A Tampa lawmaker is hoping to lower drug prices and improve care for Floridians by regulating companies that serve as middlemen in the health care industry.
Rep. Jackie Toledo, R-Tampa, filed legislation on Tuesday that would rein in the industry that helps decide how consumers get their pharmaceuticals and how much they will pay for them. Pharmacy Benefit Managers, or PBMs, such as CVS Caremark, Optum RX and Express Scripts control roughly 80 percent of the market in Florida and around the country. That means they have a large say in which medications make it on a list of drugs that are covered by insurance companies.
“This comprehensive piece of legislation will create transparency from prescription drug pricing and positively affect patients’ wallets at the pharmacy,” Toledo said during a press conference in Tampa to announce the bill.
Her legislation would control how PBMs do business in the state by creating a regulatory framework. Toledo says she expects resistance from the companies, which have made trillions of dollars in the pharmaceutical industry even though they don’t prescribe, dispense or manufacture drugs.
“There’s going to be people that are going to push back because it’s going to interrupt their profits,” Toledo said. “We’re going to have lobbyists from the PBMs that are going to fight really hard to defeat this bill, but we’re on the right side.”
One way PBMs profit is through a practice called self-dealing, where the companies steer patients to pharmacies that they own and then charge higher prices per prescription than other network pharmacies. Toledo’s bill would put an end to that practice, which she says is killing competition and has forced the closure of 15% of independent pharmacies in Florida over the past three years.
“Pharmacies in Florida are closing at an alarming rate and it’s escalating,” said Kevin Duane, a pharmacist with Panama Pharmacy, an independent pharmacy that has been operating in Jacksonville since 1928. “If you want to see lower drug prices, you want to see enhanced competition, you want patients to be able to choose the pharmacy that they use, then these practices have to stop.”
PBMs would also have to stop charging health plans one price and reimbursing pharmacies a lower price in order to pocket the difference. And Toledo’s bill would keep PBMs from profiting off rebates from pharmaceutical companies and instead force them to pass those savings on to consumers.
Finally the bill would require PBMs to report all of their revenue to the state or other plan sponsors.
“We’re all in agreement, transparency is the baseline,” said Sen. Jose Javier Rodriguez, D-Miami, who attended Toledo’s press conference and spoke in support of the bill. “We need transparency as to what’s happening.”
The bill also has support from pharmacy, patient and physician advocacy groups, including the Small Business Pharmacies Aligned for Reform.
Loretta Boesing is the founder of the patient advocacy group Unite for Safe Medications. She said she started the group after her son, who is a transplant recipient, nearly died when his medication was compromised by a mail-order pharmacy. A PBM forced Boesing to get the medication by mail, instead of from a local pharmacist. The drugs had safe temperature storage guidelines, which were not followed, she said.
“After my child’s liquid oral medications arrived on a 102-degree day in only a bag, my child went into transplant rejection,” Boesing said. “It’s not about us, it’s not about patients. It’s about profits.”
Toledo says her bill would eliminate anti-competitive practices by PBMs to keep neighborhood pharmacies from being pushed out of business.
Other patients, like Mike Stein, say they have had to fight PBMs in order to get access to medications that their doctors prescribed.
Stein, who has cancer and requires chemotherapy every month, had to switch medications when one therapy stopped working. Because he has a liver condition, his doctors recommended a certain type of medication, but his PBM would not approve it, Stein said.
Stein’s doctors negotiated for months on his behalf, writing letters and filing appeals with the PBM, before the company finally approved the new medication, he said.
“It’s ludicrous that insurance companies are able to dictate to doctors how to best treat their patients,” Stein said. “In what world can an unlicensed individual without the ability to access my medical records make medical decisions?”
Though PBM reform has been tried and failed in the past, growing consumer outrage along with a changing political tide could give Toledo’s bill the needed momentum, Rodriguez said.
“We feel like the moment has arrived. At the federal level, it’s not a partisan issue. At the state level, as you can see here, it’s not a partisan issue either,” Rodriguez said. “There’s a large group of us working together to try to get this done this year. It will not be easy, this is a very powerful industry. But we need to do it. It’s not simply a pocketbook issue, it’s a life and death issue for our constituents who rely on prescription medication.”