Government Agencies and States Look to Further Regulate PBMs

Consumers have been up in arms over problems they’ve had with pharmacy benefit managers (PBMs) for years, but companies like Cigna’s ExpressScripts, CVS Caremark, and UnitedHealth’s OptumRx have continued to grow by leaps and bounds. However, aid for consumers may soon be on the way.

Last week, the U.S. Department of Justice (DOJ) announced that it will attempt to block UnitedHealth Group’s acquisition of Change Healthcare, a company that provides payment and revenue cycle management to connect payers, providers, and patients in the health care ecosystem.

Consumers have the National Community Pharmacists Association (NCPA), in part, to thank for that effort by the DOJ. Last September, the organization publicly called for DOJ officials to block the merger, saying it would produce an unfair competitive advantage for a company that is already one of the kings of the PBM hill.

NCPA kept the heat on regulators, repeatedly raising concerns with the DOJ and the Federal Trade Commission (FTC) about the proposed acquisition and the broader vertical consolidation that is happening in the industry. The group alleged that UnitedHealth Group’s access to Change Healthcare's eRx system would be devastating to patients and independent pharmacies.

In arguing its case, the NCPA had plenty of ammunition that consumers aren’t happy with the current PBM-driven prescription world. Survey respondents spoke loudly about their dissatisfaction with health insurance plans and their PBMs. Namely, the participants took umbrage with how PBMs and insurance companies get to decide which pharmacies patients must use and whether they must use more expensive medicines when there is a less expensive alternative available. 

Getting more regulators on board
Getting the DOJ to add some muscle to its efforts is a major plus for the NCPA, but “there is far more for agencies like the DOJ and FTC, Congress, and state policymakers to act on in order to rein in PBMs and create a fairer, more competitive health care marketplace for consumers,” said NCPA CEO B. Douglas Hoey.

Before the DOJ announced its intent to block the UnitedHealth/Change Healthcare deal, the FTC had actually voted against fielding a study of PBMs and their business practices. But the agency apparently had a change of heart and has now decided that it might be a wise move to ask the public how it feels about the impact of PBMs after all. 
Requests for Information like the one the FTC has launched regarding PBMs can make a huge impact, and the agency is asking patients, employers, pharmacies, and any other entity that deals with prescriptions to comment on any issues or concerns they believe are relevant to the PBM situation. Interested parties have until April 25, 2022, to submit their comments on the FTC's website.