266 million Americans. So, their role has far-reaching consequences.
Drug discount programs offer the much needed medication for eligible patients and enhance their healthcare benefits. Programs like 340B create opportunities for PBMs to maximize their revenue by servicing vast healthcare systems clientele, who are qualified. PBMs must, therefore, ensure that they maintain a compliant program by choosing the right technology partner.
Legacy systems and other drawbacks
PBMs often find themselves spending a lot of time dealing with antiquated order processing systems which can be time-consuming and unreliable. These legacy order processing systems are still predominantly used in most healthcare organizations today. A vast majority of PBMS spend most of their time handling unproductive tasks – which are all tasks a legacy system simply can’t do. This prevents them from deriving full value from their Pharmacy Benefits programs.
Healthcare organizations might experiment with different adoption strategies on their own, but it is PBM solution experts who can effectively manage, and will able to pinpoint problems that prevent them from getting the full value from discount programs. The main challenge of moving from manual processes to an automated approach is not having access to the right tools and methodologies. Without the right tools, PBMs may find themselves struggling to keep up with the demands of getting things done on time using their current tools, which are often reactive and standalone.
In addition to dealing with legacy order processing systems, PBMs often find themselves having to deal with:
- Expired inventory and high carrying costs
- Lack of formulary automation and sliding fee scale
- Inability to provide low cost drugs to its patients
Regulatory measures
Global healthcare organizations are required to evaluate the impact of regulatory requirements and implement supporting solutions to help ensure compliance. Some of the key regulatory requirements that are driving PBMs reforms are ICD-10, Medicare, NCPDP, controlled substance dispensing and overall patient compliance. These regulatory considerations are a key influencer for PBMs to modernize their systems.
The best way forward
PBM’s to support optimal healthcare objectives, need to transition from their legacy systems to a modern solution that supports its operations in an automated fashion This is best done by partnering with a PBM solution expert who can recommend and support the right automation software.
Here’s what to consider when choosing the best Pharmacy Benefits management software and these are the key benefits:
- Robust and scalable architecture that supports a suite of web applications for all the entities in the healthcare system
- Cross-platform integration to improve third party coordination for billing, claims, eligibility processing and formulary management
- HIPAA compliance to avoid security hacks
- Automated claims and billing processes to ensure that each transaction happens in real-time
In conclusion
Having a partner with expertise within the PBM domain can enable you to build out solutions and manage your PBM programs successfully. Prime has been helping healthcare organizations understand the requirements for health benefit exchanges, better manage the patient and member experience. We have facilitated engagements to help build effective strategies for member identification, experience, and retention.
For more information on how to partner with Prime for your managing your PBM needs, contact us
