SALT LAKE CITY — With everything from cancer to hemophilia, to Crohn's disease, the increase in the price of drugs touches many and has been a source of stress for those left to figure out how to pay for them.
A local pharmacist is bringing together federal and state leaders to explain why drug prices are so high and what needs to be done to change that.
Earlier this year in May, we introduced you to five individuals, they or an immediate member of their family have a chronic disease and at one point were unable to afford their life-saving medications.
Like Carrie Ann Kemp who was keeping her cancer at bay with a medication that cost $24,000 a month.
Or nine-year-old Penny Hepworth whose cystic fibrosis treatments combined are half a million dollars a year.
They all experienced copay accumulation, that’s when insurance companies keep the copay assistance meant for a patient and use it for more profit.
The assistance a patient would be receiving does not count toward their deductible or out-of-pocket costs.
But the complexities of this side of our healthcare system go beyond the copay accumulators that leave patients scrambling to find ways to pay for treatments.
Pharmacist and owner of the Apothecary Shoppe in Salt Lake City, Kevin Demass, is trying to bridge the knowledge gap between what we all know, which is that the cost of life-preserving medications can be exorbitant, but also explain why those prices are so high.
Fox 13 was there as he hosted the commissioner of the Federal Trade Commission Melissa Holyoak, Utah's insurance commissioner John Pike, and Rep. Celeste Maloy, all asking questions about medicine’s middle-man called pharmacy benefit managers.
Pharmacy benefit managers or PBMs for short, are groups of mega-corporate thinkers hired by insurance companies to help regulate what medications a pharmacy provides for consumers.
But sometimes the drugs they choose are not generic brands which tend to be reasonably priced.
“Their incentive to manipulate those choices that they’re doing is that they consistently pick very expensive medication that they make money on the backside, that they work out rebates with the manufacturers and health plans," says Demass. "It’s a money-making, economical thing for them, and it totally pulls away from the healthcare cost at the bottom and totally inflates healthcare cost for our community and for our patients.”
One of the country’s largest pharmacy benefit managers, Express Scripts, recently sued the Federal Trade Commission (FTC) for what they say are false claims.
This, is after the FTC released a report in July about pharmacy benefit managers inflating drug costs.
For context, the FTC is a federal entity created to enforce consumer protection laws that prevent fraud, deception and unfair business practices.
Express Scripts alleges they drive drug costs down, they say the FTC has touted the opposite narrative.
While the FTC commissioner could not comment on the pending litigation, the lawsuit did prompt FOX 13 News to ask a few questions about why drug prices are in some cases unaffordable and why that’s been permissible.
Robyn: "How are we letting them take advantage of consumers? How is that legal? How do we regulate that?”
Commissioner Holyoak: “Why it’s so complex is because there’s so many players involved. You have the medication manufacturers, you have the insurance companies, you have plan sponsors you have the PBMs, the pharmacy benefit managers, the pharmacist and the consumer, and all of those parties are involved in making those decisions. There’s different incentives from plan sponsors versus drug manufacturers and then also the pricing mechanisms from what we understand, we’re still trying to understand how some of that works.”
Demass says we need PBM reform, but to get there the FTC has to further investigate the practices of PBMs and the House and the Senate need to agree on legislation to stop practices that manipulate the cost of medication.
That’s what Fox 13 asked Utah's second congressional district Rep. Celeste Maloy about.
“It gets pretty complicated when you start digging into this because it turns out Pharma isn’t always in line with the PBMs either and at first when I got into this, we were talking to independent pharmacies within the big chain pharmacies also have the same problem, so it’s tempting to quickly point the finger at somebody, but I think we’ve got a system that has multiple glitches in it and its glitches are feeding off each other," says Maloy. "If we address one, we may not have actually addressed the problem and that’s why things like this are so important.”
Maloy says she’s working with colleagues in Congress who are involved in healthcare to better understand the issue.
But will that understanding come in time for some patients?
Robyn: “There are families who need their medications now, so how long are we talking before we figure out all those complexities and people get the medication they need?”
Commissioner Holyoak: “Absolutely, that is something we want to make sure we get it right, we want to make sure that when we study PBMs that we’re looking at the evidence and coming in objectively to understand how consumers are impacted. But yes, this is something that is top of mine, and there should be greater emphasis and I am encouraging the Federal Trade Commission to make sure we work and stay remained focused on looking at this issue.”
That solution to the issue might be right in front of us.
“If we can delink the cost for the price of that drug to what they are getting reimbursed with a fair price for the pharmacy, that’s the first step because they’re not incentivized economically to pick that drug that’s $2000 more expensive," says Demass. "They’re not going make any money and they’re not going to benefit off of the drug. So let’s get another therapeutic drug for less price, let’s treat my patient, let’s get them on their way to a happy, healthy life with no link between cost of drug and the amount of money that the PBM is making.”
