Build Connections With Legislators When Advocating for PBM Reform

With heightened scrutiny from regulators and even an investigation by the Federal Trade Commission (FTC), pharmacy industry advocates are seeing renewed energy for pharmacy benefit manager (PBM) reform, according to a session at McKesson ideaShare 2022.

The PBM industry has played a large role in the health care supply chain since the mid-1980s, said speaker Matt DiLoreto, senior vice president of state government affairs and alliance development at Healthcare Distribution Alliance. It is important for pharmacists and advocates to recognize that PBMs have extraordinarily strong lobbying and public affairs power, which has allowed them to largely evade attention until recently.

Since 2017, DiLoreto said the National Conference of State Legislatures indicates that approximately 1000 PBM reform bills have been introduced at the state level, tackling everything from gag clauses to patient steering.

“It’s a kaleidoscope of targets that you’re trying to hit,” DiLoreto said. “It is very difficult to legislate your way out of contractual agreements between 2 entities.”

Legislation prohibiting gag clauses has been the most common provision since 2017, followed by bills about limiting patient cost sharing, requirements for licensing or registration, and reimbursement requirements.

Because of the challenge of addressing many different issues, DiLoreto said the response from pharmacy advocacy groups has changed. Originally, the industry tried to make terminology as specific as possible, but this allowed PBMs to simply change their language and avoid ramifications. Now, advocacy groups are trying to make their approach as broad as possible.

PBMs have also adapted, moving from a strategy of opaqueness to evasion. Instead of threatening lawsuits or telling legislators that changes could increase the costs for states, PBMs are now pointing toward wholesalers and other entities. The goal of this strategy, DiLoreto said, is to slow down the conversation and any potential legislation efforts, eventually minimizing or entirely avoiding impacts on PBMs.

With all of these changes in mind, DiLoreto said it is important to be proactive rather than reactive. The PBM industry has been remarkably proactive thus far, anticipating legislative changes and lobbying against them early.

“It’s a much different game when you are reacting to what’s already been put in place, so I think being proactive is key,” DiLoreto said.

Pharmacists and pharmacy owners have vital roles to play in these efforts, DiLoreto said. Pharmacists can offer themselves as a resource to legislators, explaining the facts and relating it to patients and the broader community. Presenter Matt Williams, vice president of state government affairs at McKesson, said pharmacists should speak to legislators as if they were a patient. Although it can be frustrating, explaining things with care and concern is more likely to be effective.

“If you come in with care and concern, I think you have a better chance of hearing that care and concern back,” Williams said.

Partnering with pharmacy organizations at both the state and national level is another way to stay informed and involved, particularly as the federal government ramps up activity regarding PBM investigations and reform efforts. In addition, DiLoreto concluded that involvement cannot simply be focused on legislators, because other entities play important roles. He pointed out that the FDA authorized pharmacists to prescribe Paxlovid without going through Congress.

Ultimately, emphasizing the accessible nature of pharmacies and why this is essential for patients can help legislators and others understand why changes are necessary.

“Independent pharmacy is hands down still the most accessible, face-to-face, Norman Rockwell view of health care in this country,” DiLoreto concluded.

REFERENCE

DiLoreto M, Williams M. A Look Ahead at PBM Reform. McKesson ideaShare 2022. July 9, 2022.