House Investigation PBM Caremark, Express Scripts, OptumRx

A key House panel has joined the chorus of critics railing against pharmacy benefit managers, increasing the government’s pressure on several major healthcare companies.

Oversight and Accountability Committee Chairman James Comer (R-Ky.) is the latest official to launch an investigation into “anti-competitive tactics” that drive up health care spending and harm patients, the committee announced in a news release Wednesday. Did.

Comer sent letters to CVS Health’s Caremark, UnitedHealth Group’s OptumRx and Cigna’s Express Scripts seeking information on topics including how they design formularies, steer patients, collect rebates from drug companies and differential pricing. Let’s set up the system. These three PBMs have a combined 80% market share and have expanded their operations to include group purchasing organizations headquartered overseas which gives the total discount to other PBMs, which Comer also inquired about. Was.

David Dobrajkowski, director of healthcare initiatives at the University of Arkansas’ Sam M. Walton College of Business, said the House investigation will give PBMs the possibility to become more transparent to avoid new government orders. “When organizations are faced with a choice between self-regulation and external regulation, self-regulation is better,” he said.

Express Scripts did not respond to a request for an interview. OptumRx and Caremark referred questions to the Pharmaceutical Care Management Association, which did not respond to an interview request. The PBM trade group last week launched a seven-figure, 10-month national advertising campaign to promote its members.

The oversight committee requested information from the Centers for Medicare and Medicaid Services, the Office of Personnel Management and the Defense Health Agency on how PBMs interact with government health programs. Federal agencies did not respond to requests for interviews and Comer declined to comment.

PBMs were already under fire from President Joe Biden’s administration, Congress and several states, both Democrat- and Republican-led.

the federal trade commission is Scrutinizing PBM Business Practices Comer is checking. The FTC last June subpoenaed six of the largest PBMs, including Caremark, Express Scripts and OptumRx, to obtain information for its inquiry. The agency did not respond to an interview request.

On the other side of Congress, Sens. Maria Cantwell (D-Wash) and Chuck Grassley (R-Iowa) introduced legislation to increase transparency in the PBM industry: the Prescription Pricing Act for the People of 2023 and the Pharmacy Benefit Manager Transparency Act of 2023. the former will direct the FTC to research its effects Consolidation in the PBM Industry nd the latter would prohibit PBMs from withholding certain payments to drugstores and require them to disclose their terms Diffuse Pricing Plans and pharmacy fee for FTC. Cantwell and Grassley, senior members of the powerful finance committee, did not respond to requests for interviews.

At the state level, PBMs have been hit with an increasing number of legal actions seeking to recover overpayments made by Medicaid and other programs.

And the Inflation Reduction Act of 2022 dealt a rare blow against drugmakers and PBMs, Dobrzykowski said. The law gives the Department of Health and Human Services the authority to set prices for certain drugs, fine drug companies that raise prices faster than inflation, and investigate secretive contracting practices.

Evidence is mixed on whether PBMs provide a net benefit to the healthcare system. For example, while University of Southern California researchers linked large discounts to rising drug prices, CMS actuaries concluded that rebates inhibit price increases.

One thing is certain: Companies in the drug supply chain face more pressure than ever to drive down costs, Dobrzykowski said. “The environment is different than it has been in the past, where there are multiple pressure points on the pharmaceutical space that can collectively drive change,” he said.

Comer, who hosted a forum on PBM issues in 2021, may be ready to do more than just investigate, said Antonio Ciaccia, CEO of drug pricing research company 46Brooklyn Research and president of consulting firm 3 Axis Advisors. Ciaccia spoke at the Commerce 2021 event.

“I’m worried about James Comer being on the wrong end,” Ciaccia said. “I don’t take that as someone who wants to go through the drama. It’s about trying to measure the size of the problem, to figure out what the appropriate solution is. Diagnose, then treat.

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