“We are asking the CMS [Centers for Medicare & Medicaid Services] to define the key terms in the marketplace: What is a rebate? What are associated costs? If we could develop clearer definitions and more transparency on rebates, we would know more about what’s happening. We plan to go to Congress and ask them to ask the CMS for answers,” Dr. Worthing said.
Rheumatologists say PBMs negatively affect patients through the use of prior authorization requirements, spread pricing, step therapy programs that determine which drug the patient must try first …
Holding Their Feet to the Fire
One success for ACR’s advocacy strategy occurred when the Senate Committee on Health, Education, Labor and Pensions (HELP) held a second hearing on drug pricing issues Oct. 17. At the hearing, both Democratic and Republican committee members asked questions about high drug prices and the effects of rebates and called for greater transparency in PBMs’ pricing practices. “Committee members held PBMs’ feet to the fire with their questions,” Dr. Worthing said. Such hearings are critical because they help drive the national conversation about the role of PBMs.
The ACR’s Insurance Subcommittee, formed eight years ago with the purpose of coordinating activities involving health insurers that have an impact on the practice environment of rheumatologists, continues to be busy with these issues, committee chair Sean Fahey, MD, a rheumatologist with Piedmont HealthCare in Mooresville, N.C., said at the Annual Meeting. “The focus revolves around drug costs, and a lot of the concerns revolve around PBMs.”
The committee is seeing increasing interactions related to the cost of drugs and the larger role of PBMs, Dr. Fahey said. “The PBM’s whole reason for being is to make money, whether by rebates, fees or contracts, and our patients too often are caught in the middle. We’ve tried the honey approach and the vinegar approach. Hopefully, over time, we’ll blend these two and find ways to collaborate with them. We’ve tried to reach out to PBMs to be more collaborative, but it’s unclear if we’ve been able to influence policy.”
Additionally in 2017, in response to the growing, negative impacts of PBM practices, the ACR, the Coalition of State Rheumatology Organizations and several other physician and patient groups formed the Alliance for Transparent and Affordable Prescriptions (ATAP) to bring further attention to the impact of PBMs on drug pricing and access. ATAP’s goal is to address PBMs’ effects on drug prices and access to treatment.
