A recent report from the House Committee on Oversight and Accountability has raised serious concerns regarding pharmacy-benefit managers (PBMs), revealing that these entities are increasingly directing patients towards costlier medications while constricting their choices regarding where they can obtain prescriptions. This investigation, which spanned over 32 months, precedes a hearing involving executives from the nation’s leading PBM firms and was highlighted in the Wall Street Journal.
PBMs serve as intermediaries managing prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and establishing out-of-pocket expenses for patients. The report points out that major players such as Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark control almost 80% of prescriptions in the U.S.
Among the key findings, the report indicates that PBMs often curate lists of preferred medications that favor higher-priced brand-name drugs over more affordable alternatives. An example provided involves Cigna discouraging the use of cheaper substitutes for Humira, a drug priced at $90,000 annually, despite the availability of biosimilars at half that cost.
Moreover, the committee noted practices by Express Scripts, which informed patients that filling prescriptions at local pharmacies would be more expensive than obtaining medications through their affiliated mail-order services. Such practices are seen as limiting patient choice and access to the pharmacies of their preference.
The Federal Trade Commission (FTC) recently published a similar report highlighting that the six largest PBMs manage nearly 95% of all prescriptions in the U.S., resulting in significant power over patients’ access and affordability of prescription drugs. The FTC pointed out that this concentration could lead to conflicts of interest, as vertically integrated PBMs might prefer their affiliated businesses, disadvantaging independent pharmacies and escalating drug prices. Additionally, it was noted that patients are potentially overcharged for critical medications, yielding over a billion dollars in extra revenue for these intermediaries.
While these findings paint a concerning picture of the landscape of prescription management, they also highlight the urgent need for reform in the PBM sector to promote fairer practices. By increasing transparency and accountability among PBMs, stakeholders can work toward ensuring that patients have better access to affordable medications, fostering a healthier and more equitable healthcare system.
In summary, the focus on the practices of PBMs underlines a significant issue in the healthcare industry, but it also opens the door for potential improvements that could enhance patient care and expand access to necessary treatments, ultimately empowering individuals in their healthcare journeys.