Lobbying Spend

Two congressional committees advanced notable PBM legislation, moving one step closer toward comprehensive changes to PBMs’ dominant business model.

The Senate Finance Committee, with a near-unanimous bipartisan majority, advanced a major Medicare- and Medicaid-focused PBM reform bill on July 26. D.C. insiders tell AIS Health, a division of MMIT, that the committee’s move bodes well for notable commercial market PBM reforms. So does the fact that senators of both parties are emphatically in favor of it, despite reluctance by some Republican members of the House of Representatives to make aggressive changes to PBM regulations.

Two congressional committees advanced notable PBM legislation, moving one step closer toward comprehensive changes to PBMs’ dominant business mode.

The Senate Finance Committee, with a near-unanimous bipartisan majority, advanced a major Medicare- and Medicaid-focused PBM reform bill on July 26l. D.C. insiders tell AIS Health, a division of MMIT, that the committee’s move bodes well for notable commercial market PBM reforms. So does the fact that senators of both parties are emphatically in favor of it, despite reluctance by some Republican members of the House of Representatives to make aggressive changes to PBM regulations.

CVS Health Co.’s Caremark PBM struck a deal with GoodRx, Inc. that will allow eligible Caremark members to automatically access to GoodRx's prescription pricing at the pharmacy counter, which may lower their out-of-pocket costs for generic medications, per a July 12 press release. Using GoodRx coupons won’t affect members’ deductible and out-of-pocket threshold calculations, CVS added, noting that “plan members only need to utilize their existing benefit card at their preferred in-network pharmacy” to access the new discounts. “Through this program, patients don't have to choose between using their pharmacy benefit or using GoodRx to save on their prescriptions — now they can do both right at the counter so they have confidence they are always paying the lowest available price, said Scott Wagner, interim CEO of GoodRx. “This collaboration can make a meaningful difference for the tens of millions of Americans that CVS Caremark serves." The pact isn’t GoodRx’s first deal with a “big three” PBM — GoodRx also has a similar discount arrangement with The Cigna Group’s Express Scripts.

The health insurer trade group AHIP recently unveiled a new advertising campaign that accuses the pharmaceutical industry of deflecting blame for its “price-gouging” practices and undermining the “evidence-based, market-driven tools” that health insurers use to keep drug costs in check. But the campaign doesn’t appear to mention PBMs, even though they’re the ones conducting drug-price negotiations with manufacturers on behalf of health plans and employers.

Health care industry observers say that omission is unsurprising since PBMs are currently facing a growing wave of scrutiny — scrutiny that insurers likely want to minimize even if they don’t want to lobby for that explicitly. Pharmaceutical Research and Manufacturers of America (PhRMA), meanwhile, pounced on the opportunity to call out what it sees as the unspoken, PBM-supporting message in AHIP’s new campaign.

The pharmaceutical and health products industry poured over a record amount — more than $373.7 million — into lobbying and outspent all other industries in 2022, according to data compiled by OpenSecrets.

During the 2021-2022 election cycle, the pharma/health products industry bucked its historical trend of favoring Republicans and distributed around 60% of donated campaign funds to Democratic lawmakers. Among the 20 lawmakers who received the most contributions from the industry during the election cycle, 14 are Democrats. Sen. Raphael Warnock (D-Ga.) topped the list, receiving over $764,000.

The health insurer trade group AHIP recently unveiled a new advertising campaign that accuses the pharmaceutical industry of deflecting blame for its “price-gouging” practices and undermining the “evidence-based, market-driven tools” that health insurers use to keep drug costs in check. But the campaign doesn’t appear to mention PBMs, even though they’re the ones conducting drug-price negotiations with manufacturers on behalf of health plans and employers.

Health care industry observers say that omission is unsurprising since PBMs are currently facing a growing wave of scrutiny — scrutiny that insurers likely want to minimize even if they don’t want to lobby for that explicitly. Pharmaceutical Research and Manufacturers of America (PhRMA), meanwhile, pounced on the opportunity to call out what it sees as the unspoken, PBM-supporting message in AHIP’s new campaign.

The pharmaceutical and health products industry poured over a record amount — more than $373.7 million — into lobbying and outspent all other industries in 2022, according to data compiled by OpenSecrets.

During the 2021-2022 election cycle, the pharma/health products industry bucked its historical trend of favoring Republicans and distributed around 60% of donated campaign funds to Democratic lawmakers. Among the 20 lawmakers who received the most contributions from the industry during the election cycle, 14 are Democrats. Sen. Raphael Warnock (D-Ga.) topped the list, receiving over $764,000.

Congressional interest in PBM reform may turn into comprehensive legislation as soon as this summer, D.C. insiders tell AIS Health, a division of MMIT, and possibly has enough bipartisan support to pass both chambers. Lobbyists representing employer plan sponsors say that measures including a requirement that PBMs be fiduciaries to plan sponsors and members, a federal ban on spread pricing, and mandatory price transparency disclosures are all under serious discussion.

Several Senate committees have made moves to advance PBM legislation. The Finance Committee held a hearing on PBMs at the end of March; the Commerce Committee has advanced legislation; and the Health, Education, Labor and Pensions (HELP) Committee seems poised to mark up legislation this month, according to press reports. In the Senate, which is controlled by Democrats, several bills have sponsors from both parties, and the HELP Committee markup will feature members of both parties, led by committee chair Sen. Bernie Sanders (I-Vt., who caucuses with Democrats) and ranking member Sen. Bill Cassidy (R-La.).

Industry groups and Medicare Advantage insurers have mounted a public fight against a CMS proposal that they contend would reduce payments to MA plans. But even before that proposal, their lobbying expenditures reached record highs.

On Feb. 1, CMS released the 2024 Advance Notice for Medicare Advantage and Part D plans — the agency’s annual proposed update to methodologies used to calculate payments to the plans — and estimated a 1.03% pay hike for MA plans, on average, when accounting for an underlying risk score trend of 3.3%. However, insurers argued that the rule would result in a cut to plans due to technical changes in how risk scores are calculated, leading to higher premiums and fewer enrollee benefits. Just prior to releasing the Advance Notice, CMS also finalized a long-dreaded final rule that will allow the government to claw back billions of dollars’ worth of overpayments to MA organizations.

AbbVie Inc. is leaving several lobbying organizations, including the Pharmaceutical Research and Manufacturers of America (PhRMA), widely regarded as the most powerful drug industry trade group, according to Politico. PhRMA has had a tough year. In August, the trade group faced its most notable political failure in a generation when Democrats passed Medicare drug price negotiation as part of the Inflation Reduction Act. In the months since, PhRMA has launched an internal review of that episode and has dismissed several of its most prominent executives.

Amgen Inc. plans to acquire Horizon Therapeutics plc. for $27.8 billion, or $116.50 per share, according to regulatory filings; the deal is the largest health care merger of the year, per the Wall Street Journal. Horizon develops specialty drugs for autoimmune and inflammatory diseases. The firm’s best-seller is Tepezza (teprotumumab-trbw), a treatment for thyroid eye disease. If, as expected, Tepezza earns approval in the European Union and Japan, Horizon projects $4 billion in global annual revenue from the drug.