Independent pharmacists push for audit of PBMs
PBMs will save Pennsylvania employers and consumers $28.5 billion over 10 years.
“While no payer is required to hire a PBM, they choose to because PBMs typically reduce drug costs by 30 percent, and are continuing to keep overall spending and out-of-pocket costs down despite massive price hikes by drug companies,” the PCMA spokesman said.
In addition to their contracts with client insurers, the PBMs also contract with pharmaceutical companies on how much they will pay for the drugs, and with pharmacists for how much they will be reimbursed for dispensing the medications.
The problem, says physician Robert Levin, is the lack of transparency in those transactions.
Dr. Levin is president of the Illinois-based Alliance for Transparent and Affordable Prescriptions, or ATAP, a group of patient and provider groups that says it was formed out of concern “that PBMs play an increasingly anti-competitive and harmful role in the pharmaceutical supply chain.”
“They tell everybody how much good they’re doing, how they’re protecting patient safety and how much money they’re saving,” said Dr. Levin in a phone interview.
“They may be saving money with the whole rebate system. The question is, who is benefiting?”
Mike DeAngelis, spokesman for CVS Caremark, said a review by Ohio’s Department of Medicaid in June found that PBMs save $145 million annually for the Medicaid managed care program. He added that CVS Caremark’s net profit for its overall PBM book of business was 3.5 percent in 2017 and 2.8 percent for the first six months of 2018.
As for pharmacists’ reimbursement complaints, Mr. DeAngelis said, “While we understand that like any business, independent pharmacies want to be paid as much as they can, it cannot be our responsibility to subsidize pharmacies at the expense of patients, payers and in the case of government programs such as Medicaid — taxpayers.”
The Ohio Medicaid report showed how much money is at stake: The report found an 8.8 percent difference between what its PBMs paid for drugs and what it paid in reimbursements, totaling $223.7 million.
Mr. DeAngelis said that spread difference is not profit but “pays for the vital clinical and benefit services we provide to clients in lieu of clients paying an administrative fee.”
Still, Ohio state officials have said they will begin requiring more pricing transparency in its pharmacy benefit management contracts beginning in 2019.
The Pittsburgh area’s two largest insurers, UPMC Health Plan and Highmark, both use Express Scripts.
In a statement Monday, Express Scripts spokeswoman Jennifer Luddy said the company’s role “is to use our expertise and scale to create a more sustainable and affordable health care system for our clients and members, and to deliver better health for all.
“With thousands of available medications, and hundreds of millions of prescriptions dispensed each year, we believe that if PBMs didn’t exist, payers would invent one to help them navigate the system.”