Amidst Congress’s delay in addressing critical healthcare reforms like site-neutral payment and Pharmacy Benefit Manager (PBM) reform, advocates maintain optimism. Despite bipartisan support for PBM reform bills, the upcoming government funding bill appears unlikely to incorporate these measures. Stakeholders express concerns over the potential adverse effects of delaying reforms, particularly on patient care access and healthcare system sustainability. However, advocates remain hopeful, citing ongoing discussions with lawmakers and the momentum behind reform efforts. Skepticism lingers regarding the transparency of major PBMs, emphasizing the need for comprehensive regulatory measures to ensure fair practices. Despite challenges, the commitment to reform persists among advocates and industry stakeholders.
Advocates for Pharmacy Benefit Manager (PBM) reform remain hopeful despite the delay in Congressional action, which mirrors the perennial dysfunction often associated with healthcare reform efforts. Amidst reports indicating that major bipartisan healthcare priorities like site-neutral payment and PBM reform are unlikely to be addressed in the upcoming government funding bill on March 8, frustration mounts as Congress struggles to reach a consensus.
With the looming threat of a partial government shutdown on March 1 in the absence of an agreement and the subsequent expiration of the Department of Health and Human Services funding by March 8, healthcare-related matters have taken a backseat. While the bill may address critical issues such as community health center funding and reversing Medicare physician payment cuts, the crucial health policies, supported across the political spectrum, seem to be put on hold.
Concerns over the exclusion of site-neutral payment reform have been expressed by stakeholders. The American Hospital Association anticipates a limited package and suggests that many issues might be deferred to the lame-duck session. The Federation of American Hospitals opposes any implementation of site-neutral cuts, citing the potential adverse effects on patient care access and hospital viability.
Similarly, a coalition comprising the National Association of Chain Drug Stores, the National Alliance of State Pharmacy Associations, and other groups emphasizes the urgent need for PBM reforms, warning against the detrimental tactics employed by PBMs that inflate drug costs and limit access to pharmacies.
Despite the setback, optimism persists among advocates for PBM reform. Both the House and Senate have advanced bills aiming to overhaul the PBM industry, reflecting bipartisan support. Senator Bernie Sanders’ Pharmacy Benefit Manager Reform Act, which seeks to ban spread pricing and enforce transparency measures, stands out as a favored initiative. Additionally, the Lower Costs, More Transparency Act, passed in the House, underscores the momentum behind PBM reform efforts.
Joe Shields, managing director of Transparency-Rx, a coalition advocating for transparent PBM practices, remains optimistic about the ongoing discussions with lawmakers. He attributes the absence of PBM language in the budget package to broader negotiation dynamics rather than a lack of substantive support for reform.
Industry experts, while acknowledging the complexity of the space, express satisfaction with the engagement with lawmakers. David Fields, president and CEO of Navitus Health Solutions, anticipates increased pressure for reform from payers, driving the momentum forward. While acknowledging the complexity of the issue, Jake Frenz, CEO of SmithRx, emphasizes the importance of getting the reform right, even if it takes additional time.
However, skepticism persists regarding the transparency of major PBMs. Jordan Feldman, co-founder of PBM Rightway Healthcare, doubts the willingness of PBMs to embrace full transparency, given their significant profit stakes. He suggests that comprehensive regulation across the entire healthcare system may be necessary to ensure transparency in PBM operations.
Federal Trade Commission Chair Lina Khan’s recent correspondence with Senator Chuck Grassley highlights concerns about the responsiveness of major PBMs to document requests regarding their business practices, indicating ongoing regulatory scrutiny.