A comparison of mail-service and retail community pharmacy claims in 5 prescription benefit plans.

Background: Little evidence has been presented to date that would either support or refute a widely held belief that mail-service pharmacy utilization routinely produces savings in drug benefit costs for prescription benefit plan sponsors.

Objective: To present a comparative analysis of mail-service and community pharmacy service drug benefit costs for 5 employer-sponsored prescription drug benefit plans.

Methods: A cross-sectional comparison of 17,725 matched transaction pairs of community and mail-service prescriptions from a data set comprised 484,987 prescription claims from a convenience sample of 5 employer-sponsored prescription benefit plans.

Rebates and spreads: pharmacy benefit management practices and corporate citizenship.

How ought we determine whether businesses in the health care sector profit fairly? One class of companies in the health care sector, pharmacy benefit managers (PBMs), deserves special consideration. We describe two specific revenue-generating practices--rebates and spread pricing--that account significantly for PBMs' profits but have been neglected in the bioethics and health policy literature as important sources of fiscal waste in our current health care system. We offer analyses of two common cases, consider employers' and employees' vulnerabilities, explore normative assumptions about how markets function, and raise questions about transparency in contract agreements between PBMs and employers.

Undocumented source of pharmacy benefit manager revenue.

Purpose: The difference between what pharmacy benefit management companies (PBMs) charge prescription benefit plan sponsors and what dispensing pharmacies are paid ("spread") was studied.

Methods: Data from prescription transaction invoices from two large employer groups, each using a different PBM, and 84 community pharmacies (which differed for each employer group due to clear geographic separation) participating in these plans between October 1, 2002, and December 31, 2004, were studied. Detailed community pharmacy payment transaction records were compared with PBM claim records from two employers.

Accounting principles, revenue recognition, and the profitability of pharmacy benefit managers.

Objectives: To contrast pharmacy benefit management (PBM) companies' measured profitability by using two accounting standards. The first accounting standard is that which, under Generally Accepted Accounting Principles (GAAP), PBMs are currently allowed to employ. The second accounting standard, seemingly more congruent with the PBM business model, treats the PBM as an agent of the plan sponsor.

The spread: pilot study of an undocumented source of pharmacy benefit manager revenue.

Objective: To document the difference between what pharmacy benefits management companies (PBMs) charge employers and what they pay dispensing pharmacies for the drug ingredient portion of prescription transactions (the "spre

Design: Descriptive, cross-sectional study.

Participants: Two large employer groups, each of which used a different PBM, and six independent community pharmacies participating in these plans during 2002.

Interventions: Two sets of financial records issued by each of two PBMs were reviewed retrospectively, including 129 line-item prescription transactions billed to the employer and the line-item transaction information that accompanies the PBM payment to the dispensing pharmacy.

Evaluation of cost savings to a state Medicaid program following a sertraline tablet-splitting program.

Objectives: To evaluate the economic impact of implementing a sertraline (Zoloft--Pfizer) tablet-splitting program on the Nebraska Medicaid program based on the change in total and per-member-per-month (PMPM) prescription drug costs and to identify any real or perceived problems with tablet splitting using switches among selective serotonin reuptake inhibitors (SSRIs) as a proxy indicator.

Design: Retrospective study of prescription claims before and after the tablet-splitting program was implemented.

Setting: Nebraska Medicaid.

Examining costs of chronic conditions in a Medicaid population.

Purpose: To compare health care costs and their components in patients with chronic illnesses.

Design: Quasi-experimental retrospective database analysis of an integrated state-Medicaid dataset.

Methods: Nine chronic illnesses and 28 two-disease combinations were evaluated in 284,060 patients.

The cost of diabetes in the presence of comorbid conditions.

Disease management programs usually focus on the target disease, with little emphasis on clinical comorbidity. The research presented here used retrospective analysis to determine the incremental costs of diabetes to a state Medicaid program when diabetes occurred with other common chronic illnesses. The study revealed that the incremental costs of diabetes were influenced by the costs of the chronic illnesses associated with diabetes.