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SAN DIEGO—Pharmacy benefit managers (PBMs) and their impact on drug prices and access to high-cost medications by the patients rheumatologists treat was a major theme at the 2017 ACR/ARHP Annual Meeting Nov. 3–8. In one session, industry experts tried to clarify the role for prior authorizations and drug formulary policies and explored ways to constructively reshape the relationship between rheumatologists and PBMs for the benefit of patients. But participants also voiced frustrations over PBM-imposed barriers to access for rheumatologic treatments. Lack of transparency on drug pricing policies for the country’s biggest PBMs remains a flashpoint for much of their frustration.
PBMs are engaged by health plans to manage their drug benefit programs, serving as third-party administrators or brokers between the manufacturer and the retailer. Originally set up to bring prescription drug utilization and costs under control, they have become very good at negotiating discounted rebates from the manufacturer’s list price. But recent industry consolidations and their resulting clout to control pharmacy costs have altered this dynamic.
The PBMs may be keeping a large part of the savings negotiated with manufacturers for themselves. PBMs also play other roles in the healthcare system, some of which may be beneficial to patients. The three biggest companies, controlling about three-quarters of the market, are ExpressScripts, CVS CareMark and OptumRx.
Dr. Worthing
Rheumatologists say PBMs negatively affect patients through the use of prior authorization requirements, spread pricing, step therapy programs that determine which drug the patient must try first, the use of specialty tiers for biologics and other high-cost medications, requiring patients to pay a percentage of the drug cost rather than just a copayment, and non-medical switching. The latter means changing the patient’s covered drug for reasons unrelated to medical appropriateness. ACR opposes non-medical switching and believes that any such medication changes should involve open discussion with the patient and physician.
All of these practices can have a huge impact on the lives of rheumatology patients. One of the biggest concerns involves the rebates charged to drug manufacturers by the PBMs. “Too often, our patients’ formularies are determined by a rebate system that incentivizes higher prices, with savings that don’t trickle down to the patient. The highest rebate is determined by the following formula: rebate equals list price times percent of rebate times market share,” explained Angus Worthing, MD, FACP, FACR, chair of the ACR’s Government Affairs Committee and a rheumatologist in practice in Washington, D.C. But because contracts between drug manufacturers and PBMs are proprietary and thus hidden from public view, it isn’t clear what’s really going on, he said.