The Truth about Pharmacy Benefit Managers

by | Jun 9, 2022 |

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Nobody wants fraud — particularly not in medical care. Accordingly, in 1972, Congress passed the Federal Anti-kickback Statute that outlawed kickbacks for referrals for medical care and other contracts in the medical field. This was to be sure that referrals of patients to other medical care professionals were in the best interest of the patients. In an interesting turn of the law, 25 years ago, the government made exceptions to the Anti-kickback statute, allowing middlemen to negotiate rebates and discounts on medical products. The problem: the middlemen typically are paid by a percentage of the rebate or discount off the list price. The higher the price they negotiate, the higher their piece of the action.

In the world of prescription drugs, pharmacy benefits managers (PBMs) are the middlemen who negotiate discounts and rebates for private and government insurers. PBMs promote the false perception that they save patients money. The rebates are supposed to go back to the government or to insurers to lower premiums or otherwise benefit patients. Instead of saving money, we now have a system where after insurance, a drug costs $150 for consumers, whereas with GoodRx, the same drug is $6.

Today, three of the biggest companies control about 89 percent of the PBM market — CVS (which owns Caremark), United Health (which owns OptumRx), and Cigna (which owns Express Scripts). Their 2021 revenues were $292.1 billion, $287.6 billion, and $171.1 billion, respectively. Given these figures, PBMs have been under increasing scrutiny in recent months from Congress and the Federal Trade Commission (FTC) for their contribution to high consumer drug prices. They want information on contract terms, rebates, fees, pricing policies, steering methods, conflicts of interest, the substitution of prescriptions, and consolidation of PBMs with pharmacies and insurance companies.

In today’s show, Dr. Marion Mass explains how the system of pharmacy benefit managers has morphed into a big money-making scheme, and patients are left holding the bag (of higher costs). 

Dr. Marion Mass is a board-certified pediatrician and co-founder of the non-partisan Practicing Physicians of America. She graduated from Duke University Medical School and completed her residency at Northwestern’s Robert Lurie Children’s Hospital, before returning to her home state of Pennsylvania, where she has practiced for 23 years. She currently works at The Children’s Hospital of Philadelphia.

Dr. Mass’s passion for quality affordable medical care stems from a personal issue that occurred to her mother and her desire for her three adult children to live in a world where quality affordable care exists.

Dr. Mass has published numerous articles on health care costs and quality in multiple outlets, including the Wall Street Journal, Philadelphia Inquirer, Washington Times, the Hill, and more. She has led two non-partisan symposiums at the Library of Congress on health policy. She serves on the volunteer boards of her County Health Improvement Partnership and the county newspaper.


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Dr. Marilyn M. Singleton

Dr. Singleton is a board-certified anesthesiologist and past president of the Association of American Physicians and Surgeons. She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at the University of California at San Francisco Medical Center, and her Anesthesia residency at Harvard’s Beth Israel Hospital. She was on the faculty at Johns Hopkins Hospital in Baltimore, Maryland, before returning to California for private practice. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional and administrative law. She interned at the National Health Law Project, and practiced insurance and health law.

Dr. Singleton has published numerous articles, given presentations on health policy, and had many radio and television appearances, and a monthly radio show, Health Freedom Now. She started a blood pressure screening clinic at her church and make-shift clinics in two rural villages in El Salvador. Dr. Singleton ran for Congress in 2012 with a message of personal freedom and limited government.

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