PBM Reform Podcast

By Pharmacy Podcast NetworkNews

PBM Reform Podcast episodes

October 14, 2023 MISSION CRITICAL: Reform the Mysterious PBM System with Antonio Ciaccia | PBM Reform
Antonio Ciaccia is the President of 3 Axis Advisors. He was born and raised in pharmacy, Antonio has been crawling around pharmacies his entire life. After three years as a pharmacy technician and two years of pre-pharmacy curriculum, Antonio diverted course, graduating from The Ohio State University in 2007 with dual degrees in communications and political science before moving into the world of association management.

3 Axis Advisors brings unique approaches to address the individual needs of each or our clients. As researchers and investigators at heart, 3 Axis endeavors are laser-focused on discovery through data-driven analysis and deep industry expertise, resulting in innovative and unique solutions.

Our obsessive passion for understanding complex systems and our immersion in the prescription drug supply chain and the broader healthcare delivery system enables us to arm our clients with the tools they need to accomplish their goals.

Reference:
Ohio regulator’s proposed pharmacy rules draw mixed response
New regs meant to promote safety at understaffed stores
https://ohiocapitaljournal.com/2023/10/02/ohio-regulators-proposed-pharmacy-rules-draw-mixed-response/
30 min
July 10, 2023 Reigning In Out of Control Drug Costs | PBM Reform Podcast
Our special guest Wendy Barnes, CEO of RxBenefits and Mark Campbell, the VP of RxBenefits.

From BenefitsPro:
https://www.benefitspro.com/2023/03/27/how-dispelling-mistrust-of-generics-will-help-patients-and-plan-sponsors/?slreturn=20240222125659

Health care spending in the United States has increased substantially the past few years, and it isn't likely to slow down any time soon. At this rate, national health care costs could reach $6.2 trillion by 2028. A number of factors, including the cost of medical supplies and drugs, contribute to those rising numbers. The financial pinch many people were already feeling has been intensified by the unsteady economy, leading consumers to call for lowered health plan costs whenever and wherever possible. Some believe reducing prescription drug spending is an easy way to do that. But consumers still deserve access to the medications they need at prices they can afford.

Generic medications: A solution to potential challenges
Using generic medications in place of high-priced, brand-name drugs offers the same clinical benefits, and it can save patients and health plan providers significant money in the long run. It's a convenient, simple way to reduce costs while making sure patients have continued access to the treatments and medicines they've been prescribed. But while generics are an obvious answer to many challenges facing the industry, they aren't embraced nearly as often as they should be. According to U.S. Pharmacist, "While generic drugs are extensively prescribed … t some consumers are still hesitant about using generic drugs and believe that they are not as safe or effective as brand-name drugs."

Consumers have a variety of reasons for their misgivings, but the skepticism is unwarranted. Many health plan administrators and pharmacy benefit optimizers are working to dispel the myths that can rob consumers of significant savings.
50 min
June 15, 2023 Titans for PBM Reform: Loretta Boesing & Antonio Ciaccia | PBM Reform
House Energy and Commerce Committee cleared a PBM bill that seems to contain more transparency loopholes and makes more limited policy tweaks to the drug supply chain middleman than the Senate HELP Committee’s bill, but the House-side legislation would pull back the curtain on specialty-drug reimbursement in a way the Senate version does not.

Two titans of PBM Reform join us today, returning guest Antonio Ciaccia with 3 Axis Advisors and Loretta Boesing with Unite for Safe Medications update our PBM Reform Podcast listeners with the latest progression in PBM Reform.

Reference:
PBM Reform: Vertical Integration, Specialty Drug Tracking Among Differences In House v. Senate Bills
https://pink.pharmaintelligence.informa.com/PS148320/PBM-Reform-Vertical-Integration-Specialty-Drug-Tracking-Among-Differences-In-House-v-Senate-Bills
43 min
March 21, 2023 Alan Rosenbloom | SCPC | PBM Reform Podcast
Let's talk about the current state of the industry.

Senior Care Pharmacy Coalition: SCPC just missed getting the LTC Pharmacy Definition passed last year. The PBM issues continue, even with gov't interest and involvement.

Let's discuss LTC pharmacy's value to dual-eligibles, and how some simple policy changes would improve care for this population and save the system millions of dollars, overall. Let's talk about how LTC pharmacies are in an increasingly tough spot because or drug pricing policies. The patients they serve often rely on price-controlled meds that often leave them serving at a loss.
This episode is sponsored by FRAMEWORK LTC: For more information visit frameworkltc.com
44 min
March 07, 2023 FTC Cornering PBMs to Improve Pharmacy Care | PBM Reform
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/
33 min
November 02, 2022 Did Tricare & Express Scripts put profits over patient care? | PBM Reform Podcast
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.”

This decision is estimated to impact hundreds of thousands of beneficiaries relying on certain pharmacies (or locations) to get prescriptions—those who cannot get their prescription at the pharmacy of their choice may fall out of care.

Consequently, patients may lose access to the potentially lifesaving treatments that specialty and independent pharmacies can provide, especially for patients with critical illnesses such as HIV, among other illnesses.
In a recent analysis, experts suggested that the contract, made with the US Department of Defense (DOD), could shrink the retail pharmaceutical network by 15,000 pharmacies.

Guest
Alan Rosenbloom
President & CEO
Senior Care Pharmacy Coalition
42 min
October 04, 2022 How will the Inflation Reduction Act Impact PBM Reform? | PBM Reform Podcast
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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1 hr
July 22, 2022 Congressman Buddy Carter and General Counsel of NCPA Matthew Seiler on PBM Reform
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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52 min
June 22, 2022 What’s the Impact of the Pharmacy Benefit Manager Transparency Act of 2022 | PBM Reform Podcast
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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41 min
April 01, 2022 Pennsylvanians Suffer while Pharmacy Middlemen Profit | PBM Reform Podcast Series
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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43 min

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Pharmacy benefit managers were created as middlemen to reduce administrative costs for insurers, validate a patient’s eligibility, administer plan benefits, and negotiate costs between pharmacies and…