Op-Ed Submission by Dr. Ben Mudd, executive director of the Kentucky Pharmacists Association
Too often, when Kentuckians visit their pharmacy to pick up a prescription, they are shocked to see the price on the register. This is frustrating for pharmacists as well as we have little control over what our patients pay. But the real reason—and what most often dictates the price you pay out-of-pocket for your medicine—may come as a surprise.
As a pharmacist, I’ve seen patients with so-called “good” health insurance forced to pay over $100 out-of-pocket for just one medication to manage their health. And many times, they exclaim, “but I have insurance!”. Sadly, insurance coverage just isn’t what it used to be.
Healthcare has evolved over the years—and not necessarily for the better. Americans are trying to navigate a system that doesn’t always prioritize their needs, whether they’re seeking care and medicines for a common cold or a chronic condition. And much of the blame falls on one healthcare monopoly: pharmacy benefit managers, better known as PBMs.
PBMs, which have come under recent scrutiny, say they’re negotiating discounts and rebates on prescription medications to save patients money. In reality, these drug pricing middlemen are using their millions of dollars in negotiated savings to increase their profit margins, while you—the consumer—pay an ever-increasing amount at the pharmacy counter.
Because PBMs operate with very little oversight and transparency, they have found deceptive loopholes to dictate what medications are offered, where Kentuckians can access them, how much patients will pay and how pharmacists are reimbursed for our services. Pharmacists have seen the consequences firsthand. In a recent survey conducted by the American Pharmacists Association, 91.5 percent of pharmacist respondents agreed that PBM practices are negatively affecting their practice and ability to provide care.
Meanwhile, PBMs continue to spin a false narrative about how they lower drug costs and improve access to care. Thankfully, few people are buying it, including lawmakers on the state and federal levels. In fact, two Kentucky congressmen are positioned at the forefront of a major debate that could help lower out-of-pocket costs of prescription medicines for everyone.
Both Congressman Brett Guthrie, chair of the Health Subcommittee on House Energy & Commerce, and Congressman James Comer, chair of the House Oversight Committee, are actively working to investigate the role PBMs play in our healthcare system and potential solutions to address prescription affordability.
Just recently, Congressman Guthrie held a hearing on the lack of transparency and competition in healthcare and the need to reform PBMs’ largely opaque role in drug pricing. In his opening remarks, he said, “we should build on our bipartisan work to make PBMs be more transparent and ensure patients as well as employers are getting the best possible deal on their prescription drug benefits.”
Congressmen Guthrie’s committee will likely be the vehicle for important legislative reforms while Congressman Comer is using his chairmanship to investigate exactly how PBMs are gaming our healthcare system.
Back in March, Congressman Comer launched an investigation into the anticompetitive and profit-driven business practices of PBMs. He has already called for the top three PBMs—Caremark, Express Scripts and OptumRx, who manage nearly 80 percent of drug claims in the United States—to provide information on their rebates, fees and mail-order pharmacy incentives.
His investigation comes after a December 2021 report by the Committee on Oversight & Reform, which revealed that PBM consolidation has negatively impacted health, increased costs for patients and distorted high-quality care for patients.
Congressmen Comer and Guthrie’s investigations are a meaningful first step toward PBM reform. Their efforts can expose just how much money PBMs are double dealing and, ultimately, should bring greater transparency to how drug prices are set and how much patients end up paying for their medications.
With their strong leadership in Washington, we are closer than ever to important reforms needed to help Americans better afford the medications they need to manage their health. We are encouraged by their efforts and applaud our fellow Kentuckians for taking on this critical issue.
At the end of the day, healthcare is about patients, not boosting the profits of third-party middlemen. Under the leadership of Congressmen Comer and Guthrie, we can move toward a more patient-centered healthcare system that allows all Kentuckians to get the medications they need at a price they can better afford.
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Dr. Ben Mudd is a pharmacist and executive director of the Kentucky Pharmacists Association (KPhA). Prior to joining KPhA, he spent most of his career in the community pharmacy setting.
