The strain in opposition to pharmacy profit managers (PBMs) continues to construct.
On Tuesday, the Federal Commerce Fee (FTC) launched its second interim workers report on prescription drug middlemen. The report examines the influence of PBMs (particularly CVS Caremark, Categorical Scripts and Optum Rx) on specialty generic medicine, highlighting substantial worth markups by PBMs on drugs for most cancers, HIV and different circumstances. The fee voted 5-0 to launch the report.
“The FTC workers’s second interim report finds that the three main pharmacy profit managers hiked prices for a variety of lifesaving medicine, together with drugs to deal with coronary heart illness and most cancers,” stated FTC Chair Lina M. Khan in an announcement. “The FTC ought to maintain utilizing its instruments to analyze practices that will inflate drug prices, squeeze unbiased pharmacies, and deprive People of reasonably priced, accessible healthcare—and may act swiftly to cease any unlawful conduct.”
The brand new report is the newest growth in a battle that has been brewing between the FTC and the PBMs. The company launched its first interim workers report on PBMs in July, which detailed how concentrated the PBM market has develop into. As well as, the FTC sued CVS Caremark, Categorical Scripts and Optum Rx over insulin costs in September, prompting the Massive Three PBMs to countersue the company in November, claiming the company’s lawsuit is unconstitutional.
Whereas a number of healthcare executives are popping out in assist of the report, the PBMs named within the report are unsurprisingly decrying its findings.
What the FTC discovered
Within the second interim report, the FTC examined specialty generic medicine distributed between 2017 and 2022 for members of business well being plans and Medicare Half D prescription drug plans managed by the Massive Three PBMs. This differs from the earlier report, which analyzed two specialty generic medicine.
The FTC discovered that the highest three PBMs utilized markups starting from a whole lot to 1000’s of % on numerous specialty generic medicine distributed via their affiliated pharmacies, together with drugs for most cancers and HIV. The PBMs additionally reimbursed their affiliated pharmacies at larger charges than they paid to unaffiliated pharmacies for practically each specialty generic drug reviewed.
Throughout the examine interval, the affiliated pharmacies of the Massive Three PBMs earned greater than $7.3 billion in shelling out income above their estimated acquisition value, as decided by the Nationwide Common Drug Acquisition Price (NADAC), on specialty generic medicine, the FTC additionally reported.
As well as, the three PBMs earned about $1.4 billion of revenue from unfold pricing on the specialty generic medicine analyzed within the report through the examine interval. Unfold pricing is when PBMs invoice their plan sponsor shoppers greater than what they reimburse pharmacies for pharmaceuticals.
“These outcomes illustrate the growing monetary significance of specialty generic medicine to the Massive 3 PBMs, in addition to to plan sponsors and sufferers,” the FTC said within the report. “The outcomes additionally reveal that the 2 case examine medicine analyzed in our First Interim Workers Report weren’t remoted examples. This report confirms that the Massive 3 PBMs impose important markups on a wide selection of specialty generic medicine.”
The response
The Massive Three PBMs have largely criticized the FTC report.
A spokesperson for CVS Well being argued that the FTC has drawn broad conclusions from “cherry-picked” specialty generic outliers in each of its interim stories.
“Between 2017-2022, specialty generic merchandise have represented lower than 1.5% of our shoppers’ complete drug spend and solely 51 out of 1000’s of medication,” stated David Whitrap, vice chairman of exterior affairs at CVS Well being, in an e-mail. “In distinction, branded specialty merchandise symbolize greater than 50% of our shoppers’ complete drug spend and are solely ignored by the FTC.”
Categorical Scripts, in the meantime, declared in an announcement that “nothing within the FTC’s report addresses the underlying trigger of accelerating drug costs, or helps employers, unions, and municipalities maintain prescription advantages reasonably priced for his or her members.”
An Optum spokesperson informed MedCity Information that the corporate continues to be reviewing the report, however pointed to work it’s doing to lower drug costs.
“Optum is decreasing the price of specialty drugs, which contains half of all drug expenditures, and offering medical experience, packages and assist for sufferers with complicated and uncommon circumstances,” the spokesperson stated. “In 2024, we helped eligible sufferers save $1.3 billion and the median out-of-pocket cost for these sufferers was $5.”
Whereas the PBMs are strongly criticizing the findings of the report, one business skilled — Antonio Ciaccia, CEO of 46booklyn — stated he’s glad to not be the one one working to reveal PBM practices. He stated he launched 46brooklyn in 2018 with an exposé on how Medicaid packages have been being overcharged for generic Gleevec, one of many medicine talked about within the report.
“We have been informed by PBMs that our concentrate on this drug was an train in cherry choosing. Since then, we now have recognized a litany of different examples of those exorbitant markups on generic specialty medicine and the way PBM conflicts of curiosity within the specialty pharmacy market have resulted in extreme prices to employers, Medicare, and sufferers,” he stated. “I’d like to say I’m shocked by the findings, however I’m not. I’m simply glad to not really feel like I’m alone in figuring out these unlucky realities.”
Ellen Rudolph, CEO of autoimmune digital well being firm WellTheory, famous that the FTC’s findings “underscore a vital difficulty in our healthcare system: the numerous markups on specialty medicine not solely pressure sufferers but in addition create substantial monetary burdens for employers.”
One other healthcare government referred to as on policymakers to step up primarily based on the findings of the report.
“Sufferers could be nicely served if these so-called specialty medicine have been capable of be distributed by their most popular neighborhood pharmacy,” stated Douglas Hoey, CEO of the Nationwide Group Pharmacists Affiliation. “As a substitute, nonetheless, for the PBMs’ monetary achieve, sufferers’ selection is oftentimes restricted to PBM-owned mail-order pharmacies and their care is sadly disrupted. That is simply the newest apparent sign to policymakers that they have to move PBM reform that would come with paying for prescriptions primarily based on the price of the drug plus a clear pharmacist skilled shelling out payment.”
Picture: z_wei, Getty Photos
