PBMs must be included in drug pricing discussion

Greater transparency and competition are necessary, agreed Members of Congress and witnesses during a Republican-only forum on the Role of Pharmacy Benefit Managers in Pharmaceutical Markets. The forum was held by the House Committee on Oversight and Reform.

“PBMs have consolidated from more than 20 regional and national players, to 3 that control roughly 80% of the market,” said Ranking Member James Comer (R-KY). “Every major PBM owns or is owned by a specialty, mail-order, or retail pharmacy, or all three.”

This consolidation and vertical integration has led to higher costs: “only the highest-priced interchangeable insulin can gain formulary access; other, cheaper biosimilar insulins are kept off formulary,” said Dr. Madelaine Feldman of The Rheumatology Group in New Orleans.

It also diminishes choice, as PBMs limit independent pharmacy participation and engage in patient steering, said Tiffany Jones of specialty pharmacy Senderra.

“Sick and vulnerable patients are threatened that they will lose coverage of drugs if they don’t comply” with requests to transfer prescriptions back to the PBM’s owned pharmacy, she said.

Step therapy, or the idea that patients must “fail first,” can harm patients further: “You basically have to have two violent attacks of vomiting before you get the drug that could have stopped it in the first place,” said Ted Okon of the Community Oncology Alliance.

Rebates have more than doubled over the past decade—but they aren’t getting to patients, explained USC’s Dr. Erin Trish. “While this has helped keep Part D premiums low, it means that beneficiaries pay more out-of-pocket at the pharmacy counter.”

In addition to greater transparency and competition, we need to pass rebates to patients at the pharmacy counter—watch to learn more.

Why it matters: The House is getting ready to pass drug price controls, yet “Democrats have decided to limit their drug pricing investigation to only pharmaceutical companies leaving a significant void in in the Oversight Committee’s review of drug pricing and many unanswered questions,” said Ranking Member Comer.