Once again, we are reading news reports about the pharmaceutical industry’s efforts to influence public policy and their latest meetings with the new Trump Administration, set against a backdrop of rising list prices and continuous TV advertisements targeting American patients to take ever more expensive drugs.
Every day, Americans hear about new pharmaceutical innovations to improve their health and their lives – from personalized medicine to breakthrough treatments for cancer to innovations in weight loss therapies. Make no mistake, this pharmaceutical innovation is a good thing. Consumers not only want – but are rightly demanding – access to these therapies and health care services that deliver on what Americans need to get and stay healthy, affordably and conveniently.
At the same time, unprecedented demand for drugs is spurring an affordability challenge. The exorbitant list prices for medications, including GLP-1 obesity medications, is increasing pressure on national health care spending, the budgets of American families, and continually putting fiscal pressure on employers offering health care coverage.
While pharma is lobbying to defend their status quo pricing practices, PBMs are not waiting for government interventions or unnecessary mandates to address what the market is demanding. PBMs have announced several new innovative programs to meet those demands – helping employers and unions offer competitive pharmacy benefits, while giving patients more convenient access to prescriptions drugs and lowering their out-of-pocket costs.
Consumers want to pay less for prescription drugs. Last month, one PBM announced actions to lower out-of-pocket costs for more patients including ensuring patients don’t pay more out-of-pocket for their medications than the amount the PBM negotiated. This foundational position is broadly endorsed across the PBM industry and the announcement is just the latest concrete action showing a proactive approach toward addressing challenges in health care to better serve consumers.
Consumers and employers want more transparent information from PBMs. Several PBMs have implemented programs that enhance transparency and simplify pharmacy benefits for patients and their health care providers, so they can understand what their costs will be at the pharmacy counter. Additional programs offer patients resources and education, helping them find affordable options, while still more are launching consumer-friendly apps so families can manage prescriptions transparently.
Consumers want their employer to design prescription drug benefits that put their concerns first. PBMs have recognized that because of employer benefit design decisions, some patients are facing unaffordable out-of-pocket costs that may prevent them from accessing their medicines. As a result, more programs are now available to plan sponsors that limit to $0 or a low dollar amount what is paid by patients out-of-pocket for many common prescription drugs.
Consumers also want lower drug manufacturer sticker (or list) prices. So do PBMs. Lowering out-of-pocket costs requires that we continue to focus on the list prices set by drug manufacturers, which are always the starting point for questions on cost and affordability. That’s why PBMs support and are calling for drug manufacturers to lower the list prices on all prescription drugs. Lower list prices means a better starting point for PBM negotiations for discounts to drive lower costs.
And, consumers want a stronger retail pharmacy market and better access to pharmacies regardless of where they live. Pharmacies offer important care to patients, far beyond filling prescriptions. To facilitate a better experience, patients need a pharmacy channel that provides a convenient access point for obtaining prescription drugs that can serve them with quality, care, and compassion, including in underserved areas. Innovative programs from PBMs are intended to strengthen access to pharmacies and empower pharmacists to expand the care they deliver to patients. New, more transparent pharmacy reimbursement models, enhanced pharmacy networks, increased reimbursement in rural areas, and expansion of the clinical services through partnerships with pharmacies will all help evolve the pharmacy market and move toward a more patient-centered future.
Challenges to patient affordability and access need to be addressed. And the PBM industry is already moving to respond, demonstrating a focus on patients and a market that is innovative and adaptive. It is crucially important that as policymakers consider proposals to intervene in the commercial insurance market with PBM mandates and limitations, they do so with a full understanding of the numerous ways the market continues to change and adapt. By avoiding disruptions to this progress, we can continue putting patients at the center of the system.
Equally critical is that policies to reform the prescription drug supply chain help meet the needs of actual patients and consumers – not special interests that advocate for misguided PBM reforms that financially benefit them and not the patients we all collectively serve. We are evolving our business to meet evolving consumer, employer, and pharmacy demand, needs, and preferences – all in an effort to contain costs and boost access. Congress should ask what other supply chain players are doing to lower costs and make informed decisions that actually help the patient – who should be at the center of all health policy decisions.
JC Scott is the president and CEO of the Pharmaceutical Care Management Association (PCMA).
