Big Pharmacy Benefit Managers Evade Oversight

As a pharmacist, I have seen firsthand the impact today’s big pharmacy benefit managers (PBMs) have on patients they claim to serve.  Most patients don’t realize that PBMs control the price you pay at the pharmacy counter. While PBMs promote health plan cost savings to businesses for their employees, their records often tell a different story. Thankfully, in Raleigh and in Washington, law makers are finally waking up to the role PBMs play in drug pricing.

For years, PBMs have operated in the shadows, signing up employers to trust them and utilize their services, while effectively evading any oversight attempts by state regulators. In 2021, the NC General Assembly passed a ban on the practice of rebate accumulating, which PBMs used to deny patients their due savings from drug discount programs.

How did PBMs escape oversight? The answer is that just a handful of large PBMs control 80% of the U.S. market. The PBMs then lobby Congress and oversight agencies to prevent any questioning of their business practices. This market domination is problematic because with no legal mechanisms in place to ensure accountability, PBMs can hide behind harmful, profit-motivated pricing practices while employers and patients pay the price.

Traditional PBMs tout their size and scale as factors that secure better deals for clients. It is true that big PBMs can procure drugs in larger quantities at wholesale prices, but they often fail to pass these savings benefits on to their clients.

Recently in Washington, lawmakers asked the CEO of UnitedHealth Group (UHG), a large PBM, to testify before the Senate Finance Committee. UnitedHealth Group’s Optum Rx unit, along with CVS/Aetna’s Caremark and Cigna’s Express Scripts, now control 80% of the PBM market. With $370 billion in revenues last year, UnitedHealth has grown so big that it now employs more than 10% of all physicians in America and even owns an FDIC-insured bank that can advance payments to providers on pending claims!

With this large of a share of the market, the American people deserve some oversight and questions to be answered. I am urging the Senate Finance Committee to keep asking companies like UnitedHealth Group to explain its rapid consolidation of the market, as well as its vertical integration that is limiting consumer choice and hurting patients at the pharmacy counter.

It is past time PBMs are held accountable for their impact on healthcare costs, and leaders in Washington need to pass PBM oversight measures. This legislation and oversight will finally bring accountability and reform to this broken system and put the focus back on patients, where it belongs.

NC Rep. Wayne Sasser (R) is a pharmacist by trade and represents Montgomery and Stanly counties in the NC General Assembly.