Pharmacy benefit managers (PBMs) are leaving more drugs off their formularies, which may prompt doctors to prescribe drugs that aren’t as effective or are more costly.

PBMs are companies that work on behalf of insurers and negotiate with drug manufacturers to create formularies, which are lists of drugs the insurers cover. PBMs also create lists of the drugs they exclude from their formularies, and these drugs therefore don’t get covered.

When drugs are left off formularies, patients have to pay more out of pocket to get the drugs they need. For those who can’t afford it, that can mean worse health outcomes and higher overall healthcare costs.

Exclusion lists have gotten longer every year, and these most often affect drugs for chronic illnesses, according to research from Xcenda, a pharmaceutical consulting firm owned by drug wholesaler AmerisourceBergen (which is expected to rebrand as Cencora in 2023).

“Who bears the consequences is really the prescriber, from a liability standpoint and also from a patient care standpoint. The patient can potentially have poor outcomes,” Robert Popovian, chief science policy officer at the Global Healthy Living Foundation, a nonprofit that advocates for increased access to healthcare services for people with chronic illnesses, told Healthcare Brew.

Back in the day

Formularies were initially created to make sure doctors prescribed patients the least expensive drugs that were still effective, according to research that Popovian conducted with the foundation in 2022.

PBMs began making formulary exclusion lists in 2011, according to Xcenda. CVS Caremark was the first to do so for the 2012 plan year, followed by Express Scripts in 2014 and Optum Rx in 2016.

Since then, the number of drugs left off formularies has risen sharply. In 2014, at least one of the top three PBMs excluded a total of 109 drugs, and in 2022, that number rose to 1,156, according to Xcenda’s research. In 2023, the top three PBMs each excluded about 600 drugs from their formularies, according to Drug Channels data.

Keep reading here.

Do you work in healthcare or have information about the industry that we should know? Email Maia at [email protected]. For completely confidential conversations, ask Maia for her number on Signal.

On Fridays, we schedule our rounds with Healthcare Brew readers. Want to be featured in an upcoming edition? Click here to introduce yourself.

This week’s Making Rounds spotlights Robert Marty, COO of Pennsylvania-based Case Specific Nutrition, which provides wellness services and medical nutrition therapy. Marty shared how misconceptions about dietitians and corresponding insurance coverage has made nutrition therapy an underutilized service in the healthcare industry.

This interview has been lightly edited for length and clarity.

Tell me more about Case Specific Nutrition’s practice model and your role there.

The reason that our private practice model is something that we’re so proud of—and we are looking to expand—is because healthcare is about trust: You have to hear, see, and understand the person in front of you. That’s where the biomedical model, with the 15-minute primary care physician visit where you’re told to consume less salt or do the Type 2 diabetes diet, is not solving the underlying issue. It is behavioral change, it is motivational interviewing, but then it’s that clinical background that makes sure that everything we’re recommending is based on science.

I do everything that isn’t providing the service: that’s our credentialing with insurance, maintaining licensure, making sure that we’ve got general liability for all our practitioners. It’s going out and talking to employers about their medical benefits, and how meeting with a dietitian or participating in the CDC diabetes prevention program might be covered through their insurance already. The marketing, the onboarding, all that stuff.

What’s the biggest misconception about the work Case Specific does

That registered dietitians are only for people with Type 2 diabetes or professional athletes. Or that a registered dietitian is going to give someone a meal plan and say, “If you can’t do this, I can’t help you.” That is a very outdated perception.

Keep reading here.

Do you work in healthcare or have information about the industry that we should know? Email Shannon at [email protected]. For completely confidential conversations, ask Shannon for her number on Signal.

Pre-travel health screenings and travel insurance are not only for study abroad students.

One-quarter of international travelers required medical attention or hospitalization while abroad, but nearly half did not obtain a pre-travel health screening, according to a 2023 survey of more than 2,000 members of Global Rescue, a medical and travel risk management service provider.

During a pre-travel health screening, travelers meet with a healthcare provider to discuss health issues that may come up during their trip as well as what they can do to reduce health risks, according to Global Rescue.

The CDC recommends that travelers make an appointment for a pre-travel health screening with their primary care provider or a travel medicine specialist at least one month before departure. Doctors can help travelers get destination-specific vaccinations and medications as well as provide guidance on other travel-related risks, including Covid-19. (Meaning there may be more risks than just getting caught in bad weather when paragliding in Interlaken.)

“Certain health conditions and medications can increase your health risks during travel, and these risks will vary by destination, activities, and mode of travel,” Jeff Weinstein, medical operations associate manager at Global Rescue, said in a statement.

The typhoid vaccine was the most commonly administered travel vaccine, according to a 2022 Kaiser Permanente study of pre-travel health screenings at six healthcare systems from 2009–2018. The mean age of the travelers in the study was 42, 56% of the travelers were female, and 42% identified as non-Hispanic white, per the California-based healthcare provider’s study. 

Keep reading here.—KW

Do you work in healthcare or have information about the industry that we should know? Email Kristine at [email protected]. For completely confidential conversations, ask Kristine for her number on Signal.

Today’s top healthcare reads.

Stat: Nearly all US hospital websites (98.6%) have shared patient health data with third-party companies, according to new research. (SC Media)

Quote: “If there is no change in patient care, then the fees seem artificial at best.”—Aditi Sen, a health economist at Johns Hopkins Bloomberg School of Public Health, on hospital bills for telehealth visits (Kaiser Health News)

Read: Mounjaro, Eli Lilly’s Type 2 diabetes drug, could soon be approved as a weight loss solution. (Fierce Pharma)

When it comes to clinical trials—AI has the potential to do a lot of good.

Drug costs are unsustainably high, but using AI in the recruitment phase of clinical trials could play a hand in lowering them.

Learn why recruitment racks up the bills, how AI can be used to cut down on costs, and how soon we can expect to see this innovation in practice.

Find the whole story here.

Catch up on the top Healthcare Brew stories you may have missed:

• eConsults technology shakes up traditional doctor referral process
• Black patients wait longer to see their doc when this scheduling algorithm is used
• How pharmacy deserts are formed