Congress Must Take Action On PBMs

by Barbara Kavanagh, Founder - Cancer Caregivers of America

There is a plant called “kudzu” that is native to areas of Japan and China.  It came to America in the late 1800s but took off in the 1950s when the Soil Conservation Service promoted the plant as a beneficial way to control soil erosion.  Thanks to that endorsement, kudzu was planted throughout the South, where the climate and temperature were perfect for its growth.  What has happened in the decades since has been nothing short of a disaster. Kudzu grew relentlessly throughout the South, spreading rapidly and overtaking native grasses, flowers, fully mature trees, and even telephone poles. It grows at a rate of 1 foot per day, and residents and experts have worked diligently in recent years to try and reign in the damaging effects that kudzu brings to its region.

The story of kudzu is relatable to our healthcare system, notably pharmacy benefit managers (PBMs). PBMs have been part of the healthcare ecosystem for nearly six decades. They started as an administrative body that would handle simple tasks like processing claims related to prescription drugs. Their role was basically to simplify the paperwork side of prescriptions for insurers and employers. In the past 20 years, though, like kudzu, their expansion and growth have become untenable. They have used that time to position themselves as “negotiators” who are there to secure discounts from drug manufacturers. The health care system had become so convoluted that the average patient (or member of Congress) rarely sought clarity on their role. As a result, PBM’s power and influence went to unprecedented levels. Nowadays, they have begun to manage drug formularies, deciding which medications would be covered by insurance plans.

The influence of this cannot be understated – PBMs have essentially been given control over drug access and pricing. The ‘kudzu-ication’ of PBMs has now spread to health insurance companies and retail pharmacies, who now are entangled together and dictating the prices we pay at the pharmacy. Now for the good news. It seems that Congress has opened its eyes to the damage that is being done to patients and has taken out its weed wacker. There are many bipartisan bills in Congress this session that aim to untangle this mess. Some bring more transparency to the PBM industry, while some look to prohibit PBMs from basing their fees on the price of the medicine. The latter proposal, also known as ‘delinking,’ aims to remove incentives for PBMs to push patients to higher list-price medicines. One that has been very popular (included in S. 3430) requires PBMs and health plans to share the savings they receive on medicines directly with patients at the pharmacy counter to lower patient out-of-pocket costs and help realign payer incentives.

Many of our leaders have spent the past few months asking for our vote. They’ve aired commercials, sent text messages, and filled our mailboxes with messages about passing policies that will help patients, seniors, and Arizonans. Now, we need those same Congressional leaders to follow through and push some of these policies, such as de-linking or sharing the savings across the finish line.  Arizona is lucky to have two of the most influential and bi-partisan Senators in Congress, Kyrsten Sinema and Mark Kelly, representing us. We also have an incoming Senator, Ruben Gallego, and influential House Republican leader, David Schweikert. These four members, along with the rest of our delegation, can work with their colleagues to get PBM policy reform passed in 2024. If not, there’s no telling how much more the PBM weed will grow.