A coalition of patient and provider groups, including the ACR, is raising awareness about the effect of pharmacy benefit managers (PBMs) on patient care and the cost of prescription drugs. The Alliance for Transparent and Affordable Prescriptions, or ATAP, argues that too few restrictions have been placed on PBM transparency, and requirements for PBMs to pass negotiated savings on to payers and patients are needed.
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The ATAP Steering Committee includes representatives from the ACR, Arthritis Foundation, National Psoriasis Foundation, CSRO, National Organization of Rheumatology Managers, Rheumatology Nurses Society and Global Healthy Living Foundation.
Adam Cooper, MS, the ACR’s senior director of government affairs, says the coalition hopes to “educate policymakers about the problem and possible solutions.” These solutions, he says, could include “legislative and other fixes that would bring about greater transparency and accountability for PBMs.”
How PBMs Affect Patients & Costs
Eugene Huffstutter, MD, a rheumatologist in Hixson, Tenn., and the ACR’s representative to the Alliance, says patient care is negatively affected by PBMs because a formulary may prevent access to certain medications. “The PBM process can negatively affect patient care by preventing new and innovative products from getting to patients. Even if a drug has been shown to be superior—or even cheaper—the PBM system is going to make you use the [drugs] on the formulary.”
Many physicians may not currently understand how the PBMs work and how they affect patient care, he says. “This is a rapidly moving field. Once people start understanding how much money is involved—[especially] in this era when we are all trying to watch costs—then there could be a lot of change. This affects not only private insurance, but also Medicare D plans.”
PBMs Left Unchecked
The Alliance contends the PBM industry is overly consolidated: Combined, the two largest PBMs cover more than 170 million Americans. This consolidation results in one-sided formulary negotiations with pharmaceutical manufacturers and a take-it-or-leave-it demand by the PBMs.
According to the Alliance, PBMs currently have no checks on conflicts of interest. Many PBMs own their own specialty or mail-order pharmacies and require beneficiaries to use their pharmacies. Not only does this reduce the ability to make choices, but a mail-order pharmacy eliminates the opportunity for a beneficiary to interact with a pharmacist. Further, drug discounts or rebates negotiated by PBMs often do not translate into cost savings for beneficiaries.
“Patients often never see any savings on the cost of drugs, because it all goes back to the insurance companies or stays with the PBM,” Dr. Huffstutter says. “Transparency about the process is greatly needed so that we understand what is going on with drug prices. This kind of arrangement artificially inflates the costs of medications.”