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This volume analyzes group purchasing organizations (GPOs) and pharmacy benefit managers (PBMs) in order to better understand the significant roles that these entities play in the healthcare supply chain. It examines who they contract with, on what terms, and who they represent and answer to while charting their historical development. The analysis reveals that the current roles of both players have historical roots that explain why they behave the way they do. Finally, the book reviews the evidence base on the performance results of these two players.

This work fills a void in our understanding about two important and controversial players in the healthcare value chain. Both organizations are cloaked in secrecy - partly by virtue of the private sector contracts they negotiate, partly by virtue of the lack of academic attention. Both play potentially important roles in controlling healthcare costs, albeit using contracting strategies and reimbursement mechanisms that arouse suspicion among stakeholders. This timely text explicates how these organizations arose and evolved to shed more light on how they really operate.

The Healthcare Value Chain: Demystifying the Role of GPOs and PBMs

Chapter 1        Introduction to the value chain

a)      What is a value chain

b)      How does a value chain work

c)      Value chains versus supply chains

d)      Issues with the term "value"

e)      Balancing cost, quality, and access to innovative products

 

Chapter 2        Introduction to the intermediaries in the healthcare value chain

a)      Number and range of intermediaries

b)      MCOs, PBMs, GPOs, wholesalers

c)      Nagging questions about value added by intermediaries

d)      Continuing calls and efforts to "dis-intermediate" the intermediaries

 

Chapter 3        Overview of GPOs

a)      What are GPOs

b)      Types of GPOs in healthcare

c)      Goals of GPOs

d)      Confusing GPOs and IDNs (integrated delivery networks)

 

Chapter 4        History of GPOs (co-authored with David Cassak)

a)      Early history of groups: 1910-1950s

b)      Rise of local shared service organizations: 1960s-1970s

c)      Emergence of contract compliance

d)      Emergence of product portfolios

e)      Rise of national and regional groups: 1970s-1980s

f)       Desperately seeking compliance: 1980s-1990s

g)      Dealing with healthcare reform, capitation, and managed care: 1990s

h)      Competitive threat posed by IDNs: 1990s

i)        Competitive threat posed by Columbia/HCA

j)        Group mergers: 1990s

k)      Aftermath: Consolidated vendors, consolidated buyers

l)        Value and performance challenges in the new millennium

m)   Senate hearings overview

n)      Group mergers in the new millennium

o)      Growing threat of regional GPOs

 

Chapter 5        Performance of GPOs

a)      GPO operations and strategy

b)      Hospital prices

c)      Value of group purchasing

d)      GPO fees

e)      GPO contracting practices

f)       GPO customer service and satisfaction

g)      GPO clinical review processes

h)      GPO oversight, codes of conduct, and self-regulation

i)        GPO competition: national and regional

 

Chapter 6        Analysis of Specific GPO Issues

a)      Price transparency

b)      Exclusionary agreements

c)      New market entry and access to innovative technology

d)      Differentiation versus commodification of GPOs

e)      Drug shortages

 

Chapter 7        Overview of PBMs

a)      What are PBMs

b)      Goals of PBMs

c)      Range of PBM functions & services to employers/insurers

d)      Types of PBMs in healthcare

e)      PBM business models

f)       Types of formularies and fees

g)      Relationship between MCOs and PBMs

h)      Direct versus indirect contracting for PBM services by employers

i)        Growth of PBMs tied to rise of outpatient care and IPAs

 

 

Chapter 8        History of PBMs

a)      Early PBMs (PCS, Medco) and claims administration: 1960s-1970s

b)      Early PBMs (DPS, Pharmacy Gold) as pharmacy departments in staff model HMOs

c)      Online claims processing and efficient benefits administration: 1980s

d)      Role of HMOs and PBMs as countervailing power to Big Pharma: 1980s

e)      Rise of mail-order pharmacies: 1980s

f)       Shift to include cost and clinical controls in 1990s (e.g., tiers)

g)      Vertical pharma-PBM mergers in early 1990s

h)      Regulatory and government scrutiny of PBM mergers

i)        New PBM functions in formulary design, DUR, & disease management

j)        Growth of PBM covered lives & growth in pharmaceutical benefits by employers

k)      Vertical mergers of PBMs with retail pharmacies (Rite Aid-PCS; CVS-Caremark): 1990s and 2000s

l)        Horizontal consolidation of PBMs (ESI-Medco) in the new millennium

m)   Government scrutiny of PBMs as possible source of high drug costs

n)      PBMs and pay-for-performance models

 

Chapter 9        Performance of PBMs

a)      Issues in measuring PBM performance

b)      Market share trends: script volumes and covered lives

c)      Prescription drug management indicators

d)      Impact of GPO rebates on Medicare Part D premiums

e)      Rise in formulary exclusions

f)       Trends in out-of-pocket drug spending

g)      Trends in employers' receipt of PBM rebates

h)      Trends in percentage change in list and net drug prices

i)        Trends and sources of rising PBM profits

 

Chapter 10      Analysis of Specific PBM Issues

a)      Uneasy relationship between PBMs and Big Pharma

b)      Rising drug prices

c)      Lack of transparency

d)      Insourcing versus outsourcing the PBM function

e)      Competition for PBM contracts

f)       Role of PBMs in opioid epidemic