skip to Main Content

Bipartisan efforts seek to rein in PBMs 
Congress continues to focus on PBMs, crafting several legislative packages that include reforms to make the role of pharmacy benefit managers in drug pricing more transparent and overhaul how PBMs are compensated, and curb potentially anticompetitive behavior. Among the specifics: requiring PBMs to report their negotiations, pricing information, and benefit designs; banning spread pricing (where PBMs reimburse pharmacies less than what they charge payers; Other proposals would ensure PBMs pass on rebates to plan sponsors and reduce out-of-pocket costs for beneficiaries. (Commonwealth Fund)
Employers: Who’s your pharmacy consultant really working for  
Employers pay consulting firms to find the best deals on prescription drugs– and to make sure PBMs aren’t “ripping them off with unfair contracts.” But a STAT investigation reports that some consulting firms are paid significantly more by the PBMs and insurers that they’re supposed to scrutinize than they are by companies they’re supposed to be looking out for. “In exchange for the payments, the dominant PBMs get steady business from employers that rarely switch vendors, and they make it more likely that consulting firms and brokers won’t tattle if PBMs bake in more ways to extract profits from employers,” STAT reports. (STAT)

Practice Transformation

CMS revises guidelines on drug price negotiations 
CMS has released updated guidelines for its program that allows Medicare to negotiate drug prices directly with manufacturers. It clarified how it will select drugs and provided additional details on the negotiation process. CMS will consider factors such as clinical benefit, unmet medical needs, and impact on Medicare beneficiaries during negotiations. CMS plans to publish a list of the first 10 drugs under negotiation by Sept. 1, 2023, with prices effective from 2026. (Fierce Healthcare)
Evidence & Innovation
To increase drug efficacy, conduct trials in the community 
Lack of diversity in clinical trials has a direct impact of the effectiveness of drugs. A report from the National Academies of Sciences, Engineering and shows that underrepresentation of population subgroups in clinical research is bad for the health of Americans. For instance, recent research showed that appropriate dosing for warfarin differs due to genetic variants. A commentary in STAT makes the case for increasing clinical trial diversity by conducting more trials in community practice settings or safety net clinics. It also proposes that the federal government incentivize researchers to conduct studies in these settings. (STAT)
Cancer Society releases PGx consensus paper 
The American Cancer Society’s Cancer Action Network recently released nine consensus recommendations for implementing pharmacogenomics testing in cancer care. These include incorporating PGx testing recommendations into treatment guidelines, creating incentives for appropriate testing, and improving coverage. “A provider’s very unlikely to order a multi-gene test, or maybe even single-gene test, if that patient is going to have out-of-pocket costs,” Dr. Jai Patel, chair of the department of cancer pharmacology and pharmacogenomics at Atrium Health’s Levine Cancer Institute, told Precision Medicine Online. “That patient’s insurance is dictating whether or not that patient’s going to receive testing.” (consensus statementPrecision Medicine Online)

Policy Solutions

Biologics coverage varies; cancer drugs have fewest restrictions
Biosimilars have the potential to reduce spending and increase access to costly biologic therapies, but there are huge variations in how biosimilars were covered, compared with their reference product, by commercial health plans, according to research published in the journal BioDrugs. Plans frequently imposed coverage restrictions on biosimilars, especially for pediatric populations, prevalent diseases, and plans without contracts with major PBMs. Biosimilars indicated for cancer treatments and those first entering the market experienced fewer restrictions. (AJMC Center for BiosimilarsBioDrugs)
In Case You Missed It!
Learn about the peer-reviewed evidence showcasing the value of CMM, through improvements in access to care, provider work life, outcomes and patient satisfaction as well as a reduction in costs. These findings outline the CMM team-based care process that can be implemented in a variety of health care systems to ensure positive patient outcomes.
Developed by the Evidence-Based Resources Subgroup of the Practice and Care Delivery Transformation Workgroup.

2022 GTMRx Resource | Comprehensive Medication Management via Telehealth Modality in Team-Based Care:A Review of the Evidence on Quality, Access and Costs, December 2022

Learn about the peer-reviewed evidence showcasing the value of CMM delivered as a service via telehealth and its challenges. Telehealth is a promising modality to improve access to care, facilitate patient monitoring and maintain the needed connection with patients that improves their care and health.
Developed by the Evidence-Based Resources Subgroup of the Practice and Care Delivery Transformation Workgroup.
See past issues of our news brief here

Back To Top
×Close search

We need your help now more than ever!