A recent report from the House Committee on Oversight and Accountability has raised concerns about Pharmacy Benefit Managers (PBMs) and their impact on medication costs and patient choices. The investigation spanned 32 months and highlights how these third-party administrators, who negotiate drug prices for health insurers and determine patient out-of-pocket costs, may be directing patients towards pricier medications.
The report indicates that the three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Caremark—control around 80% of U.S. prescriptions. It was found that these managers are promoting lists of preferred medications that favor expensive brand-name drugs despite the presence of more affordable alternatives. A specific example mentioned involves Cigna discouraging the use of cheaper biosimilars for Humira, a treatment costing about $90,000 annually, even when a similar drug was available for half the price.
Furthermore, the committee reported that Express Scripts informed patients they would pay less for a three-month supply of medication through their mail-order pharmacy than at a local pharmacy. This practice appears to limit consumer choice regarding where to fill prescriptions.
Compounding these concerns, the U.S. Federal Trade Commission (FTC) recently echoed similar findings, indicating that the largest PBMs dominate nearly 95% of all prescriptions in the country, suggesting a troubling concentration of power over drug accessibility and affordability. The FTC pointed out that this vertical integration may lead to conflicts of interest, particularly as PBMs could prioritize their affiliated businesses over independent pharmacies.
FTC Chair Lina M. Khan criticized the current system, noting that it’s leading to inflated costs for patients, particularly for cancer drugs, resulting in substantial additional revenue for PBMs.
In summary, the powerful role of PBMs and their pricing strategies raises critical questions about the accessibility and affordability of medications. Addressing these issues could potentially lead to a more transparent and equitable healthcare system, offering hope that reforms may enhance patient choices and reduce costs in the future. Encouragingly, the increased focus on this problem might incite necessary changes in legislation and healthcare practices aimed at benefiting patients directly.