PBM Reform in the House Is Officially a Thing Now

It’s official: the House package of PBM reforms -- nestled in a larger health care transparency bill -- has now been introduced. And it has a Democratic co-sponsor, so it’s technically a bipartisan bill, too.

The contents of the legislation are pretty much what was expected/predicted: a ban on spread pricing and additional requirements on what PBMs have to disclose to employers.

I’m not remotely sure this is an “Inflection Point” -- it feels like Congress would have to get pretty far down its 2023 to-do list before “PBM” reform comes up -- but progress is progress.

I’m also not remotely sure that banning spread pricing is really getting to the heart of the problem, which is something I kind of touched on in my weekend column at LinkedIn.

Call me a starry-eyed optimist, but I found the discussion about the Inflation Reduction Act (as well the legislative efforts around Medicare “negotiation” that preceded it) to be illuminating and helpful, even if the final product was (in the words of STAT’s Matt Herper) “not fully thought out.”

While the debate wasn’t perfect -- nuance tends to go down as volume goes up -- it allowed those who believe that lower drug prices should be prioritized, even in the face of consequences around innovation, to face off against those who thought that any gains from price controls has the potential to be swamped by the damage to the ecosystem that drives the development of new medicines.

And regardless of what side you’re on, that’s a useful conversation to be having. Because it’s not a conversation about right answers or wrong answers but about what kind of system we want here in the United States.

So this new Health Affairs Forefront piece scares the snot out of me. In it, two law professors seek to recast pro-innovation arguments from industry as “innovation bullying”: using the threat of fewer medical advances as “a hammer on policymakers to deter even modest regulatory initiatives.”

I have a college-aged kid and one in high school. “Bullying” means something very different today than it did when I was on the playground. It’s now a way to mark a behavior that is, without dispute, intolerable and unacceptable.

So in terming the standard give-and-take over innovation to be “bullying,” the new Health Affairs piece seeks to preemptively shut down the discussion, to declare an entire set of arguments to be beyond the pale. That’s ridiculous.

The reality is that pro-innovation messages are no more bullying than any other argument. If you believe -- as the Health Affairs authors do -- that price controls won’t impact innovation (or, more honestly, that the tradeoffs are still worth it), then make that case in the court of public opinion.

But don’t claim that pushing the innovation agenda somehow has a chilling effect on regulation. Make better counter-arguments.

It seems like the true way to chill debate is by refusing to accept a true back-and-forth and just calling your opponents “bullies.”

Not constructive.

• Payers-acting-badly-when-it-comes-to-generics appears to be a whole genre. Last week, the AAM report played up the weird impacts of PBMs on the generics marketplace, and, this morning, the Wall Street Journal published a piece that looked at why Mark Cuban is delivering much better deals than America’s payers. (The answer will not surprise you.)

• I know I’m a broken record on this one, but the lack of access-related protections in the IRA could mean that the law isn’t going to work well for patients. Emory’s Ken Thorpe, the chairman of the Partnership to Fight Chronic Disease, makes that point elegantly in this Real Clear op-ed.

• For the first time in about a month, we made it through a Friday night without any new IRA litigants. But if you’re starved for IRA-litigation coverage, here is a WSJ Heard on the Street to check out. The column makes the point that maybe it’s time for Wall Street to start paying attention to the lawsuits.

• I’m curious what the White House promised Bernie Sanders on drug prices to get him to move forward with the nomination of Monica Bertagnolli to run the NIH. Maybe the CMS “selected drug” announcement last month warmed his heart a tad. Maybe there is another shoe to drop. Bertagnolli’s hearing before Sanders’ committee is expected next month. Should be a fun one.

• Last week, there was an interesting NYT article -- with some cool graphics -- about the mysterious flattening of spending in Medicare. A bunch of people wrote to the paper and told them that the flattening wasn’t mysterious at all, offering hypotheses for the phenomenon. One of those hypotheses: the introduction of the Part D benefit drove up medication use by seniors, which improved health enough to reduce downstream spending on doctors and hospital visits.

• Medicare Part B spending growth is being driven by new medicines, not price hikes, according to a JAMA Health Forum analysis that suggested that inflation penalties were probably not the best way to address rising spending in the program.

• Lilly’s Mounjaro got the green light from the UK’s NICE cost-effectiveness watchdog, clearing the way for the medicine’s use in diabetes. As with all NICE decisions, the interesting datapoint -- the actual cost -- remains a secret. And, as a reminder, we’re talking diabetes here, not weight loss.