Following Friday’s announcement by President Trump of the signing of four new Executive Orders aimed at reducing the price of prescription drugs for Americans, Pharmacists United for Truth and Transparency (PUTT) is cautiously optimistic that some of these Executive Orders will result in the fulfillment of promises made by the President two years ago.

While we are most hopeful for the Executive Order “prohibit(ing) secret deals between drug manufacturers and pharmacy benefit manager middlemen, ensuring patients directly benefit from available discounts at the pharmacy counter” we respectfully ask the Trump Administration to consider the following questions:

• What protections will be ensured for patients, plan sponsors and providers should rebates and other proprietary “deals” be prohibited by law? A documented, defining characteristic of the PBM business model is to rename or reclassify rebates as “management fees” which are then collected and kept by the PBMs. These types of “trade secret” deals have contributed to record profits for PBM middlemen, including those recently announced for CVS and UnitedHealth, despite the COVID-19 pandemic and economic downturn experienced by the rest of the country.

• How will the Trump Administration ensure the elimination of rebates and other secret deals will not result in price increases for consumers? Since the introduction of the President’s plan to eliminate the middlemen, the PBM opposition has made direct, publicly documented threats that ending rebates will result in higher — not lower — prices for consumers. While PBMs have not articulated how the elimination of rebates will cause prices to go up instead of down — or even explained how transparency will cause price increases — they have engaged in a full-fledged PR campaign to shift responsibility onto the drug makers, the pharmacies, the prescribing physicians, the pharmacy contracting organizations and/or any other entity in the prescription drug supply chain other than themselves.

Despite numerous studies on the role of rebates in drug pricing — the most recent published in 2020 — PBMs have managed to not only thrive in the closed market U.S. healthcare system, but have come to dominate it through a series of highly-contested vertical mergers resulting in the consolidation of the insurance provider, the pharmacy benefits designer, the physicians, and the pharmacies. In absolutely no case did these mergers fulfill their promise for lower costs and better healthcare delivery, but in fact had the opposite effect — most notably the acquisition of PBM Caremark by CVS Health in 2006. In many situations, U.S. consumers have seen their drugs’ list prices increase while the net price remained stable year over year, the most famous cases being Mylan’s EpiPen and Eli Lilly’s Humalog.

The PBM business model must be reformed to ensure PBMs act as fiduciaries to the plan sponsor and not as middlemen “rent-seekers” exploiting a fragile system for their own profit gain. For true drug price reform to occur, all forms of “pay to play” compensation between PBMs and drug manufacturers must stop. Ending rebates all together would move prescription care a step closer to a free market, where true market forces, including competition, would lower costs.

As pharmacists, we wholly believe every patient needs and deserves access to affordable medication. We offer our support of any programs that will create transparency so that all U.S. healthcare stakeholders can understand the supply chain dynamics and rationale for drug pricing. We do not support the importation of drugs from other countries, including Canada. We believe this practice will create false hopes for Americans, who will be disappointed with pricing that would be marginally less than what they currently pay, but would be a great deal cheaper if the PBM middlemen and their backroom deals were simply eliminated altogether.

PUTT and our members look forward to patients and providers having the right of quality, affordable access to medication restored, and to providers receiving the respect and level playing field to which they are entitled as medical professionals.

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Pharmacists United for Truth and Transparency considers equality for all people to be the utmost priority. Pharmacists, like other medical providers, take an oath based on primum non nocere -  ”First, do no harm.” PUTT does not condone and will not stand for actions that leave communities of color marginalized, diminished, brutalized, or feeling their lives are somehow less valuable than someone else’s.

The senseless and tragic deaths of George Floyd, Ahmaud Arbery, Breonna Taylor, Tamir Rice, and far too many others have forced our nation to confront certain critical issues that belie the words of our founders in the Declaration of Independence: the inviolable right of all people, regardless of color or creed, to freely - and safely - live their lives. 

As caregivers and advocates, we will continue to fight for the rights of patients and their community pharmacies. We are pharmacists united with our communities - for truth, transparency, health, safety, and well-being.

By vetoing S6531, the PBM Licensure Bill: 

• You sold out the people of the State of New York. 
• You willfully ignored the cries for help from New York patient groups, medical providers, pharmacies and state employees who have consistently appealed to you to listen and take action against the clear and obvious abuses of PBM middlemen in your state.
  
• You sentenced the people of your state to annually paying hundreds of millions of dollars over cost of medication and well above the market value of the only service PBMs should perform - processing pharmacy benefits claims.
  
• You put patient access to medicine at risk and the welfare of multi-billion dollar PBM corporations above that of your constituents.
  

You claim that “regulation of the pharmaceutical sector is a priority of (your) administration” but simply capping insulin prices and commissioning a study of Canadian drug importation fails to address the root of the problem.  

To hold drug manufacturers “accountable” but not the middlemen who extort rebates for drug placement on formularies, and exploit pharmacies by holding them to the terms of impossible, “take it or leave it” contracts that result in the loss of pharmacy small businesses and creates pharmacy deserts statewide, is unconscionable. 

You had six months to deliberate on this bill. The fact that you issued an opinion on ERISA preemption that goes against that of your own Attorney General who before the Supreme Court in 2018 filed a brief as amici curiae stating that ERISA preemption “..threatens to interfere with States’ ability to exercise their long-standing authority to regulate PBM conduct..”, and that you chose to wait until the very last moment - and in the quiet hours of the Christmas holiday - to release your decision invalidates your claim of pharmaceutical sector regulation as a priority of your administration.

Governor Cuomo, patients and pharmacies across the country looked to you to take the lead in drug pricing reform. Your decision to side with the PBM middlemen is disappointing and misguided.
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On Tuesday April 9 and Wednesday April 10 the Senate Finance Committee and House Energy and Commerce Committee respectively convened hearings to question pharmacy benefit managers (PBMs) about their role in the high cost of prescription drugs. Unfortunately, questions asked by the Senate barely skimmed the surface of the problem, and PBM answers were predictably limited to a handful of tired talking points about “saving clients money” and “passing 100% of rebates through to their clients”.

While neither hearing resulted in transparency or even a clear definition of “client”, we applaud Rep. Buddy Carter for calling attention to the relationship between PBM-negotiated rebates and insurance companies - notably the ones that own PBMs and those that are PBM-owned. That is to say, PBMs with financial ties to insurance companies are very often negotiating and keeping rebates for their parent company, which another version of keeping the rebate to the benefit of their own bottom line.

Congress can hardly be blamed for a system so complicated and opaque that not even the antitrust division of the Department of Justice understands it enough to block the merger between CVS Health and Aetna for obvious conflict-of-interest reasons.

The latest idea to “fix” America’s broken prescription drug system is no fix at all. We, the pharmacists of Pharmacists United for Truth and Transparency, are calling out those who would have the nation believe the best way to deal with our country’s escalating medication cost crisis is to turn to another country in hopes of somehow “stimulating competition” as solution to a problem of our own making.

The complexities of prescription drug pricing notwithstanding, there are numerous reasons why drug importation is a bad idea:

• Patient and product safety and liability are not guaranteed. Several studies point to the danger and fallacy of importing drugs from “Canada”. The reality of so-called “Canadian” drug sites is that most are not Canadian, nor do they sell Health Canada-reviewed or approved medications. A 2017 review by the National Board of Pharmacies showed many of these sites do not require a valid prescription - a troublesome prospect in light of the nation’s opioid crisis. Worse, several were found to sell counterfeit medications. The World Health Organization estimates that one in ten medicines in developing countries is counterfeit – a significant public health threat to which Americans are immune given the Food and Drug Administration’s “track and trace” system that is the safest in the world. Who is liable if the imported medication is fraudulent or causes patient harm?

​WINSTON-SALEM, NC (November 13, 2018) -- Pharmacists United for Truth and Transparency (PUTT) is disappointed to learn that Virginia’s Department of Medical Assistance (DMAS) is shielding information collected from the Managed Care Organization (MCO) and Pharmacy Benefit Manager (PBM) audit report, which was undertaken for accountability to the Commonwealth of this taxpayer funded program. PUTT calls upon DMAS to act in the interest of transparency by releasing the report’s findings immediately. 

A similar report this summer in Ohio, which found taxpayers were paying an estimated $225 million to PBMs over and above the cost of Medicaid-sponsored prescriptions led to the recall of PBM contracts in that state. Reports from independent pharmacists in Arkansas and Pennsylvania led to investigations by the state’s attorney general and auditor general respectively. The $1.5 million fine assessed by the State of Kentucky for 454 reimbursement violations and 38 violations related to providing inconsistent or inaccurate information to the state’s Department of Insurance point to signs that PBMs act not in the interest of patients and taxpayers, but in their own interest. 

Pharmacists United for Truth and Transparency (PUTT) members are concerned by recent reports that the Department of Justice will not challenge the upcoming CVS Aetna merger and call on consumers, patients, healthcare providers and taxpayers to stand with us in vigorously voicing opposition to this extremely troublesome acquisition.

​Pharmacists United for Truth and Transparency (PUTT) welcomes and enthusiastically endorses President Trump’s plan for prescription drug pricing reform.

Pharmacists United for Truth and Transparency (PUTT) is calling on Illinois Governor Bruce Rauner to reconsider his statement earlier this week at an event ...