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The recently signed gun law, S. 2938: Bipartisan Safer Communities Act, contained a surprise dingleberry postponing a regulation designed to save seniors money on their pharmaceutical drugs by prohibiting kickbacks to an industry few have heard of: Pharmacy Benefit Managers (PBMs). This little-known but extremely powerful industry deserves much of the blame for ever rising prescription drugs costs in the United States. In this episode, Jen gives you the scoop on PBMs and how they make their money at the expense of Americans who are most dependent on medications. Please Support Congressional Dish – Quick Links Contribute monthly or a lump sum via PayPal Support Congressional Dish via Patreon (donations per episode) Send Zelle payments to: Donation@congressionaldish.com Send Venmo payments to: @Jennifer-Briney Send Cash App payments to: $CongressionalDish or Donation@congressionaldish.com Use your bank's online bill pay function to mail contributions to: 5753 Hwy 85 North, Number 4576, Crestview, FL 32536. Please make checks payable to Congressional Dish Thank you for supporting truly independent media! View the shownotes on our website at https://congressionaldish.com/cd255-pharmacy-benefit-managers-pbms We're Not Wrong Berlin Meetup Contact Justin at WereNotWrongPod@gmail.com Background Sources Recommended Congressional Dish Episodes CD134: The EpiPen Hearing US Healthcare Landscape Jessi Jezewska Stevens. Apr 23, 2020. "A Brief History of the Great American Healthcare Scam." Bookforum. Tanza Loudenback. Mar 7, 2019. "The average cost of healthcare in 21 different countries." Insider. Chuck Grassley and Ron Wyden. 2019. "Insulin: Examining the Factors Driving the Rising Cost of a Century Old Drug [Staff Report]." U.S. Senate Finance Committee. "Health Insurance Coverage of the Total Population." Kaiser Family Foundation. Sara R. Collins and David C. Radley. Dec 7, 2018. "The Cost of Employer Insurance Is a Growing Burden for Middle-Income Families." The Commonwealth Fund. PBMs What are PBMs? JC Scott. Jun 30, 2022. "Drug manufacturers are root cause of high drug costs; PBMs drive costs down." The Hill. Zach Freed. Jun 22, 2022. "The Pharmacy Benefit Mafia: The Secret Health Care Monopolies Jacking Up Drug Prices and Abusing Patients and Pharmacists." American Economic Liberties Project. Adam J. Fein. Jun 22, 2021. "The Top Pharmacy Benefit Managers of 2020: Vertical Integration Drives Consolidation (rerun)." Drug Channels. "Flash finding: How drug money from sick people really works." Nov 11, 2021. 46brooklyn. Adam J. Fein. Feb 3, 2019. "Don't Blame Drug Prices on 'Big Pharma.'" The Wall Street Journal. How PBMs Make Money "DIR Fees." National Association of Chain Drug Stores. "How PBMs Make Money: PBM Practices & Profits." RxSafe. True North Political Solutions. Oct 25, 2017. "White Paper: DIR Fees Simply Explained." Pharmacy Times. ACA "Vertical Integration" Loophole Peter High. Jul 8, 2019. "A View From Inside Cigna's $67 Billion Acquisition Of Express Scripts." Forbes. Angelica LaVito. Nov 28, 2018. "CVS creates new health-care giant as $69 billion merger with Aetna officially closes." CNBC. David Dayen. Oct 12, 2018. "Why the Aetna and CVS Merger Is So Dangerous." The American Prospect. Jeff Byers. April 12, 2018. "Optum a step ahead in vertical integration frenzy." Healthcare Dive. Graph: Optum opens up wider market for UnitedHealth Group Graph: Optum's pharmacy business contributes the majority of its revenue Susan Morse. May 10, 2017. "Secret weapon: UnitedHealth's Optum business is laying waste to old notions about how payers make money." Healthcare Finance. Lobbying "Client Profile: Pharmaceutical Care Management Assn." Open Secrets. The Demise of Independent Pharmacies Christine Blank. Oct 17, 2019. "Independents Prepare to Close Up Shop." Drug Topics. Paulina Firozi. Aug 23, 2018. "The Health 202: Here's why rural independent pharmacies are closing their doors." The Washington Post. What Is a Formulary? Ana Gascon Ivey. May 19, 2020. "A Guide to Medication Formularies." GoodRx. Previous Delays in Rebate Regulation Paige Minemyer. Jan 29, 2021. "In a win for PBMs, Biden administration delays rebate rule." Fierce Healthcare. Paige Minemyer. Jan 12, 2021. "PCMA sues Trump administration over rebate rule." Fierce Healthcare. "Incorporating the Effects of the Proposed Rule on Safe Harbors for Pharmaceutical Rebates in CBO's Budget Projections—Supplemental Material for Updated Budget Projections: 2019 to 2029." May 2019. Congressional Budget Office. The Gun Law Passage Process Office of the Clerk. May 18, 2022. "Roll Call 212 | Bill Number: S. 2938." U.S. House of Representatives. Tampa Bay Times Editorial Board. May 12, 2022. "Republican lawmakers should be ashamed for failing to honor Justice Joseph Hatchett." Miami Herald. Annie Karni. Apr 12, 2022. "House G.O.P., Banding Together, Kills Bid to Honor Pioneering Black Judge." The New York Times. Background on Most Important Provisions Mary Katherine Wildeman. May 26, 2022. "Data show most school shootings carried out by young adults, teens." CT Insider. Jeffrey Pierre. May 26, 2022. "Experts say we can prevent school shootings. Here's what the research says." NPR. The Dingleberry Erik Sherman. Jun 30, 2022. "Gun Safety Bill Extends Drug Middlemen Protection From Anti-Kickback Measure." Forbes. Molly Rutherford. Jun 28, 2022. "Gun legislation provision puts drug supply chain profits over patients." The Hill. Marty Schladen. Jun 22, 2022. "Deep inside the gun bill: a break for prescription drug middlemen." Iowa Capital Dispatch. Poland Train Station Taylor Popielarz, Maureen McManus and Justin Tasolides. Mar 25, 2022. "'The help given is remarkable': Inside the Poland train station that's become a hub for Ukrainian refugees." Spectrum News NY1. The Law and the Regulation S. 2938: Bipartisan Safer Communities Act Senate Vote: 65-33 (All Nos GOP) House Vote: 234-193 (All Nos GOP) Jen's Highlighted PDF of S. 2938: Bipartisan Safer Communities Act Fraud and Abuse; Removal of Safe Harbor Protection for Rebates Involving Prescription Pharmaceuticals and Creation of New Safe Harbor Protection for Certain Point-of-Sale Reductions in Price on Prescription Pharmaceuticals and Certain Pharmacy Benefit Manager Service Fees U.S. Health and Human Services Department November 30, 2020 Audio Sources The State of Competition in the Pharmacy Benefits Manager and Pharmacy Marketplaces November 17, 2015 House Committee on the Judiciary Witnesses: Bradley J. Arthur, R.Ph., Owner, Black Rock Pharmacy David Balto, Law Offices of David A. Balto PLLC Amy Bricker, R.Ph. Vice President of Retail Contracting & Strategy, Express Scripts Natalie A. Pons, Senior Vice President and Assistant General Counsel, CVS Health Clips 53:48 Bradley Arthur: The Big Three PBMs control almost 80% of the entire market and these PBMs have the upper hand both in negotiating the contract with the payer, as well as strongly influencing the actual plan design itself. The PBM industry typically states that they can use their economic power to harness enhanced market efficiencies, but for whom? However, the staggering annual revenues that continue to grow each year of the big three suggests that these efficiencies are going directly to their corporations' bottom lines. Small community pharmacies like mine are faced on a daily basis with the impact of the PBMs' disproportionate market power. Community pharmacies routinely must agree to take-it-or-leave-it contracts from the PBMs just to continue to serve our long-standing patients. As if that weren't enough, the PBMs also directly set the reimbursement rates for pharmacies, the very same pharmacies that stand in direct competition of some of these PBM-owned mail-order and specialty pharmacies. Therefore, it comes as no surprise that the PBMs present employer and government payers with carefully tailored suggested plans designs that steer beneficiaries to these PBM-owned entities. Drug Pricing in America: A Prescription for Change, Part I January 29, 2019 Senate Committee on Finance Witnesses: Kathy Sego, Mother of a Child with Insulin-Dependent Diabetes Douglas Holtz-Eakin, Ph.D., President, American Action Forum Mark E. Miller, Ph.D., Vice President of Health Care, Laura and John Arnold Foundation Peter B. Bach, MD, MAPP, Director, Memorial Sloan Kettering Center for Health Policy and Outcomes Clips 1:57:30 Sen. John Cornyn (R - TX): Can anybody on the panel explain to me why we have a general prohibition against kickbacks — they call them rebates — under the Social Security Act, but we nevertheless allow it for prescription drug pricing? What's the sound public policy reason for excluding prescription drug pricing from the anti-kickback rule under federal law? Douglas Holtz-Eakin: I can't explain that and won't pretend to. [laughter] Sen. Cornyn: I thought I was the only one who didn't understand the wisdom of that. Well, it's not a transparent arrangement and it does produce upward pressure on drug prices. And obviously, the negotiations between the PBM and the pharma in terms of what the net cost is, is not transparent, nor is it delivered to the consumer. Is it Dr. Miller? Dr. Bach? Peter Bach: It's delivered to the consumer indirectly through the reduction of the total cost of the benefit, but it is not delivered to the actual consumer using the drug, and that is a disassociation, that is a problem. Because it essentially reverses the structure of insurance. Lowering the total costs are people who use it the least, and raising the costs are people who use it the most, relative to if you allowed the rebate to be used at the point of sale, including all discounts. 1:59:49 Douglas Holtz-Eakin: If we had the negotiation be about the upfront price, so instead of a high list price and a rebate, you just negotiate a lower price, that would be the price that Ms. Sego would pay and insurance companies would look at that and say, okay, she's not paying as much as she used to, we're going to have to make up that money somewhere else and they might raise premiums. That means that people who don't have extreme insulin drug costs would pay a little bit more in a premium every month, and people who have extremely devastating medical conditions and high health care costs would get less costs. That's exactly what insurance is supposed to do. And so the rebate system is more than giving strange incentives on pricing. It's undercutting the purpose of insurance in general. Drug Pricing in America: A Prescription for Change, Part II February 26, 2019 Senate Committee on Finance Witnesses: Richard A. Gonzalez, Chairman and Chief Executive Officer, AbbVie Inc. Pascal Soriot, Executive Director and Chief Executive Officer, AstraZeneca Giovanni Caforio, M.D., Chairman of the Board and Chief Executive Officer, Bristol-Myers Squibb Co. Jennifer Taubert, Executive Vice President, Worldwide Chairman, Janssen Pharmaceuticals, Johnson & Johnson Kenneth C. Frazier, Chairman and Chief Executive Officer, Merck & Co., Inc. Albert Bourla, DVM, Ph.D., Chief Executive Office, Pfizer Olivier Brandicourt, M.D., Former Chief Executive Officer, Sanofi Clips 1:22:03 Albert Bourla: Adverse incentives that favor higher cost biologics are keeping biosimilars from reaching patients. In many cases, insurance companies declined to include lower cost biosimilars in their formularies because they would risk losing the rebates from covering higher cost medicines. I can't think of a more concerning example of a broken system and we need to do something about it. 1:33:35 Sen. Chuck Grassley (R - IA): So many of you have voiced support for the recent rebate rule proposed by the administration. Should the administration finalized this rule, will you commit to lowering your drug prices? Richard Gonzalez [CEO, AbbVie]: Mr. Chairman, we are supportive of the rule. We'd like to see it in its final form, obviously, to make a final decision, but we are supportive of taking the discount to the patient at the point of sale. Sen Grassley: Okay. AstraZeneca? **Pascal Soriot [CEO, AstraZeneca]**The same for us Senator, I would go one step further: if the rebates were removed from the commercial sector as well, we will definitely reduce our list prices. Sen Grassley: Okay. And Bristol? Giovanni Caforio [CEO, Bristol-Myers Squibb]: We have the same positions. Sen Grassley: Okay. Johnson and Johnson? Jennifer Taubert [EVP, J&J]: Yes, we're supportive, and that definitely would be my goal. We would just need to see the final legislation, provided that there aren't additional fees that are added into the system to compensate for the rebates. Sen Grassley: Merck? **Kenneth C. Frazier: I would expect that our prices would go down if we change the system. Again, on the commercial side as well as the Medicare side. Sen Grassley: Okay, Pfizer? Albert Bourla [CEO, Pfizer]: It is a very clear intention that we will not keep a single dollar from these rebates. We will try to move every single penny to the patients and we think if this goes also to the commercial plants that will be even better for more patients. Sen Grassley: Okay. Sanofi? Olivier Brandicourt [Former CEO, Sanofi]: Lowering list price has to be linked to better access and affordability at the counter for the patients. 1:35:20 Sen. Ron Wyden (D - OR): Is it correct that your company, and nobody else, sets the starting price for all drugs sold by Pfizer? Yes or no? Albert Bourla: It is a negotiation with PBMs and they are very powerful. Sen. Wyden: But you still get to set the list price? Albert Bourla: Yes, but we set this price and the rebate limit(?). 1:35:40 Sen. Ron Wyden (D - OR): Is it correct, when a hypothetical patient, let's call her Mrs. Jones, goes to pay for her drug at the pharmacy counter, her coinsurance is based on the price of the drug you set? Albert Bourla: It is correct in many cases. Sen. Wyden: Okay. I just want you all to know that the number one reason consumers are getting hammered, is because these list prices, which you have the last word with respect to where they are, are unaffordable. And the high prices are tied to what the consumer pays at the pharmacy counter. And all this other stuff you talk about, the rebates and the discounts and the coupons, all this other stuff is window dressing, all of that. And the fact is on Part D, 40% of the drugs don't even have a rebate. So I want it understood, particularly because I've asked you, Mr. Borla, I think you and others in the industry are stonewalling on the key issue, which is actually lowering list prices. And reducing those list prices are the easiest way for American consumers to pay less at the pharmacy counter. 2:12:45 Sen. Thomas Carper (D-DE): First is eliminating rebates to PBMs. That's the first one, eliminating rebates to PBMs. The second is value based arrangements. And the third is increasing transparency industry-wide on how you set your prices. 2:13:20 Richard Gonzalez: We clearly support providing the discount at the patient level, eliminating rebates essentially. 2:14:10 Pascal Soriot: If the rebates, as I said earlier, were to be removed from Part D and the commercial sector, we would actually reduce our list prices. 2:15:10 Giovanni Caforio: I would say that not only do we support all three elements that you mentioned, but I do believe those three elements together with the continued effort to develop a gen…
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