If there's one health issue that's consistently been on the minds of lawmakers on both sides of the Capitol, it's been PBM reform, Peter and Victoria report.
Why it matters: A desire to address PBMs' role in drug pricing has translated to a lot of bills — a handful of which remain in play for inclusion in a year-end funding package.
The projected savings from any of these could provide valuable offsets to other health programs. The most likely outcome, if a health package does come together, is combining pieces from some of the following:
Senate
Senate Finance package (includes Modernizing and Ensuring PBM Accountability Act)
- What's inside: Measures including delinking PBM compensation from the price of a drug in Medicare Part D, preventing the use of spread pricing in Medicaid, and lowering patient costs for certain drugs in Part D by basing cost-sharing off the net price rather than the list price.
- Savings: Roughly $1 billion in net savings from the Finance PBM provisions. A source familiar said the expectation is that savings will be even higher based on unspecified additional work on the policies over the past year.
- Outlook: The Finance package is among the likeliest prospects to make it into law, considering the 26-0 vote it got in committee, and the fact that it is limited to Medicare and Medicaid and wouldn't extend to the commercial market.
Senate HELP bill (Pharmacy Benefit Manager Reform Act)
- What's inside: New transparency reporting requirements for PBMs, a ban on spread pricing, and a requirement to pass on all rebates to the plan sponsor.
- Savings: CBO hasn't released a score.
- Outlook: The bill advanced out of committee with just three GOP "no" votes. But the policy changes would apply to the commercial market, which has been a source of friction with some House Republicans.
Senate Commerce bill (Pharmacy Benefit Manager Transparency Act)
- What's inside: It, too, would ban spread pricing, but exempt PBMs that meet requirements like passing through 100% of rebates to the plan sponsor and complying with transparency measures.
- Savings: Saves $740 million over 10 years, per a preliminary CBO estimate.
- Outlook: The measure advanced out of committee on a 18-9 vote — a sign of bipartisanship, but not as strong as other panels. Some Republicans, like Ranking Member Ted Cruz, are concerned that it would give expanded power to the Federal Trade Commission and its chair Lina Khan.
House
Lower Costs, More Transparency Act
- What's inside: Transparency requirements for PBMs to provide employer plans with detailed data on drug prices and spending, and also a ban on spread pricing in Medicaid.
- Savings: CBO estimates the transparency provision would save $23 million and increase revenue by almost $2.2 billion over 10 years. The spread pricing provision would save about $1.1 billion over a decade.
- Outlook: The House passed the bill last December in a bipartisan vote, and departing Energy and Commerce Chair Cathy McMorris Rodgers is pressing the Senate to take it up, viewing PBM reform as a legacy health care item.
Telehealth Modernization Act of 2024/The Preserving Telehealth, Hospital, and Ambulance Access Act
- What's inside: Both Energy and Commerce and Ways and Means committees' telehealth bills include a delinking measure where PBMs would only receive a flat fee instead of being compensated based on the price of the drug in Medicare.
- There were also some transparency measures on drug coverage and cost.
- Cost/savings: The CBO hasn't released a score on the total telehealth package yet, but there are reports that a two-year extension could cost several billion dollars.
- Outlook: Both telehealth bills were approved unanimously by the panels this summer (the final package still likely needs to be negotiated between the two committees).
DRUG Act
- What's inside: This bill would implement delinking requirements in the commercial insurance market, prohibit steering patients to pharmacies owned by PBMs and ban spread pricing.
- Cost/savings: Rep. Mariannette Miller-Meeks' office said the commercial delinking section of the bill saves $654 million.
- Outlook: A narrower version of the bill applying only to the Federal Employee Health Benefits program was approved by House Oversight with some bipartisan support in February, but hasn't advanced further.
Pharmacists Fight Back Act
- What's inside: Branded the "most comprehensive PBM reform" bill, this measure would ban spread pricing in Medicaid and patient steering, implement a delinking policy, require rebate sharing with patients, and put in place a transparent pharmacy reimbursement model.
- Cost/savings: No CBO score.
- Outlook: The bill was just introduced this summer by a bipartisan group of lawmakers and hasn't been considered by any committee.
