A recent report by the House Committee on Oversight and Accountability has raised significant concerns about the practices of pharmacy-benefit managers (PBMs), suggesting they are leading patients to more expensive medications while restricting their pharmacy choices. This investigation, which lasted 32 months, preceded a hearing featuring executives from the largest PBMs in the United States.
PBMs, which act as intermediaries for health insurers on prescription drug plans, negotiate prices with pharmaceutical companies and determine the out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health)—together manage around 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs are favoring higher-priced brand-name drugs over more affordable alternatives, thus disadvantaging patients. For instance, the report highlighted communications from Cigna that discouraged patients from opting for cheaper substitutes to Humira, a costly arthritis treatment priced at $90,000 annually, despite the availability of a biosimilar for half that price.
Additionally, the report noted that Express Scripts was informing patients that filling prescriptions at their local pharmacies would be more expensive than obtaining a three-month supply through their mail-order service, effectively limiting consumer choice in pharmacy selection.
A related report from the U.S. Federal Trade Commission (FTC) echoed these concerns, revealing how vertical integration among PBMs has led to their grip on nearly 95% of U.S. prescription fills. The FTC highlighted that the growing power of PBMs presents conflicts of interest, jeopardizing the affordability and accessibility of medications for patients.
The implications of these findings are profound, with FTC Chair Lina Khan asserting that these middlemen are contributing to excessive charges for medications, particularly cancer treatment, which generates over $1 billion in additional revenue for PBMs.
This investigation shines a light on the urgent need for transparency and reform within the pharmaceutical industry to ensure that patients receive fair and affordable access to their medications.
As the industry evolves, there is hope that advocacy and regulatory efforts will lead to a more equitable system that prioritizes patient well-being over profit. It could pave the way for more cost-effective solutions and empower consumers in their healthcare choices.