Contracts with large insurers provide enormous clout to PBMs when negotiating with drug manufacturers and pharmacies. This became evident this past year when certain PBMs battled pharmaceutical firms over coverage for the newer, more costly drugs used to treat hepatitis C and over the indications for the use of the PCSK9 lipid-lowering biologics.8
Our most stressful interactions with PBMs revolve around their demands to complete prior authorizations (PAs) for an ever-expanding list of drugs. Sometimes, the reasoning for a PA is obvious; the drugs we chose may be costly or the PBM has signed a contract with a specific manufacturer that offers it better rebates when we choose others. However, in a growing number of instances, the PA is required for even the cheapest generics. Examples: prednisone, alendronate, omeprazole and yes, folic acid, too. From a cost perspective, this makes no sense, and the time you waste explaining your medical judgment is of no concern to the PBM. This activity is such a far cry from why you chose to become a doctor. To paraphrase Bob Dylan, 20 years of schooling, and they put you on the day shift!
On an optimistic note, state legislatures have been pushing for greater transparency and disclosure provisions to better regulate PBMs. In addition, there has been pressure to force fiduciary duty onto PBMs that would require them to act in the best interest of insurers and insurance plans, similar to how financial advisors have a legal obligation to act in the best interest of their clients.7 Can these rules slow the PBM juggernaut? Stay tuned in 2016.
Lessons from MOC
In 2015, we witnessed the abrupt turnaround by the American Board of Internal Medicine (ABIM) regarding the imposition and now partial retraction of some of the more onerous maintenance of certification (MOC) requirements. Following an unprecedented campaign in which doctors and organizations, including the ACR, took a vocal stand and opposed its implementation, the ABIM issued a mea culpa.
Earlier, the ACR declared that “It is incumbent upon the ABIM … to engage a respected independent [the College’s underline] party to assess the impact of the MOC program and make the findings publicly available.”9
We took a stand, we organized, and we made our views known. What does this teach us? We can no longer sit by idly, gazing at our computer screens, expecting the insurers, the PBMs and the other major players in healthcare to ease their ceaseless demands. How can we, as a small specialty, have any impact on the future agenda of healthcare? There is only one way, which is for us to organize and start supporting our very own political action committee, RheumPAC.