Pharmacy benefits managers direct Medicare patients to their pharmacies

Weill Cornell Medicine researchers found that pharmacy benefit managers (PBMs), the organizations that negotiate access to medicines for most patients in the United States, steer patients toward using their own pharmacies. discovered. However, these pharmacies appear to be less utilized by Medicare compared to other market segments. These PBMs are part of integrated healthcare conglomerates that own insurance companies and pharmacies, which can create conflicts of interest.

The study, published Jan. 10 in JAMA Health Forum, found that in 2021, one-third of Medicare Part D pharmacy spending and nearly 40% of specialty drug spending within Medicare Part D will be accounted for by CVS, It turned out that the operation was carried out through a pharmacy owned by one of the four major PBMs called United Health. Group, Cigna or Humana. However, this represents a much lower market share than the market share in Medicare, which is approximately 1.

The Federal Trade Commission's 2024 report points to a two-thirds national market share. The findings could guide future policy decisions regarding how these entities are regulated.

It is surprising that, on average, these companies' Medicare market share is significantly lower than national estimates. For high-cost specialty drugs, these pharmacies account for nearly half of Medicare market share, which is still lower than all other payer segments nationwide. ”

Dr. Praya Kakani, lead study author, assistant professor of population health sciences at Weill Cornell University

Dr. Kakani said one of the reasons these pharmacies' market share in Medicare is declining is due to the Centers for Medicare and Medicaid Services' “voluntary We believe that this may be due to the “Pharmacy” regulations. Set by Medicare Part D.

“Although we have not tested this directly, our research raises the possibility that these rules have a strong effect on preventing PBM companies from gaining huge market share,” she said. said. Outside of Medicare Part D, insurance companies generally have more leeway to exclude certain pharmacies from their network, which means patients have fewer choices about where they pick up their prescriptions.

“However, despite Medicare's 'any pharmacy' provision, insurers that integrate with PBMs can still direct a significant portion of Medicare Part D plan enrollees to their pharmacies,” the study says. said Associate Professor Dr. Amelia Bond, lead author of . in Population Health Sciences from Weill Cornell Medicine. This is especially true for some expensive specialty drugs. On average, Medicare patients utilized their PBM's pharmacy at nearly 20% higher rates than would be expected without steering.

PBM-owned pharmacies captured more than 60% of Medicare's market share for the treatment of pulmonary arterial hypertension, idiopathic pulmonary fibrosis, and multiple sclerosis. “There is wide variation across disease areas in the prevalence of these pharmacies, so policymakers concerned about this issue should pay particular attention to the drug classes in which these PBM-owned pharmacies are most utilized. there is.”

The market power of PBM pharmacies and a company's ability to drive patients to its pharmacies can impact costs, access to independent pharmacies, and patient experience. Therefore, some states may consider extending protections such as “any pharmacy” in the general commercial market.

“Steering may amplify not only the potential benefits but also the potential harms of this type of integration, so further research in this area is warranted,” Dr. Kakani said. Dr. Kakani, Dr. Bond, and their research team focused on the quality of care provided by PBM-owned pharmacies, including access, timely filling of prescriptions, and adherence to patient treatment plans and prices. We plan to continue investigating some of the issues.

This project was supported by the National Cancer Institute of the National Institutes of Health, grant R01-CA255035-04.