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What the Inflation Reduction Act means for PBMs

The sweeping law President Joe Biden enacted Tuesday offers relief to some presciption drug users, but the pharmacy benefit managers that play a key role in how much patients pay for medicines will mostly carry on as usual.

The Inflation Reduction Act limits drug companies and pharmacy benefit managers from charging rates on select Medicare drugs that allow them to pocket high rebates. But it mostly spares the pharmaceutical middlemen, who have been criticized for business practices including a lack of transparency, from major changes.

Part of the new $740 billion law aims to bring down drug costs for patients. It allows the government to negotiate the prices of 10 medications under Medicare Part D drugs starting in 2026, 15 per year beginning in 2027, and 20 per year starting in 2029.

Still, Medicare’s authority to now negotiate drug prices is an “indictment” of PBMs, which are supposed to manage costs for Medicare Part D enrollees, said Antonio Ciaccia, president of 3 Axis Advisors. Government officials, "through their actions, are saying, ‘You guys, we’re cutting it, and we can do better.' So from a PBM perspective, I think that this, in some ways, undercuts their value,” he said.

Pharmacy benefit managers will still hold great sway over prescription drug prices for those outside of Medicare, and the law further delays a 2019 regulation that would have eliminated safe harbor protections for Medicare Part D rebates until 2032.

The Pharmaceutical Care Management Association, which represents PBMs, praised the law for postponing the rebate rule, but once again passed off blame for high drug prices to pharmaceutical companies and health insurers. "The sad reality is that, rather than focus on how to ensure every American can access affordable coverage and high-quality healthcare, the finger pointing is in full swing in Washington with big pharma blaming PBMs and insurers for prices only they can set," a spokesperson wrote in an email.

PBMs likely see the passage of the new law as a victory, said Lindsay Bealor Greenleaf, vice president of policy and reimbursement at the consulting firm ADVI Health. Although the statute encroaches on their Medicare Part D operations, it doesn't change anything about what PBMs do in other markets, such as employer-sponsored health insurance. And PBMs will continue to dictate what drugs make it onto insurers' formularies and how much pharmacies get paid for dispensing medicines, she said.

“They’re spared in this because there's nothing that changes their business model or their ability to operate on a rebate system,” Greenleaf said. “There is nothing requiring transparency of PBMs.

Even losing a sliver of the Medicare Part D market won't hurt pharmacy benefit managers, who are capable of making up for lost revenue elsewhere, Greenleaf said. "PBMs are crafty at coming up with new revenue streams and coming up with new fees that you know, look and smell like rebates or something else," she said.

That latter strategy has its limits, however, said Loren Adler, associate director at University of Southern California-Brookings Schaeffer Initiative for Health Policy. If PBMs could squeeze additional revenue from the commercial market, they would already be doing it, he wrote in an email. "It would have to be the case that PBMs hold bargaining leverage that they choose not to use at present, even though using that leverage would make them more money," he wrote.

This bill could have some spillover effects on the commercial market, however, where employers worry drugmakers will make up for lower Medicare Part D prices by raising costs under job-based insurance, said Laura Martin Dillon, Washington Council Ernst & Young’s senior manager.

The true effects will depend on what specific drugs the Health and Human Services Department chooses for direct negotiations. The agency is likely to select some of the most expensive medications. Because drugs like that typically face little to no competition, they offer meager rebate opportunities for PBMs, so losing them won't effect the companies much, Ciaccia said.

While the Inflation Reduction Act may not transform the pharmacy benefit manager industry, these companies continue to face scrutiny from regulators and lawmakers.

The Federal Trade Commission launched an inquiry into the consolidated industry in June. The agency is investigating how pharmacy benefit managers shape the prescription drug market, particularly given how little competition exists in the space. The same month, the Senate Commerce Committee advanced the bipartisan Pharmacy Benefit Manager Transparency Act of 2022, which would ban the industry from profiting on spread pricing and claw backs.

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I surmised that PBMs were left out of the equation and the government will have a hard time negotiating lower pricing on drugs when PHARMA is already paying hefty rebates to PBMs. Again a band aid has been put on a problem. Our health care insurance system needs totally revamped where transparency is the rule.

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