Peter Pitts Examines the Role of PBMs and their Deceptive Tactics

BIOtech Now
Andrew Segerman

A piece by Peter J. Pitts, a former FDA Associate Commissioner and President of the Center for Medicine in the Public Interest, describes the role of pharmacy benefit managers (PBMs) and tactics they use to shift a growing portion of prescription drug costs to patients and consumers.

“In the United States, nearly $15 of every $100 spent on brand-name drugs goes to PBMs, which claim they lower drug costs. However, the share of annual drug price increases that PBMs pocket – as opposed to pass on to consumers – has soared from 5 percent in 2011 to 62 percent in 2016. Three large PBMs control 78 percent of the market and use this market power to control what medicines people can use, what they pay, and where they get their prescriptions filled.”

As Pitts explains, policies being enforced like “copay accumulators” prevent financial assistance provided by drugmakers from applying to a patient’s out-of-pocket maximum or deductible. This leaves patients on the hook to cover steep costs when the value of patient assistance is exhausted.

A better term for misleading “copay accumulator” policies? “PBM bottom line enhancer,” he writes. Here’s why:

“Copay accumulators, a tool to ensure that the value of a copay card or coupon doesn’t count toward a patient’s out-of-pocket maximum expense, allows pharmacy benefit managers to further pad their pockets — but harms both patients and the public health by making lifesaving medicines unaffordable. And to make matters worse, these programs are being sold to patients as a benefit. The health care chutzpah of the PBM industry is astounding.”

It’s also important to point out that despite the billions of dollars in rebates and other discounts that innovative pharmaceutical companies provide key players across the drug cost ecosystem each year, patients are not always seeing financial relief at the pharmacy counter. The expectation is that these savings will reduce costs for patients, but mounting evidence proves that this is all too often not the case.

Sadly, while these middlemen profit, patients are unaware of why they are paying more and more for the medicines they need.

“[A] ConnectiveRx study found the level of copay accumulator awareness at 25 percent. And, if knowledge is power, ignorance is not bliss. A new report from McKesson found that, not only do patients not understand what a copay accumulator program is — what they believe to be true is wrong. … For example, 60 percent believe copay accumulators are a plan benefit, and less than 40 percent know what out-of-pocket means.”

The administration’s latest move to ensure drugmaker rebates are passed along to seniors in Medicare Part D is a step in the right direction towards lowering out-of-pocket costs for consumers. And with policymakers set to examine the role of PBMs, drug cost middlemen should acknowledge the need to engage stakeholders across all health care sectors to promote policies that ensure patients have access to innovative cures and treatments that they need at an affordable out of pocket cost.

Read the full piece here.

Full BIOtech Now Article here

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