Presidential Viewpoint BY MICHAEL JACKSON, RPH DANIEL E. BUFFINGTON, PHARMD, MBA, FAPHA
The United States Federal Trade Commission (FTC): Preparing to Study PBM Anticompetitive Practices and Its Impact on Healthcare Practice and Patient Outcomes
T
he connection between patients, pha r mac ist s, a nd hea lt h insurance companies is often clouded and negatively impacted by companies and software platforms referred to as Pharmacy Benefit Managers (PBM). These unregulated compa n ies apply cont rac t ua l mechanisms that regulate the cost and access to medications, and many even create unsupportable chargebacks or penalties as part of more global profiteering across healthcare entities. Ma ny of t hei r u n s c r upu lou s practices include withholding future payments, even after medications have been dispensed and payment claims have been adjudicated. This practice is built into their contracts, and it financially hurts healthcare providers and patients. These fees are modeled after a program implemented by the Centers for Medicare and Medicaid Services (CMS) called “Direct” and “Indirect” Remuneration (DIR) fees. However, even CMS has called out
commercial PBMs for misapplication and overutilization of these fees as unsupported late chargebacks. States across t he cou nt r y are studying the inappropriate business practices and negative fiscal impact of PBMs and increasing the level of regulatory oversight to apply controls focused on their predatory behaviors. Unregulated and allowed to continue, these PBM practices will continue to increase healthcare costs and create fewer points of access for patients and pharmacists. In many cases, PBMs strive to commandeer prescriptions away from local pharmacists and drive patients to utilize their corporately owned mail-order centers instead. Th is produces a break i n t he pha r mac i st-pat ient relat ion sh ip and increases the risk for adverse outcomes and failure to identify critical medication-related problems that can be identified at the point of care in a pharmacy practice setting. In 2003, the U.S. Congress urged the
Daniel E. Buffington, PharmD, MBA, FAPhA
Federal Trade Commission (FTC) to investigate and study the trends in PBM practices with the “Medicare Prescription Drug, Improvement, and Modernization Act.” Based on the proliferation of PBM profiteering and predatory
Lina M. Khan, Federal Trade Commission Chair, led the open commissioner meeting on February 17, 2022, which discussed a proposed study on Pharmacy Benefit Managers’ (PBMs) relationship with affiliated and independent pharmacies. FEBRUARY 2022
|
5
