1 magg 2022 anni - Pharmacy Benefit Management: manages prescription drug programs for employers who provide health benefits for their workers.

Descrizione:

NPR story
HEALTH INC.
What to know about the drug price fight in those TV ads
July 7, 2023 5:06 AM ET
FROM
KFF Health News

By

Arthur Allen


Pharmacy benefit managers are middlemen who work with drug companies and insurers, helping set the retail prices for prescription drugs Americans rely on for their health. They're now the subject of a number of new bills in Congress.
Robert F. Bukaty/AP
In recent months ominous ads about prescription drugs have flooded the TV airwaves. Perhaps by design, it's not always clear who's sponsoring the ads or why.

Or, for that matter, why now?

The short answer is that Congress is paying attention. House and Senate members from both parties have launched at least nine bills, parts of which may be packaged together this fall, that take aim at pharmacy benefit managers, companies that channel prescription drugs to patients. Here's a primer to help you decipher what's happening.

What are pharmacy benefit managers?
Known as PBMs, these companies were created in the 1960s to help employers and insurers select and purchase medications for their health plans. The industry mushroomed as prescription drug spending grew about 200-fold between 1967 and 2021. In addition to negotiating discounts with manufacturers, PBMs set payment terms for the pharmacies that buy and dispense the drugs to patients. In effect, they are the dominant middlemen among drugmakers, drugstores, insurers, employers, and patients.

New drugs. Cheaper drugs. Why not both?
THE INDICATOR FROM PLANET MONEY
New drugs. Cheaper drugs. Why not both?
How big is the PBM industry?
There are around 70 PBMs in the U.S. Through mergers, three of them — CVS Caremark, Optum Rx, and Express Scripts — have come to control 80% of the prescription drug market, and each brings in tens of billions of dollars in revenue annually. The PBMs control the drug pipeline from manufacturers to the pharmacy counter.

Their buying power allows them to obtain discounted drugs for health plans while setting prices and terms for sales at drugstores. The big three are part of massive conglomerates with important stakes in almost every sector of health care; each of them owns a powerful health insurer — Aetna, UnitedHealth, and Cigna, respectively — as well as pharmacies and medical providers.

For example, UnitedHealth contracts with 70,000 doctors, making it the biggest employer of physicians in the country. CVS Health, with the big pharmacy chain, also owns Caremark and Aetna. Secret price negotiations and hidden corners of each PBM-linked corporation make it hard to track where the money ends up.

Why am I seeing all these ads about PBMs?
Other sectors of health care are alarmed by the power of the PBMs and are appealing to the Biden administration and Congress to rein them in. Drugmakers are especially up in arms (more on that later), but employers, pharmacies, doctors, and even patients chafe at PBM practices like "spread pricing," in which the companies pocket money negotiated on behalf of health plans.

Non-PBM-affiliated pharmacists, from mom and pop stores to large chains like Kroger, say the PBMs squeeze their businesses by forcing them to sign opaque contracts that include clawbacks of money long after sales take place. PBMs often steer patients using expensive drugs to their affiliated pharmacies, cutting revenue to independents.

Doctors say PBMs act as gatekeepers for the insurers they represent, blocking or slowing coverage of necessary drugs.

https://www.npr.org/sections/health-shots/2023/07/07/1186317498/pharmacy-benefit-manager-pbm-ads-congress
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The Role of PBMs
PBMs are organizations that manage prescription drug programs for employers who provide health benefits for their workers. They are supposed to use their purchasing power to negotiate discounts from pharmacies and pharmaceutical companies on behalf of employers, and this should bring down the costs for employers and patients. However, PBMs do not always pass along to their customers all the savings they negotiate.

How PBMs Game the System
PBMs employ a variety of tactics designed to increase profits at the expense of patients and often profit more when higher cost medications are used. One example is when PBMs charge a co-pay or deductible amount higher than what they paid for a medication. They then keep the difference as profit instead of passing it along to their customer or patient. Another tactic is “spread pricing,” or paying pharmacies less than what they’ve charged the health plan, employer or patient. The intentional complexity and lack of transparency in the current system allows PBMs to benefit from high-cost drugs and results in employers, and ultimately patients, paying more.

Impact on Patients and Employers
These tactics have serious implications for both patients and employers. Patients may be forced into costly treatments or have to switch medication because a higher-cost drug offers a PBM a higher rebate, and PBMs determine which prescription drugs patients have access to. In addition, employers are left footing the bill and are most times prohibited from even auditing the PBM to see if they are getting a fair deal and paying a reasonable price. All this can lead to higher risks for patients and increased out-of-pocket costs leading some people to have to make the choice not take necessary medications.

What’s Needed
The nation’s employers are purchasing life-saving health benefits for American workers in a market that is not functioning as intended. The result is that employees and their families are being denied access to affordable prescription drugs. Federal action is essential to curb PBMs’ anti-competitive practices and to require accountability for the industry.

These actions must include:

Require full and complete transparency and reporting: PBMs and their parent companies should be required to provide strong reporting to employers on costs, fees and total manufacturer revenue, and ensure employers have the right to audit their PBM with an auditor of their choosing. PBMs should not be allowed to engage in workarounds or legal games that skirt these laws.
Ban spread pricing: PBMs should not be allowed to charge employers, health plans or patients more for a drug than the PBM paid the pharmacy for that drug.
Require PBMs to pass-through 100% of all rebates, discounts and fees: PBMs should be required to pass on 100% of all rebates and volume or access-based administrative fees to employers and plan sponsors.
Hold PBMs accountable the same way employers are held accountable: Employers are required as plan fiduciaries to be good managers of the health care benefits they provide employees and act in a manner that minimizes costs. PBMs should be held to the same level of accountability as employers and health insurance plans.

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