A recent report from the House Committee on Oversight and Accountability reveals significant concerns regarding pharmacy-benefit managers (PBMs) and their influence on drug pricing and access. The findings stem from a comprehensive 32-month investigation into the operations of PBMs, which act as intermediaries between health insurers and pharmaceutical companies, managing prescription drug plans and negotiating pricing.
The investigation highlighted that the largest PBMs—Express Scripts, OptumRx, and Caremark—control approximately 80% of prescriptions in the United States. The committee’s report indicates that these PBMs are directing patients toward more expensive brand-name drugs while limiting access to affordable alternatives. For instance, the report mentions that emails from Cigna’s staff discouraged the utilization of cheaper biosimilars for Humira, a commonly prescribed medication for autoimmune conditions that can cost patients around $90,000 annually.
Moreover, the committee found that Express Scripts incentivized patients to use their mail-order service by informing them that filling prescriptions at local pharmacies would cost more. This practice restricts patients’ choices regarding where they can obtain their medications.
The Federal Trade Commission (FTC) released a similar report, emphasizing concerns about the concentration of power among the six largest PBMs, which control close to 95% of prescriptions in the U.S. The FTC noted that this concentration not only complicates patient access to affordable medications but also potentially creates conflicts of interest by favoring PBMs’ affiliated businesses, harming independent pharmacies.
The findings from both the House committee and the FTC indicate that PBMs are significantly impacting the accessibility and affordability of prescription drugs, with FTC Chair Lina M. Khan asserting that patients are being overcharged for cancer drugs, resulting in increased revenues for these middlemen exceeding $1 billion.
Despite these troubling revelations, there is hope for reforms aimed at enhancing transparency and competition within the pharmaceutical industry. Increased awareness of these issues may lead to legislative changes that prioritize patient care and ensure fair pricing practices.
In summary, as scrutiny on PBMs intensifies, there may be opportunities for meaningful reform that could help lower drug costs and improve patients’ access to essential medications.