Committee Shines Light on PBM Practices and Specialty Pharmacy Concerns

Committee Shines Light on PBM Practices and Specialty Pharmacy Concerns

by John Conrad| Sep 12, 2024| Policy News

In a recent hearing, the Health Care Availability & Accessibility Committee delved into the complex world of Pharmacy Benefit Managers (PBMs) and specialty pharmacies, exposing a web of concerns affecting patient care and drug pricing.

The hearing, which brought together stakeholders from across the healthcare spectrum, highlighted several key issues:

PBM Market Power Under Scrutiny

Lawmakers expressed concern over the growing market power of PBMs, particularly their ability to steer patients to affiliated pharmacies. "There's an inherent conflict of interest when the PBM is trying to lower prices on the market for different providers, and they have their own provider in that mix," noted one expert witness.

Specialty Pharmacy Designation Raises Eyebrows

The committee heard testimony about the lack of a standard definition for "specialty drugs," allowing PBMs to classify more medications as specialty. This classification often requires patients to use specific pharmacies, potentially limiting access and choice.

Independent Pharmacies Feel the Squeeze

Local pharmacists shared stories of financial strain due to below-cost reimbursements from PBMs. "On any given day, at least 20 to 30 of those prescriptions are reimbursed under my cost," reported one independent pharmacist, highlighting the challenges of remaining in business.

Patient Stories Highlight Access Issues

Patients and advocates recounted difficulties in accessing necessary medications due to prior authorization requirements and forced use of specific pharmacies. One MS patient advocate stated, "This is not a one-off. This happens… and I just wanted that to be clear."

Calls for Transparency and Reform

Throughout the hearing, there were repeated calls for greater transparency in PBM practices and pricing. Suggestions for reform included standardizing the definition of specialty drugs, improving the prior authorization process, and ensuring fair reimbursement for pharmacies.

As the committee weighs potential legislative action, it's clear that the debate over PBMs and specialty pharmacies is far from over. With patient care and drug affordability at stake, lawmakers face the challenge of balancing industry interests with public health concerns.