US lawmakers near agreement on PBM oversight legislation

USA – U.S. lawmakers are reportedly close to reaching an agreement on a healthcare legislation package that would introduce stricter oversight of the pharmacy benefit manager (PBM) sector.

The proposed package also includes provisions to raise Medicare physician payment rates, extend telehealth insurance coverage and flexibilities, fund community health programs, and reauthorize substance abuse recovery services.

One of the key components of the legislation is a crackdown on PBMs, with measures potentially including a ban on “spread pricing.”

This practice occurs when a PBM reimburses pharmacies at one price for a medication but charges health plans a higher amount.

Another provision could involve “delinking” PBM fees from the list price of medicines, instead tying them directly to the services PBMs provide.

Proponents argue that these measures would reduce PBMs’ incentives to select higher-priced medications that generate more profit through rebates and fees, potentially leading to lower drug costs for patients.

However, the Pharmaceutical Care Management Association (PCMA), the trade group representing PBMs, is actively lobbying to remove these provisions.

The body claims that such changes would undermine PBMs’ role in lowering costs and providing prescription drug options to employers.

According to PCMA, the measures could lead to increased costs for health plans, employers, patients, and families, raising premiums for seniors.

Additionally, the organization argues that delinking PBM fees could result in a “US $10 billion windfall” for pharmaceutical manufacturers.

In early December, a Federal Trade Commission (FTC) document accused PBMs of anticompetitive practices that drive up prescription drug costs.

The FTC’s report highlighted the concentrated nature of the PBM market, which is dominated by six major players, allowing them to profit at the expense of patients and independent pharmacies. This report has been challenged through lawsuits.

While an agreement on the healthcare package is said to be in principle, it still requires approval by both the House and Senate to move forward.

With the current legislative cycle set to end on December 20, lawmakers are also racing to reach an agreement on funding to keep the government operating for another 90 days.

In the midst of this, President-Elect Donald Trump has also weighed in on the issue, calling PBMs “horrible middlemen” that make more money than drug companies.

At a recent press conference in Florida, he promised to “knock out the middleman” and reduce drug costs to unprecedented levels.