Conflict of interest in the pharmacy benefits management industry

"Conflict of Interest in the Pharmacy Benefits Management Industry" is concerned with conflicts of interest encountered by pharmacists working for pharmacy benefit management companies. Pharmacy benefit management companies (PBMs) provide outpatient pharmacy management services to managed health care organizations, employers, state government organizations, and insurers. It is estimated that 100 to 115 million persons in the United States have their health plan's pharmacy benefit managed by a PBM. Three major PBMs were recently purchased by pharmaceutical manufacturers for a collective $12 billion. The pharmacist who works for a PBM faces a variety of potential conflicts of interest. Consequently, key questions include how these conflicts should be understood and appropriately managed. Four analyses of conflict of interest are reviewed, with a focus on the works of Neil Leubke and Michael Davis. The debate between these philosophers centered around a number of key distinctions, including whether objective and subjective interests should count in defining a conflict, and whether the key consideration should be the correctness of decision making or the possible loss of trust from the fiduciary relationship. The author argues that a modified version of Leubke's position is the stronger understanding of conflict of interest. Four practice scenarios shared by PBM pharmacists are evaluated in light of possible conflicts of interest. In each scenario, possible harms to patients and the PBM's customers are reviewed. The author argues that the relationship between the patient and the PBM pharmacist is fiduciary in nature, and consequently, trust is placed at risk when the pharmacist is involved in a conflict of interest. A variety of strategies for managing conflicts of interest are reviewed. These include reliance on personal integrity and a code of ethics, and regulatory controls. With a focus on retaining integrity, maintaining the patient-pharmacist relationship, and appropriately managing drug expenditures, the author argues for a refocusing of the profession's Code of Ethics, the development of professional guidelines, collective action by the PBMs to create ethical standards, and oversight of managed pharmacy by consumers as necessary for the pharmacist to appropriately manage conflicts of interest.