The PBM Unbundling Has Begun: How Blue Shield Of California And Others Are Embracing New Models

Recently, major health insurer Blue Shield of California announced it would drop its traditional pharmacy benefit manager (PBM) and instead partner with innovative companies to save $500 million overall when offering its 4.8 million members pharmacy benefits. This news represents a major shift in the health care landscape. Finally, the unbundling and disintegration of the PBM market has a path forward to unlock the value that ultimately belongs to those who need the medication.

Many have questioned why Blue Shield of California is staying on with CVS Caremark for Specialty Drugs, which account for 49% of total pharmacy costs for U.S. employers by one estimate. The fact is, all PBMs must rely on multiple specialty pharmacies because there’s not one single pharmacy that can supply all specialty drugs. For specialty, a network will always be needed.

However, it’s still laudable that Blue Shield of California is taking a stance on what the future of pharmacy benefits could look like. Here’s the question I have: How are the entities going to talk to each other so that the employee-member knows where to go for what, and coordinate across the system? 

Let’s use an example: Say a member has diabetes. They may go to Mark Cuban Cost Plus for their medication. But if they also have rheumatoid arthritis, they might go to Amazon Pharmacy, or CVS, for a specialty drug. If a member is on multiple drugs, will they have to talk to three different pharmacies to get their medications?

That confusing member experience is just one reason why the participant companies will need to be brought together in a unified, patient-first marketplace or ecosystem. Blue Shield of California is working with Amazon Pharmacy, Mark Cuban Cost Plus Drug Company, CVS Caremark, Abarca, and Prime Therapeutics  – raising some conversation about the limitations of the companies – but what are these disparate companies and their other partners going to run on? All the constituents will need to incorporate the necessary elements to manage claims, route and manage payments between parties and even support third-party therapy recommendations. The commerce side of the equation must run on rails to avoid the same inefficiencies we already see with PBMs controlling the middle.

And yet, there’s one key participant missing in the conversation: the patient-consumer-member. How will Blue Shield of California and other unbundlers ensure patients are still part of the process? Current networks offer a one-direction flow of prescription information across prescribers, pharmacies, and PBMs, excluding other relevant and critical health care stakeholders, including the patient, from participating. What’s more, point of care solutions have been challenged in their success due to a lack of coordination, training and understanding.

With that one-way flow of prescription data, it’s not surprising to learn things break down at the pharmacy counter. Half of consumers say they’ve abandoned a prescription because it was too expensive. Consumers arrive at the pharmacy counter wondering: Is it affordable? Is there a less expensive alternative? Is there a place that I could go to get financial assistance? Those unanswered questions leave consumers feeling powerless, and they walk away from the prescription. Estimates put avoidable health costs between $100 and $300 billion due to prescription nonadherence. I have to wonder how we could impact that by empowering consumers with their prescription information earlier in the process.

And what’s ironic is that consumers aren’t involved in any of the information flow or the decision making on the prescription, even though they’re the participant with the greatest interest. It’s particularly worth calling out since the patient is increasingly becoming the payer through the rise in high deductible health plans. More and more of the cost for care is being pushed to the consumer, while they feel less and less empowered to make their health care decisions. And the physician is ill-equipped to help them because they are not provided with the right information to make an appropriate suggestion to their patients.

Many in the pharmacy benefits space are focused on connections with providers and prescribers. But solving the problem with the U.S. drug market and prescription drug costs will take more than that – it will take consumer behavior change, at the doctor’s office. The new approach that Blue Shield of California is taking for pharmacy benefits should also empower consumers by unlocking prescription data for patients to make more informed care decisions for themselves and their families.

In an unbundled world, as the data gets freed from the big PBMs that focus on profits rather than transparency, member-patients can become more active consumers in their healthcare, shopping around for the best deal and payment option on their prescriptions, in turn driving down costs for both the member and the employer. That’s the real end value of an unbundled PBM – but that North Star can only be achieved if the model runs on a system that can get all the different companies communicating with the consumer-patient-member at the center.


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