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Clinical Laboratories and Pathology Groups

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Clinical Laboratories and Pathology Groups

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Pharmacy Benefit Management Company Executives Testify Before Congress on Drug Pricing Practices and Market Manipulation

Because of their big share of patient prescriptions, the three largest PBMs are about to undergo scrutiny via Congressional reports and looming lawsuits that call out questionable practices

Pharmacy benefit managers (PBMs) are finding themselves under scrutiny from both Federal Trade Commission (FTC) investigations into drug pricing as well as recent Congressional hearings into anticompetitive practices.

Because of how PBMs have captured the lion’s share of patient prescriptions away from retail pharmacies in the United States during the past 15 years, pathologists and clinical laboratory managers may want to track how Congress and federal antitrust regulators respond to this development. The issue is the high cost of prescription drugs for patients and the role of PBMs in keeping drug prices high to optimize their profits.

On July 23, the House Committee on Oversight and Accountability held a hearing with top executives from the three largest PBMs to investigate the increasing drug prices and ever-shrinking options available to prescription drug customers. House members heard testimony from Adam Kautzner, PharmD, President of Express Scripts; David Joyner, President of CVS Caremark; and Patrick Conway, MD, CEO of Optum Rx—top executives from the three PBMs that control “approximately 80% of the US prescription market,”Healthcare Dive reported.

House representatives pressed the executives for “steering patients to pharmacies the PBM owns and favoring more expensive brand-name drugs on their formularies, or list of covered drugs, which result in higher rebates paid to them by drugmakers,” Healthcare Dive noted.

In his opening remarks of the full committee hearing, which was titled “The Role of Pharmacy Benefit Managers in Prescription Drug Markets Part III: Transparency and Accountability,” Committee Chairman James Comer (R-Ky) noted that the Committee had “obtained over 140,000 pages of documents and communications exposing Pharmacy Benefit Managers’ (PBMs) anticompetitive policies and their role in rising drug prices,” according to a press release.

In its final report, the Committee on Oversight and Accountability found that “PBMs inflate prescription drug costs and interfere with patient care for their own financial benefit.”

Though hearings on PBMs have been increasing, the last time PBM executives testified on the Hill was before the Senate Committee on Finance in 2019, according to Healthcare Dive.

Spread pricing and rebates benefit PBMs and have helped the three largest PBMs monopolize the pharmaceutical market … these self-benefitting practices only serve to help their bottom line rather than patients,” said Chairman James Comer (above) during a meeting of the federal Committee on Oversight and Accountability. “PBMs have been allowed to hide in the shadows for far too long. I look forward to the Oversight Committee continuing to work in a bipartisan fashion to shine a light on how these PBMs have undermined community pharmacies, raised prescriptions drug prices, and jeopardized patient care.” Clinical laboratory executives may want to track efforts by Congress to rein in PBMs so as to reduce the cost of prescription drugs to patients. (Photo copyright: US Federal Government/Public Domain.)

Turning up the Heat on PBMs

The spotlight began to grow on PBM practices back in 2023. Since then, PBMs have been the focus of three congressional hearings. The late July meeting came just hours after Chairman James Comer, R-KY, presented his report following a 32-month-long investigation “into how PBMs raise prices and reduce consumer choice,” Healthcare Dive reported.

Comer’s research found that “PBMs have used their position as middlemen to cement anticompetitive policies which have increased prescription drug costs, hurt independent pharmacies, and harmed patient care,” according to a press release announcing the upcoming hearing with the executives of the three largest PBMs.

Comer’s report uncovered “300 examples of the three PBMs preferring medications that cost at least $500 more per claim than a safe alternative medication excluded from their formularies,” Healthcare Dive noted.

Coming Lawsuits, Public Opinion

While the Congressional hearings put pressure on the three PBMs, a new threat looms on the horizon—multiple lawsuits—including one from the FTC “over their tactics for negotiating prices for drugs including insulin, after a two-year investigation into whether the companies steer patients away from less-expensive medicines,” The Wall Street Journal reported. 

State attorney generals and independent pharmacies are lining up with lawsuits targeting PBM’s questionable business practices as well, Healthcare Dive reported.

While PBMs maintain their innocence, public opinion differs. An independent survey from KFF found that approximately three out of 10 individuals surveyed reported not taking a prescribed medicine due to expensive costs.

“This includes about one in five who report they have not filled a prescription or took an over-the counter drug instead (21%), and 12% who say they have cut pills in half or skipped a dose because of the cost,” KFF reported.

Further, 82% of those surveyed described the cost of prescription drugs to be unreasonable. Still, 65% described the costs as being easily affordable, with the biggest challenge going to those with a household income of less than $40,000.

PBMs Push Back

In response to the backlash, the PBMs brought their own report to Congress, prepared by global consulting firm Compass Lexecon. It showed that “PBMs pass through almost all rebates to plan sponsors and have operating margins below 5% in recent years,” Healthcare Dive reported.

During their testimony, Conway said that Optum Rx saves over $2,000 per person annually. Kautzner claimed Express Scripts brought $64 billion in savings to patients last year and kept “out-of-pocket costs on a per-prescription basis at $15, despite brand manufacturers raising drug prices on 60% of those products,” Healthcare Dive reported.

Joyner said CVS Caremark experienced “little or no competition” from the pharmaceutical industry for brand name drugs. He blamed the pharmaceutical industry for drug pricing increases, Healthcare Drive reported.

“Let me be clear, we do not contribute to the rising list prices. Hampering our ability to negotiate lower drug cost … would only remove an essential tool and our ability to deliver lower cost for medications,” Joyner told the Congressional committee.

House representatives were not moved.

“On one hand we have PBMs claiming to reduce prescription drug prices and on the other hand we have the Federal Trade Commission, we have major media outlets like The New York Times, and we have at least eight different attorneys generals, Democrats and Republicans, who all say PBMs are inflating drug costs,” said Raja Krishnamoorthi (D-Ill), Healthcare Dive reported.

“This is why just about every state now is taking up PBM reform,” Comer said. “There’s a credibility issue.”

Because there has been a parallel concentration of market share for clinical laboratory testing among a handful of billion-dollar national lab corporations, clinical laboratory managers may want to follow these events. They are examples of federal regulators investigating the business practices of a major healthcare sector while, at the same time, members of Congress look for ways to lower healthcare costs. Prescription drugs is a high-profile target.

At some future point, the cost of genetic testing could also become a target when Congress seeks other healthcare sectors in their goal to control medical expenses.

—Kristin Althea O’Connor

Related Information:

PBMs Battle Bipartisan Scrutiny as Lawmakers Eye Industry Reform

Public Opinion on Prescription Drugs and Their Prices

Comer Announces Hearing with PBM Executives on Role in Rising Health Care Costs

Comer: Pharmacy Benefit Managers Must be Held Accountable for Role in Rising Drug Prices

Comer Releases Report on PBMs’ Harmful Pricing Tactics and Role in Rising Health Care Costs

Hearing Wrap Up: Oversight Committee Exposes How PBMs Undermine Patient Health and Increase Drug Costs

Video of Hearing: The Role of Pharmacy Benefit Managers in Prescription Drug Markets Part III: Transparency and Accountability

Final Report: The Role of Pharmacy Benefit Managers in Prescription Drug Markets

FTC to Sue Drug Managers over Insulin Prices

FTC Slams Pharmacy Benefit Managers in First Report from Ongoing Investigation

Do GPOs Help Hospitals and Clinical Laboratories Save Money? GAO Report Answers That Question

GAO investigates certain business practices of group purchasing organizations


For years, hospitals and clinical pathology laboratories have wondered exactly how much money is saved when they use the services of group purchasing organizations (GPOs). Now a newly-published government report provides interesting details about the financial activities of GPOs.

In response to a Congressional directive, the Government Accountability Office (GAO) recently studied GPOs and released a report on their findings. The GAO’s report will be of particular interest for pathologists and medical laboratory managers working in hospital laboratories.

GAO Report Looks at GPO Activities in 2008

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Drive on to Motivate Hospitals to Prevent Avoidable Readmissions

One approach is to bundle payments to hospitals, physicians, labs, and other providers

Momentum is building around a new effort to drive down existing rates of hospital readmissions. Different reimbursement proposals to encourage hospitals and physicians to reduce current readmission rates will likely also change the reimbursement status quo for laboratory testing. For example, bundling Part A and Part B payments may be one approach.

Experts increasingly believe one game changer in lowering healthcare costs and improving outcomes is avoidable hospital readmissions. One in five Medicare patients returns to the hospital within 30 days. Overall, readmissions cost Medicare an estimated $17 billion yearly. Of this total, about $12 billion are believed to be avoidable cases

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Medicare Targets Avoidable Hospital Readmissions to Jumpstart Delivery Reform

Bundled Payment Demonstration Project Changes How Labs Would Be Paid

Efforts in the nation’s capital to reform healthcare are still in the formative stage as the new President and the new Congress consider various approaches. Meanwhile, the Centers for Medicare & Medicaid Services (CMS) started the new year by launching pilots for a bundled-service payment scheme. Not only may this be the beginning of the end of the fee-for-service payment system, but it has important implications for clinical laboratories and anatomic pathology groups.

The bundled payment system demonstration projects are a first step to what’s coming next. The Medicare Payment Advisory Commission, better known as MedPAC , released its blueprint for reforming the delivery system to Congress on March 17 in its annual Report to the Congress: Medicare Payment Policy.

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