“When pharmacy benefit managers [PBMs] came into being 30 years ago, they were seen as an important component of the prescription distribution system [because] they could guide benefits and money between the patient, pharmacy and the manufacturer,” says Angus Worthing, MD, president of the Alliance for Transparent & Affordable Prescriptions (ATAP).
Health insurance companies hire PBMs to negotiate discounts and rebates with drug companies to lower prescription drug costs for their embers. As time has passed, though, PBMs have increasingly implemented questionable pricing practices behind a veil of secrecy, prompting calls for action to legislate transparency and ensure savings are passed on to patients, not hoarded by insurance companies.
Founded in 2017 by the ACR and the Coalition of State Rheumatology Organizations (CSRO), ATAP has unified provider and patient organizations concerned about the role PBMs play in driving up drug costs.
“This was especially important as biologics entered the market and [prescription] costs went up,” says ATAP Secretary Howard Blumstein, MD. “The original PBM structure was fee based (i.e., the health plan paid a fee to the middleman to negotiate a lower cost). Over time, however, this morphed into a situation [in which] the PBMs hold all the power, to the detriment of patients and providers.”
Dr. Feldman
Madelaine Feldman, MD, immediate past president of the CSRO says, “After a few years of research, I began speaking on PBMs in 2016. At that time, virtually no one but the community pharmacists even knew what a PBM was. [The CSRO] basically had a PBM roadshow and managed to begin educating legislators, regulators and patient advocacy groups about them. When I was looking forward to my term as president of CSRO, I decided we should focus on this issue by helping organize an alliance that focused on the harm of PBMs, creating an organization that did not accept funding from pharmaceutical manufacturers.”
“In 2016, when we realized patients were having increasing trouble accessing their medications, I was president of the Florida Society of Rheumatology,” states Robert Levin, MD. “I brought up the issue of the PBM stranglehold at a board meeting, where we discussed how drug prices were on the rise and copays were out of reach for many patients. These PBMs had become behemoths and were controlling everything from drug selection to cost, essentially restricting access to care.”
Dr. Levin
