Pharmacy benefit managers have been taking a beating on Capitol Hill of late amid a slew of hearings and legislative markups aimed at reform.
However, aside from a blockbuster hearing in mid-May that brought top PBM and pharma execs together, the industry itself has been largely absent from discussions about changes. And they're fed up with not being able to defend themselves against a slew of critics.
Ahead of a hearing Tuesday in the House that featured a witness from just one PBM—the startup AffirmedRx—the Pharmaceutical Care Management Association said in a statement that the lack of their voices "should raise concerns about a powerful panel pursuing predetermined conclusions to pick winners and losers in the marketplace."
“Without hearing from the wider industry in question, and without taking a broader look at the entire supply chain, the Oversight Committee risks fundamentally misconstruing the role of pharmacy benefit companies and playing right into the hands of Big Pharma, which wants nothing more than to weaken this one check on big drug companies’ otherwise unlimited pricing power and avoid accountability for their egregious abuse of the patent system that blocks competition and keeps prices high," CEO JC Scott said in a statement.
Scott added that the House Oversight Committee should "reconsider its approach to this investigation to ensure its findings, and any related policy recommendations, accurately and fairly consider the facts, and the negative implications for patients and employers of any government intervention in the market that undermines the cost-saving value of pharmacy benefit companies."
There are a slew of smaller players, but the pharmacy benefit management industry is dominated by three large players who control 80% of the market: CVS Caremark, Express Scripts and Optum Rx. All three are also vertically integrated with large insurers; CVS Health owns Aetna, Express Scripts is a subsidiary of Cigna and Optum is a sister company to UnitedHealthcare.
Those three companies' huge market share and their closeness with three national payers have been central to the discussion on the Hill over the past several weeks.
Greg Baker, CEO of AffirmedRx, said in his testimony that the lack of competition in the space is "problematic for every employer in the country."
"These PBMs are not constrained by any obligation to be transparent on their pricing or methodology, and this has caused an extreme escalation of cost to all employers using a traditional PBM," he said.
He noted that PBM rebates have grown over time, and these companies continue to turn significant profits.
"This points to the problem, but please understand this is just one out of the thousands of ways PBMs create profit for themselves at the detriment of our American society," Baker said.
Miriam Atkins, M.D., a medical oncologist with AO Multispecialty Clinic in Augusta, Georgia, testified that PBM policies often hindered patient care for her cancer patients.
“Virtually every day, I have to fight insurance companies and their pharmacy benefit (mis)managers to get my patients evidence-based, lifesaving treatment they need. PBMs and their corporate insurers want to control what treatments I give and how and where they are given. In essence, PBMs are practicing medicine without a license or regard for my patients. It is simply all about their profits and not my patients,” said Atkins, who also serves as the president of the Community Oncology Alliance.
The organization has been a vocal critic of the PBM industry.
Upward of 35% of drugs her practice uses to treat cancer are oral medications with high price tags, Atkins noted. She told legislators about her 69-year-old multiple myeloma patient, whose treatment was delayed eight weeks due to administrative red tape.
“Treatment delays, denials and rising drug costs. This is the PBM hell my patients and I live in every day,” she testified.
Senior Editor Heather Landi contributed to this report.