Special Guest:

Lindsay Bealor Greenleaf, J.D., M.B.A.,

Vice President and Head of Policy with ADVI Health Inc.

Why now: This week U.S. Sens. Chuck Grassley (R-IA) and Maria Cantwell (D-WA) introduced two bills that seek to hold pharmacy benefit managers (PBMs) accountable for opaque practices that contribute to high drug prices for consumers.

 

Expert commentary: Lindsay Bealor Greenleaf, J.D., M.B.A., vice president and head of policy with ADVI can dive deep into a discussion on PBMs expanding on the following points:

 

1) PBMs were completely spared in the IRA while the people who actually make drugs got hit with unprecedented government price setting  

 

2) Fortunately, PBMs will now face scrutiny on the Hill, including Prescription Pricing for the People Act (S. 113) and the PBM Transparency Act (S. 127) with new bills and “noisy” hearings

 

3) PBMs are also in hot seat with the FTC (from Lindsay’s perspective, the FTC is “incredibly hostile towards PBMs right now”)

Are these topics areas you’d like to explore? If yes, I’d like to line up a time for you to connect with Lindsay in the coming weeks. I look forward to your feedback on your interest in a podcast episode with our ADVI experts. 

Reference: 

State Legislatures Lead the Way on Policy Reform to Protect Personalized Medicine

Feb 22, 2023

Angela Storseth-Cooper

Lalan Wilfong, MD

https://www.ajmc.com/view/state-legislatures-lead-the-way-on-policy-reform-to-protect-personalized-medicine 

In Blow to PBMs, CMS Floats Reform of Part D Price Concessions

https://www.mmitnetwork.com/aishealth/spotlight-on-market-access/in-blow-to-pbms-cms-floats-reform-of-part-d-price-concessions-2/

The Express Scripts decision removes the option for Tricare beneficiaries to get prescriptions at the pharmacies of their choice. The National Community Pharmacists Association (NCPA) CEO B. Douglas Hoey, PharmD, MBA, warns that “access to needed medications for Tricare beneficiaries is in peril.”

 

Guest 

Alan Rosenbloom

President & CEO

Senior Care Pharmacy Coalition

Today we are hoping to make sense of the Inflation Reduction Act which is designed to protect Medicare recipients from catastrophic drug costs by phasing in a cap for out-of-pocket costs and establishing a$35 cap for a month's supply of insulin. And, as an historic win, Medicare will be able to negotiate prices for high-cost drugs for the first time ever.

Guests: 

Mark Blum 

Mark is the Executive Director of America's Agenda, an organization he’s led since its founding in 2005. America's Agenda is a national healthcare alliance that brings together labor unions, businesses, healthcare providers, and policymakers who share a common commitment to smart policy and effective action to advance our mission of affordable, high-quality, readily accessible healthcare for every American. Mark currently serves on the State Health Benefits Value and is a former member of the Quality Task Force in New Jersey and previously worked as an economics professor as well as national director of organizing for the American Association of University Professors. He completed his graduate studies at the London School of Economics.

 

A major focus for Mark in recent years has been the Pharmacy Benefit Manager issues facing our country. Mark is a founding member of the PBM Accountability Project. He works tirelessly to educate the public and advance solutions to help redirect prescription drug savings from very high PBM profits back to patients, employee health plans, and taxpayers.

Antonio Ciaccia

Antonio Ciaccia (cha-cha) is the President of 3 Axis Advisors, a firm that among many things studies drug pricing. He was recently featured on NBC’s Today Show talking about the lengths PBMs force independent pharmacies to go to find savings for their patients. He’s also spoken publicly about PBMs in the context of the Inflation Reduction Act. Antonio has been in and around pharmacies his entire life. A graduate from The Ohio State University in 2007 with dual degrees in communications and political science. For six years he headed up government affairs for the Ohio Pharmacists Association. After years of studying the pharmacy marketplace, Antonio became increasingly perplexed and concerned as he saw drug costs spiking while payouts to pharmacies were declining. Knowing something was being lost somewhere in the middle of an ever-growing transaction, Antonio has spent years working to crack the drug pricing code and pull the rug out from what he believes is one of the most dysfunctional marketplaces in the world.

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Congressman Buddy Carter and General Counsel of NCPA Matthew Seiler on PBM Reform. On this episode of the 'PBM Reform Podcast' we discuss the Pharmacy Benefit Manager (PBM) Transparency Act of 2022 (the Act) was recently proposed in the U.S. Senate and intends to incentivize “fair and transparent” PBM practices, prohibit spread pricing and claw backs of payments to pharmacies, and empower the Federal Trade Commission (FTC) and state attorneys general in enforcement actions to stop “unfair and deceptive” PBM business practices.

The Act was introduced by Senators Maria Cantwell Chuck Grassley on May 24, 2022, and was approved by the Commerce Committee with bipartisan support (19-9) on June 22, 2022. This summary provides a high-level overview of the Act’s key measures.

Prohibition on Unfair or Deceptive Prescription Drug Pricing Practices

The Act would make it illegal for PBMs to:

Engage in “spread pricing,” which is described as charging a health plan or payer a different amount for a prescription drug’s ingredient cost or dispensing fee than the amount the PBM reimburses a pharmacy for the prescription drug’s ingredient cost or dispensing fee where the PBM retains the amount of any such difference;

Arbitrarily, unfairly, or deceptively reduce or rescind (a.k.a. “claw back”) any portion of the reimbursement payment to a pharmacist or pharmacy for a prescription drug’s ingredient cost of dispensing fee; or

Arbitrarily, unfairly, or deceptively increase or lower fees and reimbursements to a pharmacy to offset reimbursement changes under any federally funded health plan.

The Act would incentivize transparency by stating that a PBM shall not be in violation of the Act if the PBM passes through 100% of price concessions to a health plan or payer and provides complete disclosure of:

The cost, price, and reimbursement of prescription drugs to each health plan, payer, and pharmacy;

All fees, markups, and discounts the PBM charges or imposes on each health plan, payer, and pharmacy; and

The aggregate remuneration PBM receives from drug manufacturers, including nay rebate, discount, administration fee, and any other payment or credit obtained or retained by PBM.

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Senator Chuck Grassley (R-Iowa) and Maria Cantwell (D-Wash.) introduced the Pharmacy Benefit Manager Transparency Act of 2022 on May 24, which would make it illegal for PBMs to engage in “spread pricing.” Spread pricing occurs when PBMs charge health plans and payers more for a prescription drug than what they reimburse to the pharmacy — and then keep the difference. For example, when a pharmacist fills a prescription, a PBM handles the process, informing the pharmacy it will be reimbursed $90. 

The PBM then charges the health insurance plan $100 for processing the same prescription. The spread of $10 is pocketed by the PBMs. Related: New PBM players banking on drug pricing transparency for success The bipartisan legislation would empower the Federal Trade Commission (FTC) to increase drug pricing transparency and hold pharmacy benefit managers (PBMs) accountable for unfair and deceptive practices that drive up the costs of prescription drugs at the expense of consumers. 

It also would prohibit arbitrary clawbacks of payments made to pharmacies and require PBMs to report to the FTC how much money they make through spread pricing and pharmacy fees.

SCPC, CEO, Alan Rosenbloom & Senior Director, Regulatory Policy at APhA, Michael Baxter join Todd Eury with the Pharmacy Podcast Network to discuss the impact of the Pharmacy Benefit Manager Transparency Act of 2022 on the Pharmacy Profession.

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Pennsylvanians suffer while pharmacy middlemen profit

By Suzanna Masartis

Pennsylvanians are getting crushed by the costs they face at their neighborhood pharmacy counter. The situation has grown so bad that a shocking one in five Keystone State residents report they are unable to take their medications as prescribed due to the cost burden.[1]

As a lawmaker and an advocate who speaks to patients in Pennsylvania every day with liver disease, diabetes and other chronic conditions, I am convinced more strongly than ever that we need to reform the prescription drug supply chain.

To understand how we got here we need to understand what’s driving increasing costs. A new report found that, in 2020, manufacturers of brand-name and generic medications received only 37 cents of each dollar of the more than $680 billion spent on medications. If you look exclusively at manufacturers of brand-name medications, the drug makers are taking in just under 50 cents on the dollar. So where is the money going? Turns out that it’s little-known middlemen corporations, Pharmacy Benefit Managers (PBMs), that are taking a bigger and bigger share of the pie.[2]

PBMs were created to negotiate with insurers and drug manufacturers and establish which prescription drugs are covered by a health plan. In reality, they demand steep discounts from drug makers off of the original list price as a condition to include those drugs on the approved list of medications – and then keep the savings for themselves. But here's the real rip-off: Patients at the pharmacy counter still face co-insurance charges based on the list price -- not the discounted price insurers actually pay. In other words, PBMs are enriching themselves while hiking prices for the rest of us. {3}

Worse still, PBMs manipulate their powerful market position to reduce the availability of prescription medications by excluding them from formularies. PBMs make their money when they demand exorbitant rebates from drugmakers and charge patients full cost, meaning they prefer to include drugs with higher list prices on their formulary over an equally effective drug with a lower list price. As a result, a number of drugs are excluded from formularies because PBMs can’t make as much money from them. In 2020, the three largest PBMs excluded 846 FDA-approved drugs, denying patients access to more medications than ever before.

This market manipulation has disastrous results for patients. A study published last year found that these practices, called “drug utilization management,” can lead patients to abandon their prescribed medications and delay treatment. Approximately 20% of prescriptions in the U.S. are never filled, according to the study.[4] This outcome is simply unacceptable, and our leaders need to take action.

Congress needs to ensure that any attempt to rein in out-of-pocket prescription drug costs includes taking a close and hard look at PBMs. Doing so would go a long way toward ensuring every patient and healthcare consumer in our state can access and afford to take their medications as prescribed by their doctor.

Suzanna Masartis of Pittsburgh is the CEO of the Community Liver Alliance.

[1]https://www.healthcarevaluehub.org/advocate-resources/publications/pennsylvania-residents-worried-about-high-drug-costs-support-range-government-solutions

[2]https://ecommunications.thinkbrg.com/44/2328/uploads/brg-pharmaceutical-supply-chain-2022.pdf?intIaContactId=24HydQaSTYqd85tTztTDcQ%3d%3d&intExternalSystemId=1

[3] https://www.fiercehealthcare.com/payer/study-drug-utilization-costs-health-industry-93b-a-year-patients-bearing-most-cost

[4] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2021.00036

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Dave Teckman, Executive Chairman at ActiveRADAR joins the PBM Reform Podcast series about the impact of therapeutic interchange technologies on PBM pricing & the powerful data at the pharmacist's fingertips with ActiveRADAR.

Through rigorous clinical evaluation of all drugs in over 112 therapeutic categories, ActiveRADAR first establishes which drugs are clinically equivalent and therefore therapeutic alternatives to one another. This creates our Clinical Catalog of over 26,000+ therapeutically equivalent “perfect pairs”. Then ActiveRADAR determines the economic value using plan specific data to value each drug within its respective therapeutic class and sets pricing and reimbursement accordingly. This type of program has historically been called “reference pricing”, however ActiveRADAR takes it a step further by establishing both THE CLINICAL AND ECONOMIC VALUE OF EACH AND EVERY DRUG IN EACH THERAPEUTIC DRUG CLASS.

About ActiveRadar:

ActiveRADAR, formerly RxTE Health, is a healthcare analytics and patient education company providing unique data-driven, cost-saving customized prescription options. Using proprietary technology, ActiveRADAR identifies the lowest cost prescription options.

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Madelaine A. Feldman, MD, FACR

Dr. Madelaine Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans, LA. She is President of the Coalition of State Rheumatology Organizations, Chair of the Alliance for Safe Biologic Medicines and past member of the American College of Rheumatology insurance subcommittee.

Dr. Feldman is a Clinical Assistant Professor of Medicine at Tulane University School of Medicine, and lectures extensively to patients, physicians, regulators, and legislators both locally and nationally, speaking before the Health subcommittee of Energy and Commerce in 2019.  She has spoken and written on the drug supply channel, particularly the effect that formulary construction and utilization management tools have on pricing and access to drugs (availability & affordability).

Dr. Feldman is honored to be the recipient of the American College of Rheumatology's 2021 Innovation in Clinical Care award. She received the Distinguished Service Award for Tulane Medical School, was named one of the Top Women in New Orleans by City Business in 2017 and is the former radio talk show host of “Driving with Dr. Mattie.”

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Speaking to the Pharmacy Podcast Network, Dr. Marion Mass, a pediatrician, patient advocate and founding member of the Practicing Physicians of America, spoke about the original intent of PBMs, which started in 1968, and what they’ve become today.

“PBMs were created with the vision that they would act like giant drug-buying networks, with their buying power cutting health care costs and consumers realizing the savings in the end. However, through consolidation, three companies now control 90 percent of the market,” she said.

Dr. Mass further explained, “This unhealthy market share has led to an unhealthy control over formularies,” which can cause life-and-death situations for her young patients. “Patients are at risk of death or harm when drugs such as chemotherapies, antibiotics, epinephrine and anesthetics are not available.”

Pharm D Mel Brodsky, executive director of the Philadelphia Association of Retail Druggists and former CEO of the Keystone Purchasing Alliance, explained, “This outsized market share takes advantage of drug manufacturers, pharmacists and, most importantly, patients. The result is a net negative for all parties except for the large PBMs.”

In his estimation, the net result of this imbalance “has led to an erosion of the doctor-patient relationship and a decimation of Main Street pharmacists throughout the nation.”

“With the current system in place, independent pharmacists are being squeezed to the point that many jump when the large groups offer to buy them out. With the depletion of community pharmacists comes the loss of personal touch and a watered-down version of health care to patients,” Brodsky said. 

Both participants agreed that action must be taken on the federal level, citing Pennsylvania Sens. Bob Casey and Pat Toomey’s abilities to rein in the large PBM market imbalance

Our Guests: 

Dr. Marion Mass. Dr. Mass is a pediatrician in the Philadelphia suburbs. She received her medical degree from Duke University School of Medicine and has been in practice for more than 20 years. She is the co-founder of Practicing Physicians of America - and leadership in the Free2Care coalition-a consortium of grassroots physician advocacy groups that believe that the key to good care starts with the relationship between a patient and their doctor. She sits on the editorial board of the Bucks County Courier, Times and is a member of the Bucks County Health Improvement Partnership.

Mr. Mel Brodsky is the Executive Director of the Philadelphia Association of Retail Druggists (PARD), an association of community pharmacies representing 250 independently owned pharmacies in Southeast Pennsylvania. PARD works closely with State Associations like the Pennsylvania Pharmacists Association (PPA). Mr. Brodsky is also CEO of the Keystone Pharmacy Purchasing Alliance, headquartered in Philadelphia with 400 member stores in 5 States. Mel has an amazing understanding of how PBMs impact the effectiveness and growth of vital healthcare service providers like Community Pharmacies.  

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Special interview w/  award-winning ProPublica reporter Marshall Allen, a primer for anyone who wants to fight the predatory health care system--and win.

We welcome back two patriots in PBM Reform on the interview w/ Marshall. 

Monique Whitney - CEO of Pharmacists United for Truth & Transparency and PUTT President and Pharmacy Owner Scott Newman.  

Every year, millions of Americans are overcharged and underserved while the health care industry makes record profits. We know something is wrong, but the layers of bureaucracy designed to discourage complaints make pushing back seem impossible. At least, this is what the health care power players want you to think.

Never Pay the First Bill is the guerilla guide to health care the American people and employers need. Drawing on 15 years of investigating the health care industry, reporter Marshall Allen shows how companies and individuals have managed to force medical providers to play fair, and shows how you can, too. He reveals the industry's pressure points and how companies and individuals have fought overbilling, price gouging, insurance denials, and more to get the care they deserve. Laying out a practical plan for protecting yourself against the system's predatory practices, Allen offers the inspiration you need and tried-and-true strategies such as:

Analyze and contest your medical bills, so you don't pay more than you should

Obtain the billing codes for a procedure in advance

Write in an appropriate treatment clause before signing financial documents

Get your way by suing in small claims court

Few politicians and CEOs have been willing to stand up to the medical industry. It is up to the American people to equip ourselves to fight back for the sake of our families--and everyone else.

See omnystudio.com/listener for privacy information.

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