Corporate Pharma & US Government Regulators

Today I’m writing about what happens when a monopolist gets mad. In this case, it’s health giant Cigna taking revenge on rural pharmacies and patients after the Biden administration tried to slightly reduce the firm’s profits from Medicare prescription drug benefits.

A few months ago, the Biden administration put out a rule to regulate the pharmacy benefits management business, an opaque but massive part in the pharmaceutical drug supply chain. PBMs handle the drug benefit piece of insurance plans. They maintain a list of drugs for insurance companies, they negotiate drug prices, and they manage reimbursements to pharmacies.

The original idea behind PBMs is they would be able to get enough bargaining power by representing multiple insurance companies that they could negotiate to bring down drug prices. And accumulate bargaining power they did, merging until three PBMs control 80% of the insurance market. They are also vertically integrated with insurance companies and drug store chains. The top three PBMs are owned by CVS, United Health, and Cigna.

Unfortunately, because of an exemption from anti-kickback laws, PBMs don’t use their bargaining power to reduce consumer prices. Instead, they force pharmaceutical firms to compete over who will give the PBM the biggest kickback, which in the industry is known as a rebate.

The many bad practices of PBMs are legendary. PBMs often force customers to buy more expensive drugs over their generic counterparts, likely because they get kickbacks when customers do so. This ends up making this obscure group of firms a lot money. The combined revenue of the top three firms, who comprise just a small part of the U.S. health system, is larger than the entire amount France spends on all medical care for its entire population.

PBMs are particularly bad for independent pharmacies, who are a critical lifeline in many underserved parts of America. 77% of independent pharmacies serve communities with fewer than 50,000 people. In these places, the independent pharmacist often is the health care infrastructure. Seven in ten do free home delivery, a service which is virtually non-existent with chains. The amount that PBMs have been reimbursing these pharmacists has been going down for years, to the point that many are losing money depending on the medicine they are filling for customers.

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