Stepping Toward a More Affordable Future:

Stepping Toward a More Affordable Future

Building a More Accessible and Affordable Health Care System

PBMs provide $145 billion in value for the U.S. health care system annually by lowering prescription drug costs. Additionally, PBMs enable better health outcomes for patients and offer employers and other health insurance plan sponsors the choices and guidance they need to expand access and provide quality prescription drug coverage for millions of Americans. PCMA’s vision of an Affordable Future prioritizes patient access and improving health outcomes. It also suggests methods to enhance the competitive market for drugs and biologics, making them more affordable and sustainable.

In fact, the top 20% of non-rebated drugs with the most price increases saw an average price increase of 93%. Specialty drugs specifically have continued to rise in price. From 2010 to 2019, specialty spending jumped from $9.4 billion to $46.8 billion. In 2023, the median cost for non-oncology specialty medicines was $44,000, while oncology therapies had a median annual cost of $299,000.

These rising costs are directly impacting patient affordability—3 in 10 adults in 2024 reported skipping medications due to price, and 98 million prescriptions were abandoned in 2023 with 55% of those with a final out-of-pocket cost above $250 being left unfilled. Further, more than half of insured patients worry about affording their prescriptions. These issues highlight the urgent problem of high drug prices and the magnitude of the impact on Americans. The Pharmaceutical Care Management Association (PCMA) is offering this comprehensive set of proposals to address some of the most pressing concerns of policymakers around this issue.

3 in 10

Adults in 2024

Reported skipping medications due to price

Resources

Three steps to propel us forward:

Step 1: Ensure system sustainability by further enabling competition

The best way to control prescription drug costs is by cultivating a competitive market for prescription drugs that promotes innovation while facilitating timely entry of affordable alternatives for patients.

Step 2: Promote widespread, affordable access to prescription drugs through support for pharmacists and pharmacies

Pharmacies are the most frequent touchpoint in the health care system for patients across the U.S. They are vitally important partners in providing drug access, promoting adherence and, in many cases, providing other basic health care. PCMA and its members support efforts to help clinicians, including pharmacists and other health care practitioners, “practice at the top of their training” to optimize use of their clinical expertise and counseling abilities for the benefit of patients and the broader health care system.

Step 3: Enhance patient outcomes and improve patient experience

In addition to improving drug affordability and facilitating drug access for patients, pharmacy benefit managers (PBMs) use their specialized prescription drug expertise and care coordination tools to support better health outcomes and provide recommendations to meet each patient’s needs.

Building on our previous recommendations, the 2025 Affordable Future policy platform is intended to support policymakers’ efforts to address high drug prices, avoid unintended consequences, and maximize effectiveness. We continue to welcome all stakeholders to partner with us to work toward a more functional, equitable, and affordable market for prescription drugs.

Conclusion

Efforts to lower drug costs must start with an understanding that prices are set by drug companies. A drug company sets the price for any drug it manufactures, and that price dictates cost throughout the supply chain, from the wholesaler’s negotiation for discounts, to pharmacy acquisition costs, to its markups to pharmacies, to the amount that the insurance plan sponsor and patient ultimately pay.

PBMs exist to reduce drug costs for plan sponsors and, most importantly, for the patients our companies serve. In doing this work, PBMs generate tremendous value for society, estimated at $145 billion annually, and save plan sponsors and patients an average of $1,040 per person per year. Much of this value is generated by the savings PBMs negotiate with pharmaceutical manufacturers and pharmacies. PBMs are enabled to negotiate most effectively when there is a competitive prescription drug market.

In addition to driving competition among drug companies to control costs in support of plan sponsors and patients, PBMs serve patients by promoting a high-quality, competitive pharmacy market. PBMs need a stable pharmacy market, capable of supporting patients across the entire country in order to function effectively and be competitive enough to win business. The proposals herein serve as meaningful steps toward a more affordable future for drug access in America.

Sources

Brill, A. (2024). Rebates and drug price increases: an analysis. https://getmga.com/wp-content/uploads/2024/01/WP_Drug_Price_Increases.pdf

Hayford, T. B. (2024). Role of specialty drugs in rising drug prices for Medicare Part D. JAMA Health Forum, 5(5), e241188. https://doi.org/10.1001/jamahealthforum.2024.1188

IQVIA. (2024). The Use of Medicines in the U.S. 2024. https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/the-use-of-medicines-in-the-us-2024

Sparks, G., Kirzinger, A., Montero, A., Valdes, I., & Hamel, L. (2024, October 4). Public opinion on prescription drugs and their prices | KFF. KFF. https://www.kff.org/health-costs/poll-finding/public-opinion-on-prescription-drugs-and-their-prices/

IQVIA. (2024). The Use of Medicines in the U.S. 2024. https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/the-use-of-medicines-in-the-us-2024

Casey Mulligan. 2022. https://www.nber.org/papers/w30231

Visante. 2023. https://www.pcmanet.org/wp-content/uploads/2023/01/Pharmacy-Benefit-Managers-PBMs-Generating-Savings-for-Plan-Sponsors-and-Consumers-January-2023.pdf

PCMA. 2024. PBMs and Pharmacies. https://www.pcmanet.org/pharmacy