Preserve Patient Access to Neighborhood Pharmacies
Studies and Data
AHCA Commissioned Analysis of FL Medicaid Confirms Over $90Million in PBM Spread Pricing
This recent independent analysis of Florida Medicare commissioned by the Agency for Health Care Administration (ACHA) sheds light on PBM fee and pricing practices in Florida's Statewide Medicaid Managed Care System (SMMC). The analysis confirms that PBMs have taken over $90 Million per year in excess profits through the use of spread pricing.
Legislative Leaders are Calling for Action
“Markets fail when markets get corrupted and that is what has happened here. When the middleman is allowed to own the end-retailer then the middlemen’s incentive to manage cost appropriately for the benefit of the chain is broken. And that is what has happened here.”
-- Rep. Randy Fine
“The power and control of PBMs has grown significantly over the last five to ten years. What we’re seeing is insurance companies owning PBMs and PBMs owning insurance companies. What is happening in the long run is that the price of prescriptions are going up.”
-- Sen. Gayle Harrell
“The practices PBMs use to drive up profits are complex, but the solution is simple: We need to increase access to care for all Floridians while ensuring that prescription drug savings make it to the patient and not the pockets of predatory PBMs.”
-- Rep. Jackie Toledo
When it comes to PBMs,
we all pay the price.
Pharmacy Benefit Managers (PBMs) are middlemen who have strayed from their original purpose of negotiating savings for patients and now keep the profits for themselves, leaving the rest of Florida’s consumers to pay higher drug prices. PBMs use anti-competitive practices to short-circuit the free market and create health care monopolies.
These predatory tactics decrease access for patients, force neighborhood pharmacies to close down, and raise costs for everyone. We need legislation that will increase transparency and accountability on PBMs and ensure that patients are prioritized over profits.
Who do PBM predatory tactics hurt?
Forcing neighborhood pharmacies out of PBM health networks causes many patients to drive extra miles from their home to receive medications simply because their local pharmacy is not in their plan. This not only steers business away from neighborhood pharmacies, it severely restricts patients’ access to medications and drives up their costs.
Many neighborhood pharmacies diligently refill prescriptions only to be hit with reimbursements that are pennies on the dollar – with some even facing negative reimbursements or clawbacks – while PBMs continue to make record-breaking profits. No business can sustain operations under this model, and it is a clear manipulation of the system that promotes anti-competitive practices.
PBMs are overstepping their scope and making medical decisions best left to physicians and pharmacists – and their years of training. PBMs are motivated by profit, not by what is best for the patient, and many times PBMs require the use of drugs or specialty medications that are not the most beneficial for the patient.
The anti-competitive policies that PBMs push increase health care costs for everyone. PBMs don’t make or provide the drug – they don’t even touch the drug – yet they add costs to the overall health care system that must be absorbed by pharmacists, patients, and all Floridians.
How Can We Fix This?
This year, the Florida Legislature is considering legislation to address these challenges. SB 1444 and HB 961 implement transparency, accountability, and free-market policies that will help preserve patient access and keep drug prices affordable.
Here are some highlights of the legislation:
- Protect the free market by prohibiting anti-competitive policies that reduce patient choice and create health care monopolies
- Eliminate the practice of steering patients to PBM-owned pharmacies, especially when it involves taxpayer dollars
- Prohibit the predatory practices that PBMs use to squeeze independent pharmacies, including post-adjudication fees, spread pricing, and cumbersome audit practices
By supporting this legislation, we can bring about concrete change in the industry and put a stop to the abuses that leave Floridians suffering.
Florida Politics, December 24, 2019 State Sen. Tom Wright is pushing legislation for the upcoming 2020 Session that would increase regulation of pharmacy benefit managers (PBMs). A PBM is a company that helps determine which drugs will be covered by insurance plans. PBMs negotiate on behalf of insurers to secure discounts from drug manufacturers. But critics argue patients are being left behind when it comes to benefiting from any prospective savings. Wright’s bill (SB 1338) would up state-level regulation of those PBMs in several areas. First, it would increase the ability of the Office of Insurance Regulation (OIR) to examine the practices of those PBMs. Health insurers, health […]Read More
Tampa Bay Times by: Dr. Michael Diaz December 26, 2019 When patients are battling a life-threatening disease like cancer, they want a skilled and qualified physician advising them about treatment plans and the best way to beat this insidious disease. But that’s not always what they get. Sometimes, predatory middlemen called pharmacy benefit managers insert themselves into the decision-making process between the doctor and patient. As just one example, our team was working with a patient who had metastatic kidney cancer. Both the medical oncologist and urologic surgeon determined that the patient was not a candidate for surgery because of the patient’s other health conditions […]Read More
The Capitolist December 20, 2019 Calling out Pharmacy Benefit Managers, or “PBM’s” for predatory business practices, a bipartisan group of lawmakers that includes Republicans Jackie Toledo and Randy Fine, Democrat State Rep. Kamia Brown and Democrat State Senator Jose Javier Rodriguez, unveiled new legislation this week designed to increase Floridian’s access to prescription drugs while lowering costs. The proposal would limit the practice of forcing patients to get their prescription drugs from pharmacies owned by pharmacy benefit managers. At a news conference announcing the plan, the lawmakers were joined by patients, doctors and pharmacists and small business owners who say PBM’s are pocketing most of the alleged savings they are able to […]Read More
Tampa Bay Business Journal December 18, 2019 In an attempt to lower health care costs for Floridians, a Tampa Republican and other lawmakers want to crack down on the role of pharmacy benefit managers. Rep. Jackie Toledo held a news conference Tuesday to announce a proposal (HB 961) that would create a new law called the “Prescription Drug Cost Reduction Act” and make clear that certain practices, such as directing patients to pharmacies owned in whole or in part by pharmacy benefit managers should be prohibited. The 53-page bill was lauded by the Florida Pharmacy Association, which maintains that so-called PBMs are driving independent pharmacies out of business. But […]Read More
Florida Daily December 19, 2019 Florida state Rep. Jackie Toledo, R-Tampa, was joined by fellow lawmakers, patients, physicians, pharmacists, and small business owners this week to announce legislation that she says would increase Floridians’ access to prescription drugs while lowering costs. Supporters of the legislation say new legislation is needed to directly address what has been called “predatory practices” by Pharmacy Benefit Managers (PBMs). “Our priority is advocating for Floridians who have felt the pinch in their wallets because profit-driven policies by PBMs are robbing patients of savings that should rightly be theirs,” said Toledo. “Consumers need to know that their state lawmakers are fighting for their […]Read More
Florida Politics December 19, 2019 Rep. Jackie Toledo filed legislation Tuesday to crack down on what she describes as over-charges on prescription medication caused by predatory practices among Pharmacy Benefit Managers, or PBMs.” Those are pharmacy middlemen established to facilitate claims approval for medications that require authorization in real-time. The bill (HB 961) addresses the pricing disparity between how much PBMs charge insurance providers compared to how much they reimburse pharmacies, paying self-owned pharmacies more than other pharmacies or steering patients to pharmacies they own and PBMs not passing along savings from third-party rebates. The bill would also increase transparency by requiring all information, including PBM revenue, to be reported […]Read More