Ilisa BG Bernstein, PharmD, JD, FAPhA
The momentum is building for PBM reform and APhA remains focused on challenging PBM’s anticompetitive business practices which create an unequal playing field in the marketplace that disadvantages patients, pharmacists, and communities.
Last year, following significant pressure from APhA and our pharmacy partners, CMS eliminated retroactive DIR fees beginning January 1, 2024, and FTC released a statement restoring the agency’s policy of rigorously enforcing the federal ban on unfair methods of competition and intent “to exercise its full statutory authority against companies that use unfair tactics to gain an advantage instead of competing on the merits.”
APhA did not let up on the gas pedal and recently hosted a bipartisan, educational PBM 101 briefing for congressional staff with the goal to equip them with the knowledge—including real-life examples and data—and the tools needed to restore equity to the PBM marketplace and protect access to pharmacist-provided patient care services and affordable medications, with a particular focus on rural and underserved communities, where pharmacists may be the only health care provider for miles.
Members of APhA’s Government Affairs Team Michael Baxter and Doug Huynh, JD, joined me in sharing presentations from APhA partners and PBM experts Greg Reybold, JD, director of healthcare policy and general counsel of the American Pharmacy Cooperative, Inc.; and Antonio Ciaccia, CEO of 46brooklyn Research and president of 3 Axis Advisors.
The briefing was sponsored by key members of the powerful House Energy and Commerce Committee with direct jurisdiction over health care/PBM issues, including Reps. Larry Bucshon, MD, (R-IN), vice-chair of the Health Subcommittee, pharmacist Buddy Carter (R-GA), and Diana DeGette (D-CO)—all of whom APhA will be working with on increased congressional oversight and PBM reform legislation.
Also highlighted during our educational PBM 101 briefing were the results of APhA's recent PBM reform survey, which included key findings such as
- 91.5% of respondents agreed that PBM practices negatively affect their practice and their ability to provide patient care.
- 93.3% of respondents agreed that patient steerage practices impact their pharmacy and the patient care they provide. (Patient steering is requiring or incentivizing patients to use certain pharmacies, often ones owned by the PBM.)
- 88.5% of respondents agreed that “clawback” fees impact their pharmacy and the patient care they provide. (These are fees collected by the PBM after the point of sale, increasing patient out-of-pocket costs for medications. They are also known as DIR fees or price concessions.)
This latest APhA survey data add to the increasing evidence that PBM practices and tactics are resulting in inflated out-of-pocket drug costs for patients and continued struggles for America’s pharmacies to keep their doors open to provide patient care, further building the case that PBM reform is needed now.
The following day, the House Oversight and Accountability Committee Chair James Comer (R-KY) launched an investigation into PBMs’ role in rising health care costs. The committee’s investigation calls for documents, communications, and information related to PBM practices that are distorting the pharmaceutical market and limiting high-quality care for patients.
This is all very exciting and APhA will not let up until we have restored equity and promoted a more consumer-friendly marketplace that improves patients’ access to medicines and services at their local pharmacies, including independent, chain, or those associated with health systems.