Pharmacy Benefit Manager Reform
The ACR introduced Resolution 215, Pharmacy Benefit Manager Reform as a State Legislative Priority, to address the abusive pharmacy benefit manager (PBM) practices that continue to plague both providers and patients. Over the last few years, the rate of state-level PBM reform has slowed, but the recent Supreme Court decision in Rutledge v. PCMA has now granted states greater authority to regulate PBMs. It is imperative that states use this broadened authority to regulate abusive PBM practices.
During the pandemic, physicians and patients have seen more aggressive tactics by PBMs, with exclusionary formularies, mandatory drug switching, copay accumulator policies and white bagging becoming more common. These policies pose dangers to patients and threaten the integrity of the provider/patient relationship. Although PBM transparency will not solve these problems, it will provide policymakers and regulators with more insight into the motivations behind these policies.
Additionally, the ongoing COVID-19 pandemic has left patients more vulnerable than ever to the economic pressures associated with higher prescription drug prices. Policymakers must have the tools to analyze the role that PBMs play in increasing drug prices, particularly the perverse incentives created by the rebate system. It is imperative that the AMA leads on this issue to ensure that the interests of physicians are represented in future state-level PBM legislation.
The ACR’s Resolution 215 would have the AMA:
- Explicitly make PBM reform a state legislative priority;
- Draft model PBM legislation or adopt model legislation from other organizations;
- Actively advocate for the passage of PBM reform in state legislatures across the country; and
- Update its Health Care Reform Objectives and the AMA Vision for Health System Reform to reflect this priority change and the importance of effective PBM regulation.
The Association of Clinical Oncology joined Resolution 215 as a cosponsor.
Sequestration
The ACR is also co-leading Resolution 212, Sequestration, introduced by the Association of Clinical Oncology. This resolution would have the AMA prioritize strong advocacy in opposition to the application of sequestration to Medicare, including to drugs administered under Medicare. Medicare sequestration relief temporarily implemented earlier in the COVID-19 public health emergency is set to expire at the end of 2021, with a 2% sequester set to take effect on January 1, 2022. With additional cuts, including PAYGO, commencing on the same date, rheumatology practices face a total of 9.75% cuts to their Medicare reimbursement (the Medicare “cliff”). These upcoming cuts place an unreasonable burden on practices and severely threaten patient access to care as many practices will struggle to keep their doors open.
