The U.S. pharmacy benefit management (PBM) market size is to reach USD 700 billion by 2025, growing at a CAGR of 7% during 2020-2025. The United States healthcare landscape is complex. It is riddled with wastage, drug abuse, and fraud due to a whirlwind of causative factors, putting patients at risk and creating a dilemma for insurers. It translates to high out-of-pocket costs, increased incidences of inappropriate spending, higher premiums, reduced benefits or coverage for consumers, increases cost of doling out insurance benefits for governments, and private employers. With a high number of consumers being enrolled in high-deductible health plans, there is a need for coordinated and broad effort to fix loopholes. Pharmacy benefit managers are well-positioned as patients advocate to work with players across the board, with every member in the healthcare industry. PBM pharmacists can witness a complete picture of the member’s medication background. This has enabled them to drive awareness among pharmacists and doctors/physicians to identify challenges and enable the delivery of better treatment through better communication and care coordination across the healthcare continuum for each patient.
- The specialty pharmacy services segment is expected to witness an incremental growth of over $51 billion by 2025 due to the increased importance of drug utilization review, patient education and management, compliance monitoring and clinical intervention, and clinical reviews.
- The healthcare plan segment is projected to observe an incremental growth of over $81 billion on account of the growing adoption of employer-sponsored health insurance plans.
- With the annual healthcare waste accounts for $935 billion, PBMs, which are increasingly turning to data and evidence-based approaches, can go a long way to correct the wrong practices in the healthcare industry.
U.S. PHARMACY BENEFIT MANAGEMENT MARKET SEGMENTATION
This research report includes a detailed segmentation by
- Health Plan
- Business Model
U.S. PHARMACY BENEFIT MANAGEMENT MARKET INSIGHTS BY SERVICES
Specialty pharmacy - a segment of the U.S. Pharmacy Benefit Management market, which is a collaborative, clinical, integrated environment, is recording significant growth in the US pharmacy benefit management market. The segment has cemented its place in the continuum of healthcare, backed by a healthy level of activity in payer access and data systems. As specialty drugs have outpaced all the other elements of healthcare costs, the segment is keeping payers’ on the edge of their seats. Since specialty pharmacies and mail-order pharmacies operate on a similar model in terms of medication deliveries. There are apprehensions about conflicts of interest and about how PBMs tag specific drugs as “specialty.”
The growth of huge retail networks and mega-mergers is leading to consumer health engagement in a retail setting from getting OTC medicines to having lab tests by clinicians. The patient-pharmacist connection and face-to-face interactions are more prevalent and pronounced than ever as the latter has become critical in driving up the likelihood that patients take medication as prescribed by their doctor. This, along with the threat from Amazon’s entry, has driven more interest in the retail environment as a hub for health and engagement among managed care executives. As a result, the retail pharmacy services segment is poised for strong growth during the forecast period.
INSIGHTS BY HEALTH PLAN
Drugs, which treat auto-immune conditions, are growing at the fastest rate in commercial health plans. With emerging therapies that come at a high cost, the per-member, per-month spending on these therapies has witnessed an upward trend over the past couple of years. The increased focus of commercial health plan providers is on monitoring use and keeping the cost of drugs in check. This has led to an increased focus on utilization monitoring and formulary design, driving better prospects for the segment.
Commercial plan sponsors are also looking to increase resources to help employees access behavioral and mental health services as they struggle with maintaining the usefulness of prescription management services. The enrollment in Medicare Part D plans has grown 2X times over the last 15 years. Seeing as Medicare is designed to absorb risk, providing for individuals with complex, expensive medical needs, along with relatively healthy individuals, these plans rely heavily on PBMs.
While mid-sized firm interest in the same has subsided, large firms have increasingly distanced themselves from these plans. In 2018, almost 63% of insured US employees were covered by these health plans - 14% of covered employees in small and 79% in large firms. A good share is occupied by companies that carve out their pharmacy benefits, naturally, seeing as these employers assume the risk and pay for the most of their covered drug benefits. Overall, 73% of employers spend 15% or more of their healthcare budgets on pharmacy benefits, and this can go up to 28%, and specialty drugs are driving this segment. Specialty pharmacy services are thus a lucrative segment in the U.S. pharmacy benefit management market.
INSIGHTS BY BUSINESS MODEL
The U.S. pharmacy benefit management market is well backed, fortifying future growth by ramping up the capital investment in data analytics capabilities and technology R&D. As employers continue to concentrate on whole-person health, providing a total benefits solution, which is vital to draw and keep talent, this segment is expected to grow.
As insurance companies launch new products for gene therapies, they are considering offering therapy management techniques. The key market players are keeping a tab on the gene therapy pipeline and tracing patient outcomes, which are being used as a starting point for value-based arrangements that the company is on with pharma manufacturers. This is drawing attention, particularly from employers, creating favorability for players with these business models. The US pharmacy benefit management market is highly fragmented.
INSIGHTS BY VENDORS
The U.S. pharmacy benefit management (PBM) market share has changed considerably in the last couple of years, where acquisitions led the market to where it is today, occupied mostly by a couple of giants. As a result, the PBM industry is highly concentrated with Caremark, Express Scripts, and OptumRX, accounting for more than 70% of claims volume. They have been the shapeshifters in the PBM space. However, that again is changing as insurers have been building their presence in the market by dissolving existent relationships with PBMs and acquiring or launching their own.
- CVS Caremark
- Express Scripts
- Humana Pharmacy Solutions
The U.S. pharmacy benefit management industry report includes in-depth coverage of the industry analysis with revenue and forecast insights for the following segments:
By Health Plans
- Commercial Health Plan
- Self-insured Employer Plan
- Medical Part D Plans
- Managed Medicaid Programs
- Specialty Pharmacy Services
- Retail Pharmacy Services
- Mail-order Pharmacy Services
- Benefit Plan Design & Administration
- Formulary Management
- Clinical Programs & Services
By Business Model
- Insurance Companies & Retail Pharmacies
- Pure Play PBMs