Industry groups representing pharmacies are expressing concern about a new media report that suggests pharmacy benefit managers are looking to get out ahead of potential reform efforts.
Policy changes for the PBM industry have seen bipartisan support, though meaningful actions haven't made it out of Congress yet. But a new report from Bloomberg suggests the Pharmaceutical Care Management Association (PCMA), which represents PBMs, is coming directly to the Trump administration with new proposals.
In the article, it says the PCMA is pitching business changes to the Centers for Medicare & Medicaid Services in a bid to avoid further regulation. Proposals include increased payments to rural and independent pharmacies, a larger focus on the use of lower-cost biologics and steps to ensure patients' costs aren't higher than cash-pay rates, per the report.
Pharmacy groups, however, are skeptical of the industry's motives in reportedly taking these steps.
Steven Anderson, the CEO of NACDS, which represents drug stores, supermarkets and other mass-market retailers that have pharmacies, called the idea that PBMs could regulate themselves a "ludicrous" one.
"NACDS stands firm in rejecting the notion that PBMs will suddenly act in good faith, given their years of driving up Americans' drug prices and forcing pharmacy closures that dangerously impede patient care," he said in a statement.
"We've seen this play before: PBMs announce voluntary 'fixes' but these moves are only riddled with loopholes for their own gain, never real solutions for patients or pharmacies," Anderson continued. "This proposal is a classic delay tactic, intended to avoid real, enforceable reform, maintain high profits, and put patient access and pharmacy survival at risk."
The National Community Pharmacists Association, meanwhile, told Bloomberg that it would be "foolish for the administration to trust the PBMs to regulate their behavior."
The potential voluntary changes echo the insurance industry's decision earlier this year to broadly pledge to reform prior authorization amid growing criticism of behavior around claims denials and delays. That promise includes all six of the major publicly traded insurers and the two largest lobbying organizations, AHIP and the Blue Cross Blue Shield Association.
PBM contracts are highly concentrated among three major firms: CVS Caremark, Express Scripts and Optum Rx. All three are vertically integrated with a major health plan, as Caremark is a sister company to Aetna, Express Scripts is a subsidiary of Cigna and Optum Rx is an arm of UnitedHealth Group, parent of UnitedHealthcare.
That vertical integration has drawn attention from regulators and lawmakers, with the Federal Trade Commission currently undertaking a broad probe of major PBMs.