Key players in the US healthcare landscapeby@shashankagarwal

Key players in the US healthcare landscape

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A well-functioning healthcare system working in harmony is constructed and organized based on trained and self-motivated healthcare workers, well-sustained infrastructure, strong health plans, and a reliable supply of cost-effective medicines supported by adequate funding to fulfill the basic needs of the patient. The healthcare landscape consists of a widely complex array of interrelationships among the PBMs, drug manufacturers, physicians and insurance companies. By working together with each other they provide optimal health to the patient at the minimal cost.

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A health care system consists of a myriad of organizations, people, pharmaceutical industries, and actions where the primary aim is to promote, maintain, and restore patient health. A well-functioning healthcare system working in harmony is constructed and organized based on trained and self-motivated healthcare workers, well-sustained infrastructure, strong health plans, and a reliable supply of cost-effective medicines supported by adequate funding to fulfill the basic needs of the patient.

The following are the key players who play a crucial role in developing the overall US healthcare ecosystem.

Pharmacy Benefit Manager (PBM)

PBM, also known as pharmacy benefits manager, acts as a liaison between health insurers and pharmaceutical companies. They serve to develop and maintain formularies, contract with pharmacies, and negotiate drug pricing with pharmaceutical manufacturers, drug wholesalers, and health insurers to be reimbursed from pharmacies and manufacturers on the base of the total sale volume of products. The main purpose of the PBM is to create innovations that allow them to reduce the cost of pharmaceuticals for employers, health insurers, and patients. PBM plays a crucial role behind the scene in facilitating maximum patient access to medications at a lower cost.

Drug Manufacturer

The pharmaceutical manufacturer is involved in the production, extraction, propagation, compounding conversion, and processing of purified and packaged chemical materials to be used as medicine to combat innumerable illnesses and diseases affecting today’s global community. They play a key role in the healthcare ecosystem by researching and testing the particular active ingredients used as a medicine or antidote for certain diseases.

Physician

A physician is a healthcare professional who directly contacts the patient and serves a critical role in the entire healthcare infrastructure. They perform it by maintaining, promoting, and restoring health by, diagnosis, studying, and treating several injuries and diseases based on their specialization. To provide optimum care to patients, physician work with nurses, pharmacists, and other members of the healthcare team to determine the best course of treatment according to a patient’s medical condition and plan a follow-up on recovery.

Health Insurance company

A health insurer is an organization that helps people to pay medical bills by managing the risk of high healthcare costs among a large number of patients by charging them a monthly premium based on their specific demographics. The main purpose of health insurance is to pay for medical facilities by monetary protection to patients with catastrophic health events, broader access to free or low out-of-pocket cost services, negotiation with health companies to make pharmaceuticals accessible at low cost, to enhance and ensure the quality of hospitals and clinicians, and encourage individuals toward staying healthy, etc.

The inter-relationship between healthcare key players

The healthcare landscape consists of a widely complex array of interrelationships among the PBMs, drug manufacturers, physicians, and insurance companies. By working together with each other they provide optimal health to the patient at a minimal cost.

To better understand the complex relationships between various stakeholders in the healthcare landscape, it is essential to follow the flow of funds, drugs, and services among them. A conceptual framework of pharmaceuticals distributed in retail settings is included below :

Source: USC White Paper, 2017. The flow of money through pharmaceutical distribution

Source: USC White Paper, 2017. The flow of money through pharmaceutical distribution


References

[1] Neeraj Sood , Tiffany Shih , Karen Van Nuys and Dana Goldman. June 2017.Flow of money through pharmaceutical distribution

[2] Murray Aitken, Michael Kleinrock, Pennente K. Medicines Use and Spending in the U.S. — A Review of 2015 and Outlook to 2020. Parsippany, NJ: IMS Institute for Healthcare Informatics; 2016.

[3] Aitken M. Medicines Use and Spending in the U.S.: A Review of 2015 and Outlook to 2020. Parsippany, NJ: IMS Institute for Healthcare Informatics; 2016.

[4] Rubenstein E. AMCP Guide to Pharmaceutical Payment Methods. Alexandria, VA: Academy of Managed Care Pharmacy; 2013.

[5] Fein AJ. The 2016 Economic Report on Retail, Mail and Specialty Pharmacies. Philadelphia, PA: Drug Channels Institute; 2016.

[6] Langreth R. Secret Rebates: Why Patients Pay $600 for Drugs That Cost $300. Bloomberg News 2016.

[7] Appleby J. Filling A Prescription? You Might Be Better Off Paying Cash. Kaiser Health News. June 26, 2016.

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