- [Presenter] You might think
the process that determines how much you pay for something
is pretty straightforward, and it often is. For example, here's the
supply chain for a beverage you might buy at the
drugstore, say, a Pepsi. Pepsi Co. Manufactures
the soda and sends it to a retailer, who sells it to a customer. The customer pays the retailer, and the retailer pays Pepsi Co. Simple, right? Well, that is not the
case for the products behind the pharmacy counter. The drugs. Here's a typical supply of
chain for prescription drugs. It looks really different. That's because the way
that drugs are priced is not at all a straightforward process. Experts and politicians argue
that the very complexity of this chain is part of why drug prices have grown so high for customers. - Everyone involved in the broken system, the drug makers, insurance companies, distributors, pharmacy benefit managers, and many others contribute to the problem. - [Presenter] To understand this debate, first, you should understand
the flow of drugs and money within this chain. Let's start here with the
pharmaceutical companies. They are the ones who develop
a drug and set a price, known as the list price. This isn't a straightforward
as it might look, which I'll explain in a moment. Next you have the wholesalers
who transport the drugs and sell them to the pharmacies. The patient pays the copay
and the pharmacy sends out a bill that gets paid by
the insurance company. That's simple enough,
but we're missing a link. The link that manages
this transaction and adds a lot of complexity to the chain. Meet the pharmacy benefit managers or PBS. They are who the drug
companies and some politicians are talking about when
they refer to middle men. They work for insurance companies, big employers, and government agencies. And a big part of their
job is to bring down the cost of drugs for their employers. They do this by negotiating with pharmaceutical companies for rebates. Yup, for many of the drugs a
pharmaceutical company sells, it pays a rebate to the PBM. The PBM sometimes pockets
a portion of the rebate and passes another portion on to the insurance company or employer. Why the pharmaceutical
company pays these rebates is the source of a lot of controversy. What happens is the drug
company gets moved up on something called a formulary. So what's a formulary? It's the list of drugs that
the insurance company covers. And it's grouped in tiers. Each tier represents what
portion of the list price the patient pays and what
portion of the list price the insurance company pays. The highest tier in the
formulary is the lowest copay for the patient. And the lowest tier is the
highest copay for the patient. When the pharmaceutical
company pays a higher rebate, the PBM will move the
drug up on the formulary. Pharmaceutical companies
want high placement on the formulary. That's because patients are
more likely to take the drug that's most affordable. And that usually means higher sales for the pharmaceutical company. If the patient wants to take
a drug that's lowered down on the formulary or not on it at all, they have to pay higher copays
or even the full list price of the drug. If this seems confusing,
that's because it is. Let's take another walk
through that transaction, this time with an example. Say a hypothetical drug costs $100. A PBM negotiates a $50 rebate,
$10 of which they pocket, and $40 of which they pass on to the insurance company or employer. In return for that rebate,
the PBM moves the drug to a better spot on the
formulary making it cheaper for the patient to buy the drug. This transaction is important
because the pharmaceutical companies say it's a big reason they keep raising the price of drugs. You've probably seen a
chart like this before. It's the rise in the
price of a drug in the US, in this case, Humalog, according
to its maker Eli Lilly. Th pharmaceutical company say
they have raise less prices to protect their sales and
profits from the demands of these higher rebates. Here's the CEO of the
pharmaceutical company Merck at a hearing on drug prices. - If you bring a product to the
market with a low list price in this system, you get
punished financially and you get no uptake because
everyone in the supply chain makes money as a result
of a higher list price. - [Presenter] And here's
that Humalog chart again this time with a net price, where the average revenue that Eli Lilly says they take in under this system. For their part, the PBM
say that drug companies don't have to raise prices
to boost their bottom lines and that rebates reduce the cost of drugs, not inflates them. They say rebates reduce the
real cost of prescription drugs because they lower the price
that insurance companies pay. That helps the insurers lower the premiums that the patients have
to pay for their plans. Here's Derica Rice, an
executive vice president at CVS Caremark, one of the
pharmacy benefit managers. - Our job is to work with
the employers, unions, and government programs
who serve to ensure that when their members get
to the pharmacy counter, they get the medicines that they need at the lowest possible cost. - [Presenter] So what
does all of this mean for the patient back at
the pharmacy counter? That the heart of all this
is what the patient pays is often based on the list price, not the price the insurance
company is responsible for after the rebates. And patients who don't have
insurance or coinsurance or who have really high deductibles sometimes pay the entire list price. It's important to know that
the details surrounding rebates are shrouded in mystery. Pharmaceutical companies
and PBMs don't release their rebate data saying it's proprietary. But it's clear that different
people and different insurance companies pay different prices for the same drugs. As you can see, the way
that prices work behind the counter is totally different from how they work in front. (calm techno music)
I'm glad one of the main focus of the video is how these middlemen, the PBMs, are crooks. They even made an advertisement to portray the pharmacists as the rich evil bastard driving around in his Mercedes while you can't afford your medicine.
https://www.youtube.com/watch?v=nazo4LMu6j4
It always drives me absolutely nuts figuring out what's covered and how much it might cost - and I found this video helpful to review part of the problem. Even this description is oversimplified because it leaves off half the rebates up and down.
The drug companies are giving money to the PBMs and the wholesalers to get their products covered. They're also giving money directly to the patients/pharmacies through the manufacturers discount cards.
The PBMs give money to the manufacturers and the insurance companies - and get money from the pharmacies.
The wholesalers give money to the pharmacies and the manufacturers.
The insurance companies give money to the PBMs and pharmacies - and in more ways than one, because they also rebate money back if the pharmacies do other things like send us letters about statins.
The pharmacies get money from the patient and insurance company - but often have to rebate part of the money back to the PBM.
The patient pays money for the drug - but as long as they don't have governmental insurance, can get some or all of that back from the manufacturer through a discount program.
It gets even more complicated when two or more of the above parties are owned by the same company (Like Aetna CVS Caremark merger - soon to be insurance company, PBM, and pharmacy all in one).
In the end, no one has any clue what the net cost is of any given medication, because no one pays the list price for anything (except maybe a cash pay patient). The list price is more of a fiction than the MSRP on a new car - and yet that's what makes the headlines.
We have these discussions periodically on this sub and I'm in strong favor of using every tool possible within this dysfunctional system to save my patients the money while getting them the drugs I think will help them - including heavy use of manufacturers discount cards and (when things aren't covered) GoodRx and similar. But others will argue that is harmful to the system as a whole. What can you do?
It seems like the PBMs (aren't they basically employees of the insurance companies? Why are they seperate?) enable the price spiral.
For germany well basically the prices in the medicin chain are regulated by the state if the medicin needs to be prescribed. There can be different prices for the same thing, but the insurances have a pay-limit (and most of them are an agency).
Video needed the patient screaming at the pharmacist for things 100% out of her control.