Pharmacy benefit managers could soon get back in the hot seat
As key lawmakers prepare for the new Congress, at least one industry will be caught in the crossfire: pharmacy benefit managers.
Prescription drug brokers are essentially third parties that help administer prescription drug benefits on behalf of both general and commercial insurance companies. Some senior lawmakers have already pledged to oversee results-based management practices, accusing them of contributing to the high cost of drugs.
While they do this, the main PBM lobby – and Pharmaceutical Care Management Association — prepares to advance a political agenda as she maintains that the industry is helping to lower costs for patients.
That dynamic is just the latest shot in the years-long drug pricing wars, as lawmakers drag CEOs before congressional committees and launch investigations in attempts to demystify the nation’s complex pricing schemes. But even when lawmakers in both parties agree that they want to address an issue, that doesn’t mean they’ll be able to craft bipartisan legislation that can pass a divided Congress. And some experts want to make sure that lawmakers don’t let other industries off the hook as they seek to scrutinize PBMs.
- “PBMs are not, in fact, the only reason patients can’t afford their medications, And so the effort by some members of Congress to focus on results-based management as the primary bad actors I think is incomplete,” he said. Rachel Sachs, Professor at Washington University School of Law in St. Louis. “But certainly results-based management reform must be part of a broader investigation.”
Pharmacy benefit managers are No stranger to the spotlight, Audit tends to revolve around several different tactics.
For example, this criticism fell on a practice known as spread pricing, when PBMs charge their payers more than they pay the pharmacy and keep the difference. Lawmakers also called for the introduction of bills aimed at Spread pricing ban – which the industry claims could be an important ‘risk mitigation model’ for results-based management – and require public disclosure Of the total amount of rebates that manufacturers pay to PBMs, how much of that is then transferred to health plans.
On Capitol Hill, some lawmakers are preparing for their attacks amid an ongoing investigation by Federal Trade Commission.
- Rep. James Comer (R-Ky.), chairman of the House Oversight and Accountability Committee, plans to hold During a hearing regarding drug intermediaries early in the 118th Congress, he told The Health 202 in a statement.
- Rep. Buddy Carter (Republican), Pharmacist W frequent PBM critic, He said in an interview that he plans to launch Congressional Patient Access Conference, which will focus on results-based management initially, although its eventual scope will be broader.
- Other lawmakers have expressed interest in addressing the industry, while noting their focus could be broader as well. President of the Senate Finance Ron Wyden (D-Ore.) “is deeply concerned with the behavior of PBM” and is “committed to taking responsibility for all drivers of drug price hikes that harm American families, including pharmacy benefit managers,” said a committee spokesperson. Meanwhile, Republicans will “prioritize making healthcare and prescription drug costs more affordable,” including working on measures related to PBMs, per Energy and Trade House official speaker.
JC Scott, He wants the industry to take advantage of the moment, says the PCMA’s president and CEO – and avoid the “finger pointing” and “blame game” often seen in the drug supply chain.
“For me, it’s an opportunity to do a better job of educating policymakers, Capitol Hill, the administration, and others about who we are, what we do, and the value that results-based management brings to the health care system,” he said.
The trade group plans to unveil a political platform with its own ideas on how to increase affordability. Scott did not elaborate on these proposals, but referred to the idea of promoting competition in the market and “addressing[ing] places where the system is gamed,” specifically citing the eradication of the patent jungle as drug companies allegedly file Several patents on the same product.
- “I hope it’s an inflection point where the supply chain can all focus on more constructive tactics focused on specific policy solutions,” Scott said.
Slipping into measles vaccinations in kindergarten sounds the alarm
just about 93 percent From the American Kindergarten Complete vaccination against measles During the 2021-2022 school year, more than 250,000 Children at risk of fatal disease, our colleague Lina H. Sun reports.
It is the second year in a row that measles, mumps and rubella coverage has fallen below 95 percent The level required to prevent the spread of the virus in the community, according to a report Released yesterday by Centers for Disease Control and Prevention.
While a two percentage point drop in measles vaccination rates may seem insignificant, even the smallest drop allows the virus to spread more quickly, causing outbreaks in groups of unvaccinated children, Lina notes.
- Immunization coverage among kindergarteners has fallen below 90 percent in D.C. and nine states, Including Ohio and Minnesota, where Measles disease outbreak More than 100 children fell ill last year.
- Kindergarten vaccination rates also continued to decline For three other childhood vaccines to prevent diphtheria, tetanus, pertussis (DTaP), polio, and chickenpox.
why does it matter: Recent data underscore concerns that growing parental resistance to routine immunizations for children is fueling a The resurgence of vaccine-preventable diseases. The pandemic has inflated the issue due to the politicization surrounding it Corona Virus Vaccines, the ongoing consequences of closing schools and reducing the number of children going to the doctor at the height of the pandemic.
Dan Keating from The Post:
The Maine health official has been named the CDC’s second in command
Nirav Shah He is leaving his position as Maine’s top infectious disease official to serve as senior deputy director of the Centers for Disease Control and Prevention. he will Start in MarchMaine. Janet Mills (d) announced yesterday.
Shah, who has led the state’s coronavirus response as director of the Maine Center for Disease Control and Prevention, will replace Debra Houry as CDC Director Rochelle Walensky‘s second in command. His appointment comes amid a major shakeup at the agency following sharp criticism of the agency’s handling of COVID-19 and a record smallpox outbreak last year.
California is suing insulin makers over alleged price gouging
This item has been updated with a response from OptumRx.
California is suing a group of the nation’s largest insulin manufacturers and pharmacy benefit managers, accusing them of using “illegal, unfair and deceptive” practices to cost raise Of life-saving diabetes medication, Attorney General Rob Ponta (d) announced yesterday.
suit claim it Eli LillyAnd Novo Nordisk And Sanofi – who turns together 90 percent of global insulin supplies – and PBMs CVS CaremarkAnd express scripts And optumRx Taking advantage of their market power to inflate the price of insulin “closely to each other,” a violation of the state’s unfair competition law.
Bonta is seeking further court action to prevent future violations of the law as well as unspecified damages to California residents who overpaid for insulin.
Daphne DorseyEli Lilly, associate director of media relations at Eli Lilly, said the company was “disappointed by the California attorney general’s false accusations.” She said the average monthly cost for a nightly insulin is $21.80Urge anyone over paying $35 per month for Lilly insulin to contact the company.
In an emailed statement, OptumRx said it “welcomes the opportunity to show the California Attorney General’s office, just as it has done for other state attorneys general, how we work every day to provide people with access to affordable medication, including insulin.” None of the other drug companies or PBMs responded to The Health 202’s requests for comment.
The bigger picture: Attorneys general in Kansas, Arkansas, Mississippi, Minnesota and Kentucky have them Similar lawsuits have been filed In recent years, they have all accused companies of abusing their power to stifle competition and increase their profits by inflating the cost of real estate, News agency reports.
Health Access CA, the California healthcare consumer advocacy organization:
It is clear that insulin companies and PBMs are using their monopolistic market power to drive up costs, forcing some to ration or even travel to other countries to get their medication.
We salute this move @employee And we will fight to lower pickup costs for all Californians! https://t.co/KveGhN0xWE
– Health Access CA (healthaccess) January 12, 2023
From the notebooks of our correspondents
Our colleague Lina H. Sun out this morning With step by step guide Make an easy-to-assemble, inexpensive portable air filter using materials found at a hardware store or online.
Do not consider yourself handy? Do not do Lena, but with a little time, and pebbles a lot From duct tape, you’ll be breathing cleaner air in no time.
why does it matter: Corona virus will not go away soon. And while vaccination, rapid testing, and masking are important tools for protecting against disease, improving indoor air quality is one of the safest ways to limit the spread of the virus (check out Health 202’s coverage of this issue. here).
scientists in National Institute for Occupational Safety and Health Tested the effectiveness of do-it-yourself air purification units, incl Corsi Rosenthal Fund made by Lena, have helped reduce exposure to respiratory aerosols such as covid-19, and their study found that DIY units “reduced exposure to aerosols up to 73 percentdepending on the design, filter thickness, and fan airflow.
We know what we’re going to do this weekend. Give it a try and let us know how it goes at McKenzie.Beard@washpost.com.
- Ohio Federal Court of Appeals It upheld a lower court ruling Preventing the Biden administration from enforcing a coronavirus vaccine mandate For workers who contract with the federal government in Kentucky, Ohio, and Tennessee, Bloomberg Law reports.
- A former nurse practitioner at CVS Health he is He filed a lawsuit against the pharmacy chain Claiming discrimination against her religious beliefs after she was expelled for refusing to prescribe contraceptives, according to the lawsuit filed yesterday.
- Montana health officials are seeking doctors’ requests To provide information that supports the need for Abortion to save the patient’s life or for any other medically necessary reason for Medicaid to pay for the procedure, News agency reports.
Thanks for reading! See you all Tuesday.