While there is little agreement among opponents of the PBM on what action Congress should take, industry lobbyists are offering Democrats a menu of options to consider, such as requiring PBMs to pass on a most of the discounts they negotiate with drug manufacturers to consumers or employers. They could also ban a common practice called spread pricing in which PBMs charge health plans more than they pay the pharmacy dispensing a drug, and pocket the difference.
PBMs have responded with their own lobbying and blitz, and insist they are scapegoats. JC Scott, who heads the Pharmaceutical Care Management Association, the business group for PBMs, said targeting its members might be good policy and distract from drugmakers at a critical time in the debate, but it would not reduce the drug costs.
While there are dozens of PBMs, the industry is consolidated, with three of them – CVS Caremark, Express Scripts and OptumRx – controlling nearly 80% of the prescription market. Health insurers, employers, and the government hire PBMs to manage prescription benefits for their health plans, placing them at the center of a supply chain made up of drugmakers, insurers, and pharmacies.
Critics allege that the role of PBMs in negotiating discounts from pharmaceutical manufacturers and developing prescription drug lists that health insurers will cover encourages them to prioritize more expensive drugs where they can get discounts. more important rather than focusing on lower cost drugs.
“Democrats are focused on lowering costs for patients – and that absolutely includes making sure pharmacy benefit managers get the best deal for patients, not themselves,” said Senator Patty Murray ( D-Wa.) In a statement.
The $ 1.7 trillion spending bill, which the House passed last month, includes provisions that require PBMs to leaking some information to employer plans, in a bid to help them negotiate better drug prices, but other industry lobbyists want Democrats to go much further, which could make the Senate move much more complicated.
Independent pharmacists and their patients have sent thousands of letters to Congress at the behest of the National Community Pharmacists Association, which will launch its own television advertising campaign in the coming days urging senators to put the brakes on PBMs.
The pharmaceutical industry launched a nationwide seven-figure advertising campaign on Friday urging lawmakers to force PBMs to pay discounts directly to consumers at the pharmacy counter. Called point-of-sale discounts, PBMs and others argue that this would eventually increase premiums.
âThere is recognition on both sides of the aisle that PBMs play an important role in a failing insurance system, but somehow a bill designed to cut drug costs does not. nothing to address the role these intermediaries play in determining what patients pay out of pocket for drugs. “said Sarah Sutton, spokesperson for Pharmaceutical Research and Manufacturers of America (PhRMA), which broadcasts advertisements on television, radio and the Internet.
She was unwilling to reveal the price of the new ad spend, but PhRMA spent more than $ 2.5 million on its TV ad purchases over the summer, opposing Liberal efforts to have Medicare negotiate the drug prices, based on AdAnalytics data analyzed by POLITICO. And the group spent more than $ 22 million on lobbying in the first nine months of 2021, a 10% increase from the same period in 2020.
While pharmaceutical companies were the main target of Democrats’ efforts to reduce drug costs, PBMs, which spent $ 5.9 million on lobbying in the first nine months of this year, a 20% increase compared to the same period in 2020, came out largely unscathed in the home version.
While the PBM industry is still concerned about the transparency provisions, it was successful in preventing Democrats from including a price ban on spreads. The industry has also supported the repeal of the Trump administration’s so-called surrender rule, which made it the House’s version of the bill.
This has forced lobbyists for drugmakers, pharmacies and employer groups to take their cases to the Senate, where Sen. Ron Wyden (D-Ore.), Chairman of the Senate Finance Committee, has previously expressed his interest in a more in-depth examination of the role played by PBMs. in the reconciliation file.
âPresident Wyden is the champion on this issue,â said James Gelfand, executive vice president of public affairs at the ERISA industry committee, which represents the benefit interests of the nation’s largest employers. “So it would be crazy to think that he wasn’t thinking right now, ‘What else can I do in this space? “”
“This is the legislative opportunity of the century,” he added. “You’re not giving up on this, are you?” “
In a statement to POLITICO, Wyden said pharmacy benefit managers “are taking advantage of this dysfunctional system while families and local pharmacies foot the bill,” adding that “the status quo with regard to PBMs needs to change as much as for Large pharmacy.
Scott, the leader of the PCMA, says his industry is being unfairly maligned for two reasons: an attempt to push through long-desired policies through a massive spending bill that has nothing to do with cost. drugs and misplaced anger against the industry.
âThere’s this sentiment around some stakeholders who think, ‘Well, damn it, if any part of the drug supply chain is going to be affected by this legislation, then the PBM industry has to give its book away too. of flesh ââ he said. “And I don’t know if that’s a very thoughtful consideration to take into political decisions.”
The group launched its own advertising campaign last week, accusing rivals of trying to blame the rising drug prices.
âIronically, the industry that controls the list price of prescription drugs has tried to point the finger at those who focus on reducing the cost of prescription drugs to patients and payers,â the text reads. digital campaign, which is targeted in the Beltway.
But Gelfand, from the Employers’ group, said continuing with the status quo is untenable for patients.
âEveryone involved in all of this knows that the current system is totally unsustainable,â Gelfand said. “There are those who are trying to change it and then there are those who are basically trying to get what they can while they can.”