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.bde-section-36062-100{background-color:#616161;background-image:url(https://fideres.com/wp-content/uploads/2017/02/Pharma-Hands_main-image-scaled.jpeg);background-repeat:no-repeat;background-position:center center}.breakdance .bde-section-36062-100>.section-background-overlay{background:linear-gradient(99deg,rgba(0,0,0,1) 0%,rgba(0,0,0,0) 100%)}.breakdance .bde-section-36062-100>.section-background-overlay{opacity:0.7}</style><section class="bde-section-36062-100 bde-section"> <div class="section-background-overlay"></div> <div class="section-container"><h1 class="bde-heading-36062-101 bde-heading"> What Do PBMs Have To Hide? </h1><div class="bde-div-36062-120 bde-div"> <ul class="bde-post-meta-36062-102 bde-post-meta"> <li class="ee-postmeta-author-wrap"> <span class="ee-postmeta-author"><span class="ee-postmeta-before">By </span>Max Theiler</span> </li> <li class="ee-postmeta-custom-wrap"> <span class="ee-postmeta-custom">febrero 10, 2017</span> </li> <li class="ee-postmeta-custom-wrap"> <span class="ee-postmeta-custom">Research</span> </li> </ul><div class="bde-shortcode-36062-119 bde-shortcode"> <span class="span-reading-time rt-reading-time"><span class="rt-label rt-prefix">Reading Time:</span> <span class="rt-time"> 3</span> <span class="rt-label rt-postfix">minutes</span></span> </div> </div></div> </section><section class="bde-section-36062-103 bde-section"> <div class="section-container"><div class="bde-rich-text-36062-104 bde-rich-text breakdance-rich-text-styles"> <h2>Key Points</h2> <ul> <li>Payment flow and pricing structure are highly complex and nontransparent within the US pharmaceutical industry. No single entity having a complete view of how much a drug actually costs.</li> <li>Fideres has identified a number of issues with the role of Pharmacy Benefit Managers (“PBMs”) that warrant further investigation: potential conflicts of interest, complex and confidential rebate structures and a general lack of regulation.</li> </ul> <h2>The Hidden Role of PBMs and Insurers in the Supply Chain</h2> <p>While not a direct link in the physical supply chain, PBMs play an integral part of most consumer purchases. As is the case with manufacturers, wholesalers and pharmacies, the market for PBMs is highly concentrated. Following years of M&A activity, the top five PBMs account for more than 80% of all prescriptions dispensed in the U.S.</p> <p><img loading="lazy" class="size-full wp-image-36467 aligncenter" src="https://fideres.com/wp-content/uploads/2017/02/Picture-1-PBM_Market_Share_by_Total_Equivalent_Prescriptions_2014-1.png" alt="" width="2727" height="1361" /></p> <h6 style="text-align: center"><em><span style="font-size: 10pt">Source: The 2015 Economic Report on Retail, Mail and Specialty Pharmacies, Drug Channels Institute January 2015</span></em></h6> <p>PBMs provide services to insurers including claims processing, record keeping, reporting programs, utilization review, disease management and consultative services. Their main role is to:</p> <ul> <li>Establish and maintain a benefit structure, including drug formularies</li> <li>Develop a network of pharmacy providers</li> </ul> <p>Manufacturers pay rebates retroactively to PBMs based on their ability to include drugs on a health insurer’s formulary and increase a manufacturer’s market share. These rebates are kept private and confidential. PBMs profit by taking a percentage of the spread between the list price and the “Net Price”. The “Net Price” generally means the true costs of the drug that insurers will pay, taking into account discounts and rebates. Pharmacies contract with PBMs to join their pharmacy network, which provides pharmacies with access to a greater number of customers, buying power and stable reimbursement.</p> <h2>The Hidden Incentives of the PBMs</h2> <p>Substantial conflicts of interest arise when a PBM owns their own pharmacy operations as incentives shift from negotiating the lowest cost method of drug distribution to driving profits from its own pharmacy operations.</p> <p>The two biggest PBMs, Express Scripts and CVS, also own the two largest specialty pharmacies, These pharmacies have been rapidly expanding and now accounts for over 31% of all prescription drug spending.<sup>1</sup> PBMs also own a number of mail order and retail pharmacies. For example, the CVS retail chain pharmacy accounts for nearly 14% of all prescription revenues.<sup>2</sup></p> <p>Due to the non-transparent and secret nature of rebates between manufacturers and PBMs it is difficult to know what percentage of these rebates are passed on as savings to insurers and how much is kept by the PBM.</p> <ul> <li>There have been a number of complaints that allege the PBMs are accepting undisclosed incentives from manufactures and not passing rebates through to insurers.<sup>3</sup></li> <li>A more recent complaint alleges that manufacturers increased list prices while keeping net prices for insurers unchanged in order to incentivize PBMs (through profiting on the spread) to promote their products over competing products.</li> </ul> <p>Towards the end of 2016 Express Scripts received subpoenas from the DOJ and United States Attorney’s Office requesting information about its relationship with pharmaceutical companies, specialty pharmacies, prescription drug plan clients and payments made to and from those entities.<a href="https://fideres.com/wp-content/uploads/2023/02/25-October-2016-Reuters_Express-Scripts-gets-subpoenas-over-drug-company-pharmacy-ties.pdf" target="_blank" rel="noopener"><sup>4</sup></a></p> <h2>Open Questions</h2> <p>With most consumers at some stage having to pay the list prices for drugs, the questions is, how much are the PBMs profiting from the “Spread”?</p> <p>To date PBMs have received surprising little scrutiny over drug price increases, however is it time to start taking a deeper look into their business model?</p> <p>To read a full overview of the pharmaceutical market, including detailed overviews of the full supply and payment chain, please click <strong><a href="https://fideres.com/media/fideres-pharma-market-structure-report.74.pdf" target="_blank" rel="noopener noreferrer">here.</a></strong></p> </div><h1 class="bde-heading-36062-112 bde-heading"> Sources </h1><div class="bde-rich-text-36062-111 bde-rich-text breakdance-rich-text-styles"> <p><span style="font-size: 10pt"><sup>1</sup> The Express Scripts 2014 Drug Trend Report</span></p> <p><span style="font-size: 10pt"><sup>2</sup> The 2016 Economic Report on Retail, Mail and Specialty Pharmacies</span></p> <p><span style="font-size: 10pt"><sup>3</sup> “Federal and State Litigation Regarding Pharmacy Benefit Managers”</span></p> <p><span style="font-size: 10pt"><sup>4</sup> <a href="https://fideres.com/wp-content/uploads/2023/02/25-October-2016-Reuters_Express-Scripts-gets-subpoenas-over-drug-company-pharmacy-ties.pdf" target="_blank" rel="noopener">https://fideres.com/wp-content/uploads/2023/02/25-October-2016-Reuters_Express-Scripts-gets-subpoenas-over-drug-company-pharmacy-ties.pdf</a></span></p> </div><div class="bde-shortcode-36062-105 bde-shortcode"> <div class="saboxplugin-wrap" itemtype="http://schema.org/Person" itemscope itemprop="author"><div class="saboxplugin-tab"><div class="saboxplugin-gravatar"><img src="https://fideres.com/wp-content/uploads/2022/08/maxt.png" width="100" height="100" alt="" itemprop="image"></div><div class="saboxplugin-authorname"><a href="https://fideres.com/es/author/max_theiler/" class="vcard author" rel="author"><span class="fn">Max Theiler</span></a></div><div class="saboxplugin-desc"><div itemprop="description"><p>Max joined Fideres in 2016. He has led the development and implementation of economic models for major collective actions in the US and the UK, contributing to litigation on a variety of topics. His reports and econometric work has been included in cases for conduct including, among others, the FX and LIBOR benchmark manipulation, digital market monopolisation by Apple and Amazon, and consumer claims against a cartel of US generic drug manufacturers, abuse of market power by large regional US hospital systems, restriction of the right to repair by John Deere, and the combined abuse of dominance by Visa and Mastercard in UK payment systems. Before joining Fideres, Max worked at the national laboratory in Los Alamos, New Mexico, as part of a team designing neural networks for applications in machine learning. Max holds an MSc in Economic History from the London School of Economics.</p> </div></div><div class="clearfix"></div></div></div> </div></div> </section><section class="bde-section-36062-124 bde-section"> <div class="section-container"><div class="bde-columns-36062-125 bde-columns"><div class="bde-column-36062-126 bde-column"> <div class="bde-shortcode-36062-123 bde-shortcode"> <div class='next-post-bg' style='background-image: url(https://fideres.com/wp-content/uploads/2017/02/Fulton-Street-scaled.jpg);'><a href='https://fideres.com/es/european-closet-indexers-3-shades-of-grey/' class='next-post-link'><span class='link-label'>Previous Post</span><span class='post-title'>European Closet Indexers: 3 Shades Of Grey</span></a></div><br> </div> </div><div class="bde-column-36062-127 bde-column"> <div class="bde-shortcode-36062-122 bde-shortcode"> <div class='prev-post-bg' style='background-image: url(https://fideres.com/wp-content/uploads/2017/01/Main-image-scaled.jpeg);'><a href='https://fideres.com/es/us-generics-price-increases/' class='prev-post-link'><span class='link-label'>Next Post</span><span class='post-title'>US Generics Price Increases</span></a></div><br><br> </div> </div></div></div> </section><section class="bde-section-36062-106 bde-section"> <div class="section-container"><h1 class="bde-heading-36062-130 bde-heading"> Quizá También Le Interese </h1><div class="bde-post-loop-36062-108 bde-post-loop"> <div class="ee-posts ee-posts-grid"> <article class="ee-post"> <a class="bde-container-link-35993-102-36579 bde-container-link bde-container-link-35993-102 breakdance-link" href="https://fideres.com/es/keeping-your-options-open/" target="_self" data-type="url"> <div class="bde-image-35993-100-36579 bde-image zoomable-image bde-image-35993-100"> <figure class="breakdance-image breakdance-image--36580"> <div class="breakdance-image-container"> <div class="breakdance-image-clip"> <img class="breakdance-image-object" src="https://fideres.com/wp-content/uploads/2019/02/Analytics-scaled.jpg" width="2560" height="1717" loading="lazy" > </div> </div> </figure> </div><div class="bde-div-35993-110-36579 bde-div bde-div-35993-110"> <h1 class="bde-heading-35993-101-36579 bde-heading bde-heading-35993-101"> Research </h1><h1 class="bde-heading-35993-103-36579 bde-heading bde-heading-35993-103"> Keeping Your Options Open </h1><div class="bde-rich-text-35993-104-36579 bde-rich-text bde-rich-text-35993-104 breakdance-rich-text-styles"> <p>Damages in 10b-5 claims.</p> </div><div class="bde-div-35993-106-36579 bde-div bde-div-35993-106"> <div class="bde-image-35993-105-36579 bde-image bde-image-35993-105"> <figure class="breakdance-image breakdance-image--"> <div class="breakdance-image-container"> <div class="breakdance-image-clip"> <img class="breakdance-image-object" src="https://fideres.com/wp-content/uploads/2023/08/steffen.png" width="2048" height="2048" > </div> </div> </figure> </div><div class="bde-div-35993-109-36579 bde-div bde-div-35993-109"> <h1 class="bde-heading-35993-108-36579 bde-heading bde-heading-35993-108"> febrero 18, 2019 </h1><h1 class="bde-heading-35993-107-36579 bde-heading bde-heading-35993-107"> Steffen Hennig </h1> </div> </div> </div> </a> </article> <article class="ee-post"> <a class="bde-container-link-35993-102-36858 bde-container-link bde-container-link-35993-102 breakdance-link" href="https://fideres.com/es/was-the-uk-vaccine-rollout-discriminatory/" target="_self" data-type="url"> <div class="bde-image-35993-100-36858 bde-image zoomable-image bde-image-35993-100"> <figure class="breakdance-image breakdance-image--36859"> <div class="breakdance-image-container"> <div class="breakdance-image-clip"> <img class="breakdance-image-object" src="https://fideres.com/wp-content/uploads/2021/08/covid-19-vaccine_pexels-scaled.jpg" width="2560" height="1707" loading="lazy" > </div> </div> </figure> </div><div class="bde-div-35993-110-36858 bde-div bde-div-35993-110"> <h1 class="bde-heading-35993-101-36858 bde-heading bde-heading-35993-101"> Research </h1><h1 class="bde-heading-35993-103-36858 bde-heading bde-heading-35993-103"> Was The UK Vaccine Rollout Discriminatory? </h1><div class="bde-rich-text-35993-104-36858 bde-rich-text bde-rich-text-35993-104 breakdance-rich-text-styles"> <p>No – It was the picture of fairness.</p> </div><div class="bde-div-35993-106-36858 bde-div bde-div-35993-106"> <div class="bde-image-35993-105-36858 bde-image bde-image-35993-105"> <figure class="breakdance-image breakdance-image--"> <div class="breakdance-image-container"> <div class="breakdance-image-clip"> <img class="breakdance-image-object" src="https://fideres.com/wp-content/uploads/2021/10/Ellie-web-resized.jpg" width="2048" height="2048" > </div> </div> </figure> </div><div class="bde-div-35993-109-36858 bde-div bde-div-35993-109"> <h1 class="bde-heading-35993-108-36858 bde-heading bde-heading-35993-108"> agosto 24, 2021 </h1><h1 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Structured Credit Ratings </h1><div class="bde-rich-text-35993-104-36519 bde-rich-text bde-rich-text-35993-104 breakdance-rich-text-styles"> <p>Still navigating in troubled waters?</p> </div><div class="bde-div-35993-106-36519 bde-div bde-div-35993-106"> <div class="bde-image-35993-105-36519 bde-image bde-image-35993-105"> <figure class="breakdance-image breakdance-image--"> <div class="breakdance-image-container"> <div class="breakdance-image-clip"> <img class="breakdance-image-object" src="https://fideres.com/wp-content/uploads/2023/08/alberto2.png" width="2048" height="2048" > </div> </div> </figure> </div><div class="bde-div-35993-109-36519 bde-div bde-div-35993-109"> <h1 class="bde-heading-35993-108-36519 bde-heading bde-heading-35993-108"> enero 16, 2018 </h1><h1 class="bde-heading-35993-107-36519 bde-heading bde-heading-35993-107"> Alberto Thomas </h1> </div> </div> </div> </a> </article> </div> </div></div> </section><section class="bde-section-36062-128 bde-section"> <div 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