The pharmaceutical benefit manager (PBM) industry faces mounting scrutiny over its role in drug pricing and healthcare accessibility, with industry experts calling for substantial reforms to increase transparency and reduce anti-competitive practices.
Fred Barton, PharmD, vice president of clinical product and partnerships at AffirmedRx, highlighted critical concerns about PBM operations during the Community Oncology Alliance (COA) 2024 Payer Exchange. He emphasized how PBMs' control over drug formularies and manufacturer contracts significantly impacts patient access to medications.
Impact on Drug Pricing and Access
PBMs serve as intermediaries between drug manufacturers, pharmacies, and healthcare plans, wielding considerable influence over medication costs and availability. "They're designing formularies to decide what is covered on different benefit designs, and ultimately, they're controlling which medications individuals have access to," Barton explained.
The current system allows PBMs to prioritize medications that generate higher profits, potentially at the expense of patient care and cost-effectiveness. This practice, known as "price spreading," involves PBMs paying pharmacies one amount while charging employers a higher price for the same prescription.
Vertical Integration Concerns
A particularly troubling trend is the increasing vertical integration within the industry. "Today, we have PBMs that own retail pharmacies, mail order solutions, and specialty pharmacies," Barton noted. This consolidation creates potential conflicts of interest and can lead to increased costs for employers and patients.
Barriers to Reform
Several obstacles impede meaningful reform in the PBM sector:
- Limited data access for employers
- Resistance to transparency in formulary design
- Anti-competitive practices during PBM transitions
- Complex pricing structures that obscure true costs
Proposed Solutions
Industry experts advocate for several key reforms:
- Mandatory data access rights for employers
- Restrictions on vertical integration
- Enhanced oversight of pricing practices
- Improved collaboration between stakeholders
"We need to continue to find ways to improve the value of benefit design," Barton stated, emphasizing the importance of developing clinical programs and utilization management activities that genuinely benefit employers while ensuring patient access to necessary medications.
The push for PBM reform represents a critical step toward improving healthcare affordability and accessibility. As scrutiny intensifies, stakeholders across the healthcare spectrum must work together to create a more transparent and equitable system for medication access and pricing.
