Former PBM chief medical officer: ‘Our motives were murky at best’

There are a few days I’ll never forget from my years as chief medical officer at Express Scripts, one of the nation’s largest pharmacy benefits managers (PBMs).

One day I walked into the corporate cafeteria and Alex, a senior salesperson, was sitting in front of a pile of papers he’d spread across an entire table. He was clearly struggling with an important decision. 

“What are you working on?” I asked Alex. 

“I’ve got a major client presentation tomorrow and I just can’t decide if I should pitch ‘safer and more affordable’ or ‘alignment’.”

We both laughed at the absurdity of the game we were playing.

“We make the use of prescription drugs safer and more affordable” was a mantra we had cooked up to prove the value of companies like ours to federal legislators when they were crafting Medicare Part D. We desperately wanted them to see how vital PBMs were to the pharmaceutical industry, so that they wouldn’t decide to cut out the middleman, to “disintermediate” us. 

Were they to allow Medicare to negotiate directly with pharmaceutical manufacturers, we claimed, they would be unwittingly ceding the tremendous cost savings and safety benefits we provided ... and, of course, stop us from taking our cut out of the middle. We very much wanted any Medicare prescription drug benefit to support commercial profiteers like us rather than some streamlined, simplified universal program run by the federal government on behalf of all Medicare beneficiaries. 

Both claims – safer and more affordable – were ridiculous. And yet, I believed them both.

As chief medical officer, one of my lookouts was improving the safety of the use of prescription drugs. We constructed elaborate evidence-based systems to notify dispensing pharmacists when we had reason to believe a patient was potentially filling prescriptions for medications that might have a dangerous interaction with each other, or with an illness we inferred from their prescription profile. Our claim was that by sending these alerts to the pharmacist at the moment of filling the allegedly risky medication, the pharmacist could do some research, query the patient, call the prescribing physician, or just not fill a dangerous medication.

The catch was we couldn’t demonstrate this was helping.

For those interactions we were particularly worried about, we introduced a “hard block” that required the pharmacist to enter a code and tell us which of those interventions they took. Hurrah, evidence of our improving the safety of medication use. The dirty little secret was that pharmacists were paid on production and didn’t have time for this foolishness. We were able to measure that it was roughly one second between our alert and the pharmacist reporting their actions addressing our alert. In other words, they were ignoring us.

Pharmacists are among the most conscientious and thoughtful professionals I’ve ever worked with. Our PBM’s system, however, was almost entirely redundant with the system their own pharmacy provided. Granted, we were able to provide data from across retail outlets, but that’s not something that requires a massive profit-centric intermediary.

My sales friend Alex and I both knew that our claim of “safety” was pretty thin.

How about “affordable”? It’s true that PBMs negotiated lower prices than the manufacturers wanted, but we typically kept most of those rebates along with a percentage of the total cost. Ultimately, for us to make any money, patients had to spend money at a pharmacy. No drugs, no margins or profits. Our motives were murky at best. 

I never heard how Alex resolved his dilemma.

We proudly proclaimed that our enterprise valued “alignment” with our clients –  the businesses that contracted with us to manage the pharmacy benefit they offered their beneficiaries (e.g., employers, unions, government agencies.) Our claim was that we made money when our clients saved money, proudly pointing to our clinically sound formulary, patient-friendly programs to encourage prudence, and business model that gave us larger margins on less expensive medications. We never pointed out that we only made money when patients filled prescriptions, and that even a smaller percentage of margin on a very expensive drug was more favorable to us than a larger percentage of a less expensive drug. 

You can see why Alex was struggling to pick the best misleading message for his client.  

I also remember the day our too-clever head of marketing had prepared a meeting of hundreds of sales staff with a piece of paper on every chair. He had written out a proposal for our company’s guiding values, the kind of salute-the-flag, mom-and-apple-pie stuff that could inspire and arm the legions of sales folks in their quest to differentiate us from our competition. 

Everyone read it, heads nodding in approval, and we all declared his genius in so clearly spelling out our aspirations.

The big reveal was that this proposal was lifted directly from one of our competitors. Even we didn’t see any real difference between us. 

None of this bothered me at the time. Supporting my company was almost a sport, a game to see if we could succeed over our competitors in capturing PBM market share. And why not play that game; I thought that there would never be the kind of fundamental reform that actually made a difference, and maybe we were accomplishing some good.

That all changed for me with the election of President Obama in 2008. I realized that things I’d thought impossible were perhaps actually worth working towards. That perhaps our nation could confront the fragmentation and profiteering that renders American health care twice as expensive as it is elsewhere in the world, that perhaps we could put an end to the plague of tens of millions of Americans who can’t afford their rent, their food, their children’s school books, and their insulin. 

Perhaps, just perhaps, it was time to start fighting for the only health-care system yet to be adopted in the USA – universal coverage through a single payer national health program. 

That inspired me to study the economics, logistics, health impact, and frankly the politics of the single-payer movement, and I decided to work as hard towards that end as I can. 

After practicing family medicine for 20 years at Rush Medical Center in Chicago, Ed Weisbart moved to St. Louis in 2003 to serve as chief medical officer of Express Scripts until retiring in 2010. Weisbart serves as president of Consumers Council of Missouri, a non-profit organization that works to build a more inclusive and equitable community through advocacy, coalition building, collaboration, and community education. He also is the national board secretary and Missouri chapter chair of Physicians for a National Health Program, a non-profit non-partisan organization of more than 25,000 physicians and other healthcare advocates in support of a publicly financed, non-profit single-payer national health insurance program that would fully cover medical care for all Americans.