Involvement of physicians and community oncology practices is key to ensure pharmacy benefit managers (PBMs) adhere to state-level legislation on white bagging, prior authorization, and other issues, as well as for legislators to better understand the anti-competitive nature of vertical integration, said Angela Storseth, associate director, Government Relations & Public Policy, The US Oncology Network.
Storseth-Cooper participated in a panel discussion at the 2022 Community Oncology Conference, titled, “Going After Pharmacy Benefit Managers (PBMs) at the State Level.”
Can you speak on how the influence of PBMs varies from state to state in regards to vertical integration?
So, in the past few years, we have seen the vertical integration of plans with PBMs that are owning their own specialty pharmacies. And what the states are actually starting to realize is how much they can have an impact or affect some of PBMs—some of their behaviors.
A lot of the states, I think, it's an educational opportunity for us, because a lot of these legislative bills that are going through a lot of these committees are going through house insurance committees or business and commerce committees, and [often] there are no physicians that sit on those committees or pharmacists.
So, there's a lot of education that we have to do that kind of explains the PBM practices. And so, within the past couple years, I think because of that education, a lot of our lawmakers are really seeing the anti-competitive nature of vertical integration. So, we have seen some states that have already acted upon some of these behaviors, but I think we'll see even more in the next few years because of that consolidation with that vertical integration.
What are the most pressing issues regarding PBM influence in community oncology and what are some state-level strategies to address these concerns?
I think the most pressing issue right now facing community oncology is protecting the physician/patient relationship. A lot of the strategies that state legislatures are looking at now that they are aware that they can act a little bit more on some of these PBM practices is looking at legislation to prohibit white bagging mandates, legislation to focus on prior authorization.
I know Texas recently passed our gold card legislation that a lot of states are looking at, in regards to prior authorization, as well as we've seen legislation around step therapy and other legislation similar to that. I would say the biggest focus this year is around prohibiting white bagging mandates, and sort of the strategy around that is building really large coalitions to go up against the plans and PBMs.
What steps can community oncology practices take to ensure PBM contracted pharmacies are aligned in the pursuit of high-value, cost-effective care?
So, I think the biggest thing from my perspective when we're working on state legislation is the implementation of a lot of these bills. So, for example, in Texas, we did pass anti-steering legislation, but now it's up to the Texas Department of Insurance to provide rulemaking. And so one way that I think that community oncology practices can get involved is making sure that they are tracking—especially if they’re tracking, for example, anti steering—state plans [who] need to abide by this law.
PBM non-compliance needs to be tracked from the community cancer perspective, and that needs to be submitted to the regulatory body. In our case, with a lot of the anti-steering legislation, making sure that we're submitting non-compliance through the Texas Department of Insurance. Once there's enough evidence to show that they're not complying with a lot of these state laws, that needs to be escalated on to the legislature.
So, I think it's a 2-fold process. Yes, we need to get the legislation passed, but we also need to make sure it's implemented, and that comes from community oncology practices to really be focused on and making sure that they're tracking the non-compliance. Another piece of that is if they're not complying, and the regulatory body is not solving those issues through their rulemaking process, it does need to be escalated back to the legislature so that they get involved to make sure that the true intent of the bill is being followed by these PBMs.
I think the biggest piece of the panel that I'm sitting on—what states are doing to go after PBMs—the biggest component of that is getting physician involvement. Getting our physicians to speak to their legislators—these legislators have day to day jobs, and the physicians are the experts, our pharmacists are the experts, and it's so important to share that expertise with these legislators who are bankers or engineers.
Some of them are doctors, physicians, and pharmacists, but it's just very important for them to go and tell that story to better understand the full process, in our case, the standard of care of how we're treating our patients today. It's more than them just coming in and getting treatment. It's that entire integrated care that they're receiving in a community cancer practice.