Top Lawmakers Fed Up With Drug Makers, Benefit Managers

Customer showing prescription to female doctor

Photo: Getty Images

BOSTON (State House News Service) - One lawmaker accused pharmacy benefit managers of making "disingenuous" arguments about soaring medication costs. Another described the industry middlemen as "taking a mob-like approach." And a former governor recalled being driven to her "boiling point" because of the struggles her daughter had accessing a vital prescription drug.

Pharmacy benefit managers, which negotiate between health insurers, manufacturers and pharmacies, landed in the hot seat Tuesday as lawmakers ponder how to rein in health care spending following years of disagreement among House and Senate Democrats.

Both chairs of the Legislature's Health Care Financing Committee lambasted a representative of the pharmacy benefit manager industry, who came to the panel's hearing to defend PBMs and argue that they are not responsible for rising costs often passed along to patients.

"No one is required to use a PBM. Plans choose to do so because PBMs save on prescription drug costs," Sam Hallemeier, director of state affairs for the Pharmaceutical Care Management Association, told the committee. "PBMs are the only entity in the drug supply chain that exists to increase competition and drive down costs. We're concerned that attempts to remove PBM tools will increase costs, lower competition and, at times, add no value to patient care or outcomes."

The legislative barbs came out quickly.

"I just wish you all would come to the table in a meaningful and honest way, and what is so disturbing to us is that we can't have conversations with you where you're honest about what you're doing," co-chair Sen. Cindy Friedman replied when Hallemeier completed his prepared remarks. "That is why we are so hellbent on trying to solve this problem, because people are suffering, they're dying, they can't afford it. And to point fingers at everybody else, it's disingenuous, and it's not useful."

"I don't mind if you guys make money. I really, really don't. It's really okay. But the amount of money is, it's almost obscene, and it's on the backs of people who need medication and who can't afford it," she added. "So please take that back to your organization."

Fellow co-chair Rep. John Lawn jumped in, saying that the companies "are really taking almost a mob-like approach to this."

"There's a lot of players in here that are making money, but we have an obligation to try to have drugs that are available to the citizens of Massachusetts that are affordable, and when you have a group that comes into this and injects itself into this drug supply chain that doesn't innovate, does not do anything in research and development, and extracts billions and billions and hundreds of billions of dollars, it's hard to say how those are lowering drug costs unless there's some transparency," Lawn said. "Show us, then. Show us how. Itemize it. The industry would be welcome to sit down and try to help us break down these costs and show us how. We hear so often that if they give us any transparency, it's going to raise drug prices,and I just find that very hard to believe."

Lawn filed legislation (H 1215) would require PBMs to be licensed, offer patients a "reasonable" network to access prescription drugs and avoid the use of "spread pricing," when they pay a pharmacy less than they bill a payer and pocket the difference.

Other bills on the committee's agenda, including the latest version of a Friedman prescription drug pricing control bill the Senate has approved in two straight sessions, also seek reforms to PBMs.

The growing campaign to subject PBMs to new scrutiny and regulations gained a new ally Tuesday: former Gov. Jane Swift.

Testifying about legislation at a committee hearing for the first time in two decades, Swift told lawmakers about years of struggles that she and her daughter, Lauren Hunt, have endured to secure medication for Hunt's juvenile arthritis.

Hunt said the medication she needs is only available from specialty pharmacies that contract with pharmacy benefit managers, so she cannot pay out-of-pocket to get it elsewhere in a pinch. That means that when the medication suddenly becomes unavailable or fails to be delivered by mail, she goes weeks without taking her regular dosage, suffering debilitating and unnecessary pain.

This winter, Hunt recalled, a PBM failed to fill her prescription "with one lame excuse after another." After hours of frustrating phone calls that Swift said pushed her to her "boiling point," they learned that the medication shipment had been delayed because of computer errors impacting the PBM's communication with Blue Cross Blue Shield of Illinois.

Yet the pharmacy benefit manager had "no obligation" to inform Hunt or other patients, she said.

"I have the best rheumatologist in the country. I now pay for not only one, but two great insurance plans. I have a mother who is the former governor of Massachusetts. I have a degree from a prestigious U.S. university. Yet my access to the medications I need to live not only a healthy lifestyle, but one where I can simply get out of bed in the morning, is non-existent," Hunt, 22, told the committee.

Swift, who served as governor following former Gov. Paul Cellucci's resignation in 2001, contrasted the lack of consumer protections she and Hunt faced with the widespread coverage of Southwest Airlines's service meltdown this winter.

"There are absolutely no systems in place to protect vulnerable patients when the system breaks down. None. If your flight is canceled, that has to be reported to the federal government," Swift said. "If your meds that you need, lifesaving meds, aren't mailed to you, no one has to be told and the problems don't have to be reported. That is just not right."

When Swift and Hunt wrapped up their remarks, Friedman said lawmakers take the issue "incredibly seriously."

"Part of where I feel like we failed is we did not really explain or push a sense of urgency for this. While a number of us have been working very hard in this area, PBMs and pharma, clearly, we haven't been good at getting the Legislature to understand a sense of urgency," Friedman said.

Her ire was not aimed solely at pharmacy benefit managers. The Arlington Democrat on Tuesday also blasted representatives from pharmaceutical research companies -- who themselves criticized PBMs -- while accusing them of not helping the state rein in costs.

"What gets me so upset is I have been listening for now going on for 15 years that pharma isn't the problem, that we will destroy people's access to drugs if we try and reduce it, or even if we try and find out what is going on, how is the price set -- that somehow, that is going to ruin everybody's health and everybody's access," Friedman said. "I don't buy it. You guys need to come to the table in a very different way. We are so willing to listen, so willing to have this be a balanced approach. You are not our partners, and we need you there."

At one point, Friedman likened the competing finger-pointing from different industry facets as "kind of like being with my kids."

Policymakers for years have been unable to agree on a solution to address concerns they have heard about pharmacy benefit managers and rising prescription drug prices more broadly, even as the cost-containment experts on the state's Health Policy Commission continue to ask for more tools to scrutinize the pharmaceutical sector.

As part of broader prescription drug bills, the Senate in two straight lawmaking sessions sought to subject the middlemen to licensing requirements and oversight from the HPC and Center for Health Information and Analysis. Neither measure advanced in the House, where top Democrats have focused on strengthening review of large hospital expansions that impact smaller, lower-cost community hospitals.

Lawn's frustration with the PBM industry could drum up interest in his chamber to act. The Watertown Democrat told the News Service "the focus, now, is really trying to extract how they've gotten a grip on this industry and how we can break it down."

Asked if the House and Senate would be in alignment on their approach to health care cost containment legislation this session after previously taking different approaches, Lawn replied, "I do."

"I think it'll be a comprehensive bill that will involve a lot that we talked about, whether it's the [determination of need] process and dealing with expansions of hospital systems, to PBMs, to other drivers of our health care costs," he said in an interview after the hearing. "But I think we'll see something, probably, hopefully very early next year."

Written By Chris Lisinski/SHNS

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