Week 12: PBMs + physical activity Flashcards
(24 cards)
8 things to notice about PBMs
-drug prices
-industry consolidation
-rising fees
-new layers of cost and opacity
-total manufacturer revenue
-drug manufacturer price increases
-brand and generic drug definitinos
-formulary decisions
Who is at fault for drug prices going up?
-PBMs over manufacturers
Rebates
-get one rebate per rx despite day supply
-monthly supply is 12 rebates vs 90 days is 4 rebates
-disregards clinical criteria
-get filled bc PBMs own retails
Industry consolidation
-reduces transparency and raises costs
-top 3 PBMs make up 80% of PBM market
-been consolidating specialty pharmacy and provider services
-creates conflicts of interest between business units, makes harf to trace flow of drug cost funds
Vertical development
-insurer + PBM + speiclaty pharmacy + provider
PBM fees
-rebates have been dec as largest profit portion
-keeping less rebate money
-charge fees to cut into rebates so they’re not actually giving 100% of rebate back to employers
-largest profit from specialty pharmacy
Group Purchasing Orgs (GPOs_
-created by PBMs to keep cost murky
-basically creat another PBM that contracts w drug manufacurers and PBM contracts w them so companies don’t see how many contracts they acutally have
-intermediates between drug manufacturers and respective PBM operations
-5-8% in fees
-help insulate PBM operations from audits and legislative cost remedies while reducing PBM ability to share cost data w purchaseers
Brand and generics
-each PBM follows own definition
-makes formularies hard to audit (pricing and rebates)
-tadalafil: upcharged at PBM owned pharmacy as specialty drug
-pass-through vs spread pricing
-spread: charge employers and pharmacy different rates w/o them knowing
-pass through: transparency and PBM can’t mark up employer for pharma
-BUT PBM owns pharmacy, get to decide what they pay the pharmacy and put all the profit into pharmacy
Formulary decisions
-driven by PBM financial interest, not clinical guidelines
AffiremedRx
-complete ownership and access to all pharmacy benefit data
-report insights
-has lots of in network pharmacies
-will never own mail order or specialty pharmacy = conflict of interest
-focus on local/personal service for members
AffirmedRx cost
-single net cost
-single, fixed fee per script (not %)
-no conflict when building formulary
-full data access, including rebates
-simple contracts
-no hidden recenue
-lower costs, guaranteed
% of americans meeting physical guidelines
-50% reported
-5% acutal
Why physical activity matters
-10% of all premature mortality from failure to meet levels of physical activity
-obesity rate more than doubles
-adolescent rates 4x
-disqualifies 1/3 ages 17-24 from military, only 2/5 qualified
How much physical activity needed
-at least 150 min mod activity per week (150-300 min best benefits)
-strength training at least 2 days/week
-some is better than none
Sedentary behavior inc risk of
-all-cause mortality
-CVD mortality
-HTN
-T2DM
-colon, endometrial, lung cancer
Pharmacists
-most accessible
-see medicare pt 2x as much as they see their PCP
-first line of triage
-lots of counseling
Challenges for physical activity promotion in healthcar
-time
-integration into EMR
-no reimbursement for counseling
-access to professionals: who is an exercise professional?
Physical Activity Vital Sign
-how many days, how many minutes
-let em read the guidelines
mod intensity
-3-5.9 METs
-5 or 6/10
vigorous intensity
-6+ METs
-7-8/10
Talk test
-mod intensity: can talk, can;t sing
-vig: cannot say more than few words w/o breath
ONE MET
-energy spent sitting at rest
=resting/metabolic rate
-2: light gardening, chores
-3: walking
-4: salsa
-5: softball, 3-4mph, mowing, biking
Physical Activity Readiness Questionaire (PAR-Q)
-age
-exercise capabilities
-prescribe activity (more adherence)
