Getting a medication that is prescribed by your doctor should be an easy transaction right? Step 1. Bring prescription to pharmacy. Step 2. Pharmacist gives you medication. Well, like most things in healthcare these days, even the transaction of filling a prescription is a complex tangle of relationships involving middlemen, contracts, negotiated costs, and rules that, often times, patients aren't entirely given. Patients are at a disadvantage when they play this prescription-pharmacy-insurance game because most patients really only understand a fraction of the rules and so commonly end up with penalties such as very high costs for prescriptions, denied approvals for certain medications, or worse, patients ultimately just give up playing the game completely because it's all just too complicated.
A shift in healthcare is happening though. The increasing dissatisfaction felt for these unnecessarily complex healthcare transactions is providing fuel for change. There seem to be two common themes emerging in this renaissance of healthcare consumerism: transparency and simplicity. I wrote a blog post in 2019 on other ways to pay for prescriptions besides presenting your health insurance card at the pharmacy window and playing "what am I paying today?" roulette. I encourage shopping around for the best prices for your prescription medications using now familiar apps like GoodRx and RxSaver or taking advantage of free medication lists at big box retail pharmacies like Publix. Many direct primary care clinics like my own (Cardona Direct Primary Care) have small pharmacies on-site. Patients are able to fill prescriptions at significantly reduced prices from these on-site pharmacies as a benefit of their direct primary care membership. But more and more options continue to become available for patients.
Last month Mark Cuban, American billionaire who is known to many as the owner of the professional basketball team Dallas Mavericks or to others as an investor on the reality TV series Shark Tank, launched the online pharmacy Cost Plus which was born months after he launched the Mark Cuban Cost Plus Drug Company (MCCPDC), a pharmacy benefit manager. According to the pharmacy's website, the mission is for every American to have access to safe and affordable medicines. Mark Cuban and his pharmacy hopes "to dramatically reduce the cost of drugs" and "introduce transparency to the pricing of drugs so patients know they are getting a fair price."
Traditionally, a PBM (pharmacy benefits manager) is the third-party entity that is central to your prescription drug plan. Every health plan has a PBM to manage its prescription drug programs. Examples are: CVS Caremark, ExpressScripts, OptumRx, PrimeTherapeutics. The PBM has three main functions:
negotiate contracts with pharmacies, negotiate contracts with drug manufacturers, and manage prescription claims payments for insurance companies. The PBM is the middleman who manages the prescription side of your healthcare plan but it doesn't do it for free. The PBM gets paid by the insurance company, the pharmacy, and the drug manufacturers. And ultimately, some of their costs will trickle down to.... you guessed it... YOU.
In Mark Cuban's new venture however, Mark Cuban IS the PBM and Mark Cuban IS the pharmacy. And Mark Cuban is already a billionaire. So now he just is trying to negotiate prices with the drug manufacturers for the lowest prices and his company's goals are to keep the prices transparent to the patient and pass those prices on to you, with the exception of an additional nominal pharmacy fee and 15% markup. On top of this, Mark Cuban has plans to complete a 22,000 sq ft pharmaceutical factory in Dallas by the end of this year with the hopes of providing even better prices for the patient.
In 2022, there are so many more options for affordable prescription drugs that presenting your health insurance card at the pharmacy window might very well be your least attractive option. SHOP AROUND. Know that you have options. Choose where and how you will fill your prescription. In 2022 it is easier to find out the actual price of your medication BEFORE you are standing in line at the pharmacy wondering what it will cost when you get to the cash register. With all of these advances there still is, however, a very long way to go with prescription drug costs in a number of areas (i.e. the number of affordable, generic respiratory medications or diabetes medications available significantly pales in comparison to the large numbers of brand-name, expensive respiratory and diabetes medications that are often recommended in current clinical practice guidelines). As quickly as the landscape of healthcare consumerism is changing though, there certainly is potential for even those drug costs to be tackled as well. Maybe that will be on Mark Cuban's 2023 to-do list.
Comparison of 90-day supplies of commonly prescribed prescription medications using GoodRx app, prices listed on Cost Plus pharmacy website , and current prices for Cardona Direct Primary Care patients on-site pharmacy
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