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PBM landscape in for a shakeup

May 18, 2023
Illustration of medical pills with half of the capsule created from paper money.

Illustration: Rae Cook/Axios

A Congressional panel unanimously advanced legislation with new transparency requirements for pharmacy benefit managers on Wednesday.

Why it matters: Increased scrutiny on PBMs, many of which are vertically integrated with insurance carriers, will engender a more competitive independent pharmacy ecosystem.

Zoom in: The legislation takes aim at "spread pricing," a practice in which PBMs charge an insurer more than they pay a pharmacy for a drug, and pocket the difference.

  • Sens. Mitt Romney (R-Utah) and Rand Paul (R-Ky.) objected to the ban, arguing smaller employers prefer spread pricing as a less expensive option.
  • Romney proposed instead requiring PBMs to offer spread pricing as one option alongside others, but that amendment was tabled.

What they're saying: The current PBM structure funnels the majority of volume and profits directly to insurers and employers, one health care banker says.

  • In turn, independent pharmacies in particular get squeezed, he adds.
  • DTC pharmacy Cost Plus Drugs founder Mark Cuban had choice words for PBMs at last year's Axios BFD, saying if he'd ever been pitched the model on "Shark Tank," it would have been a hard no.

Yes, but: Alicia Boler, CEO of digital pharmacy Alto Pharmacy, had a more charitable view at this year's Axios BFD.

  • "I put myself in a large employers perspective, and if I have employees, I want a company with expertise to manage the pharmacy benefit too," she said.
  • "To really be an expert in managing what type of medications are available, what the cost should be — that's not something as a company I would be an expert in."

Meanwhile, the Federal Trade Commission is doing its own examination of how PBMs impact access and affordability of prescription drugs.

  • The FTC ordered two PBM group purchasing organizations to provide information and records on their business practices.

Be smart: Myriad digital pharmacies have emerged in recent years — and while they simplify supply chain processes, that's a small percentage of the costs associated with drug dispensing and distribution, the health care banker says.

  • The "gross-to-net bubble" — or the growing difference between the list price of brand name drugs and the actual price after rebates, incentives and returns — is ballooning primarily because of formulary rebates and 340b discounts, he maintains.

Flashback: The vertical integration wave that yielded deals like CVS Health-Aetna and Cigna-Express Scripts, along with other partnerships, has squarely contributed to a lack of competition and high costs.

  • "It's just the flip side of the same coin from when Merck owned one of the largest PBM and mail pharmacies," the banker says, citing the pharmacy giant's 1993 purchase of Medco, which was later spun off as an independent entity.
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