Could a pair of studies this week change the national conversation — and legal ramifications — surrounding pharmacy benefit managers?
In Ohio, several other states and a recent U.S. Senate hearing, much of the focus has burrowed into the “traditional” model of PBM finances: spread pricing. That simply means these drug middlemen give pharmacies less money than the PBMs themselves get from health insurers — ultimately, taxpayers’ money in Ohio Medicaid’s case.
But the new research points to a different moneymaking tactic by the PBMs: specialty drugs, which are often expensive — and potentially lucrative.
One example of a specialty drug: the generic form of Gleevec, known as Imatinib Mesylate, a drug used to treat leukemia.
Here’s how it all works.
The PBMs, such as CVS Caremark, generally determine which medications are defined as “specialty drugs.” And at least sometimes the PBMs also declare that a “specialty pharmacy” must hand out the drugs.
The rub is that these specialty pharmacies are often run by the PBMs’ parent companies, such as CVS’ retail and mail order operation.
So in these instances, the PBMs essentially are funneling money that insurerstaxpayers are paying for the specialty drugs right back into the PBMs’ own company.
As part of the setup in Ohio, PBMs work in concert with managed care health plans; in the state’s Medicaid program, CVS Caremark works for four of the five managed care organizations hired by the state.
Ohio’s largest such organization, CareSource, notes on its preferred drug list that it “works with CVS Caremark to supply specialty medications that health partners may prescribe. CVS Caremark can help members get prescriptions filled or moved to CVS from another pharmacy.” It then gives a toll-free phone number for CVS Caremark.
The study tracing these interactions was conducted by 46Brooklyn, run by Antonio Ciaccia of the Ohio Pharmacists Association and Eric Pachman, a former Ohio pharmacist who specializes in researching drug costs.
They noted the generic Gleevec purchases were highly lucrative: The pharmacies that filled them made about $5,000 a prescription on average.
“Due to the general lack of transparency on drug distribution trends within state Medicaid programs, it is hard to definitively say where all those Imatinib Mesylate prescriptions — and those $5,000+ margins — are going, but it certainly looks like the pharmacies most likely grabbing them have some interesting ties to the health plans and PBMs that are steering traffic in their own direction,” the Ohio duo found.
The other study was performed by Dr. Adam J. Fein of Philadelphia, CEO of a pharmaceutical economics consultant, Drug Channels Institute. It provided even more evidence the PBM-owned entities are grabbing a lion’s share of the cash-laden specialty drugs business.
“PBMs and insurers dominate specialty drug dispensing channels,” his research found.
“The top four companies—all of which are fully or partly owned by a PBM—accounted for more than 70% of prescription revenues from pharmacy-dispensed specialty drugs.”
And because of mergers and acquisitions within the drug industry, the specialty drugs business is growing for the pharmacy benefit managers.
“PBMs are earning an increasing share of their profits from specialty dispensing activities,” Fein said.
That’s not an accident; the PBMs try to narrow the scope of who can dispense specialty drugs.
“PBMs and health plans typically further limit the number of specialty pharmacies selected by the manufacturer by requiring patients to use the specialty pharmacy that the plan or PBM owns and operates,” he noted.
If details in these studies are confirmed, the information could enlarge the focus of state and federal regulators to halt the cascading profits through specialty drugs as well as the money gained by PBMs through spread pricing.
Perhaps of more immediate relevance: The apparent manipulation of the system to enable PBMs to direct business on pricey prescriptions to their own company’s pharmacies could provide more ammunition to opponents of the proposed CVS-Aetna merger, currently pending before a federal judge in Washington.
Sumber: togel online via pulsa