The American drug system is extremely complex due to the presence of many stakeholders along with a lack of transparency. There is a dearth of choice as the drugs that get the spotlight in the market are decided not by consumers but by those involved in the pharmacy industry. Consumers are becoming more conscious in the way they engage in prescribed drug and health plan purchases. All this is creating a space for operators to build models and enable higher visibility, choice, and transparency in the prescription drug marketplace. Pharmacy benefit management are operators tasked with the responsibility of fulfilling these needs. For a long time, they were familiar only with the insiders and now their roles and impact are under the spotlight. Furthermore, claims processing has been the core service offered by PBMs, and the market is heavily commoditized. Total pharmacy claims volume is increasing, driving the growth of this segment. Six PBMs process more than 95% of prescription claims in the US.
Pharmacy network contracting space is also becoming increasingly sophisticated as players focus on adding granularity for better management of real-time pharmacy payments. Some of the segments in the pharmacy benefit management market are witnessing a lot of dynamism and faster growth trajectory. As drug prices used to treat complex or rare conditions are becoming more demanding for payers, patients, and providers, it is driving the specialty pharmacy segment upward. It is consequently creating a need for new ways to safeguarding patients by expanding access to their prescription drugs. The pharmacy benefit management market in the US is expected to reach USD 700 billion by 2025, growing at a CAGR of 7% during the forecast period.
Market Insights Include:
- The expensiveness and lack of transparency in the current medical system in the US has driven up dependence on healthcare system and lead to costs spiraling out of control. This is driving demand for pharmacy benefit management (PBM) to help stem costs.
- PBMs are reinventing themselves and reinforcing the roles they play in the healthcare system by shifting from a siloed mindset to vertical integration by combining with specialty pharmacies and insurers.
- The future of PBMs is going to be dictated by the implementation of state and national-level policies with respect to revenue streams and business practices in the pharmaceutical space.
Increased Engagement in High-Touch Care Management
Inflexible formularies overlook the issues of the total cost of care and inappropriate medication utilization. The slew of attacks on pharmacy benefit management in the media regarding their profit-making practices and intransigent formularies that slip up on improper medication utilization has led players wanting to change their narrative. As a result, they are increasingly considering to offer high-touch care management that allows them to closely engage in patient care. The cost management and quality are interlinked, dabbling actively in-patient care is a natural extension for these players. While high-touch care management is not a new concept in the healthcare industry, it is certainly fresh in the PBM space. Since most Americans receive prescription benefits via a PBM, their role in orchestrating the care of a patient on the front lines has largely been underutilized in the past. High-touch decision support tools have also come into the picture, which are intended to help physicians to order complex drug regimens and ensure they are appropriately utilized. Furthermore, there is a lag in terms of knowledge, general education, training, and reassurance of technique on self-administered injectables and specialty drugs. All these factors offer opportunities to improve patient experience and outcomes while curbing healthcare costs. Pharma benefit managements can use high-touch care management to raise their competitive edge, and as a result, more and more players are compelled to find their position in this style of management.
Competitive Landscape in the US Pharma Benefits Management
The pharmacy benefit management market’s competitive landscape consists of players that are independently owned and operated, and players that are subsidiaries of major drug chain stores or managed care plans. While standalone players serve health plans, employers, and unions, health insurer owned PBMs mainly serve their plan members. The competitive landscape of PBM has changed considerably from the last couple of years, where acquisitions led the market to where it is today and occupied mostly by a couple of giants. Recent entrants that have made a mark in the market are few in number. PBMs are expected to witness a more competitive and challenging atmosphere due to increased consumer pressure, political pressure, legal scrutiny, and due to the forces of new, innovative players in the health care space. If manufacturers and PBMs could team up instead of fighting over profits, creating patient-centric solutions, that would serve both these healthcare players well.
FAQs about Pharmacy Benefit Management in US:
Q. What is the market size of the US pharmacy benefit management?
A. The US pharmacy benefit management market size will reach revenue USD 700 billion by 2025.
Q. What is the market growth of US pharmacy benefit management?
A. The US pharmacy benefit management market is projected to grow at a CAGR of over 7% during the forecast period.
Q. What is the global market segmentation of the US pharmacy benefit management?
A. The US pharmacy benefit management market is segmented by services, health plan, and business model.
Q. What is the market insight of the US pharmacy benefit management?
A. The increasing integration of pharmacy and medical benefits is gaining immense traction in the US pharmacy benefit market.
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