Overcoming the Challenges of PBMs: Expanding Patient Access to Affordable Treatments

In an interview with Pharmacy Times® at the Community Oncology Alliance (COA) 2024 Payer Exchange, Fred Barton, PharmD, and vice president of clinical product and partnerships at AffirmedRx, explains the challenges of PBMs in the health care industry and the steps that need to be taken to promote more transparency.

Pharmacy Times: What factors regarding the role of PBMs were most significant in your session?

Fred Barton: Yeah, we discussed a lot today, obviously, about transparency. It's the big kind of thing in the space. But really, what does transparency mean? What can transparency change when it comes to PBM and then also some of the factors around, really, the lawsuits related to things that are happening in the PBM space? Those are the major topics of the discussion today.

Pharmacy Times: How do PBMs impact drug pricing and patient access to medications?

Barton: PBMs, ultimately, are the ones that are out contracting with drug manufacturers and working with pharmacies to get contracted rates for medications. They're designing formularies to decide what is covered on different benefit designs, and, ultimately, they're controlling which medications individuals have access to based on that formulary design. And really, the formulary is built based on what drugs are preferred because of the discounts that PBMs are getting from drug manufacturers.

Pharmacy Times: What are the primary obstacles to introducing more transparency into PBM operations?

Barton: Back to the point of designing the formulary, a lot of that is built, especially in the traditional space of PBMs, to drive individuals to medications that could potentially make more profit for the PBM. So, there is a lot of, I would say, opaqueness when it comes to how a formulary has been built and what drugs are actually getting preferred on that formulary. Then, the pricing that comes in. There are a lot of PBMs today that are still spreading the price, meaning they're paying the pharmacy one amount, but charging the employer more for that prescription. And we think bad things start happening when a PBM also owns their own fulfillment and is deciding what they pay themselves off the pharmacy.

Pharmacy Times:What further regulatory or legislative measures do you believe are necessary to promote transparency in PBM practices?

Barton: I think a few things, obviously continuing to push for full access rights to data for employers. But we also have to continue to find ways to break up some of the vertical integration that has occurred in the space. Today, again, we have PBMs that own retail pharmacies. They own mail order solutions. They own specialty pharmacies. When they own that full fulfillment chain, bad things continue to happen. We see that employers continue to get charged more than they should be for medications that are available for much less through different fulfillment solutions. The other thing that I think we need to continue to work on is this idea of anti-competitive behavior that seems to happen in the market. When employers, especially large employers and some small employers, decide to make a transition and leave the big 3, the large traditional PBMs often make it very difficult. The transition process is not easy, whether it be charging fees for access to data, not sharing data at all, or delayed time for getting data over to the employer.

Pharmacy Times: How can PBMs, payors, providers, and policymakers collaborate to ensure more transparent pricing and improve patient outcomes?

Barton: I think it's continuing to work together and to find ways to improve the value of benefit design. But also designing clinical programs and utilization management activities that truly benefit the employer and allow members to have access to the medications that they need.