The whole system is incredibly f'ed up by bureaucracy because no one pays for themselves.

Healthcare costs are subsidized at a 90% rate on average in the U.S. That is, only 10% of health costs are paid out of pocket by the healthcare consumer.

Now, think about any other thing you buy in your life. How f'ed up would your demand for a product be if it was subsidized at a 90% rate? If a Lambo cost went from $200,000 to $20,000, the question won't be "When Lambo" it will be "How many Lambo".

The need for things like PBM is because of this f'ed up system.