Good morning, and happy Friday! Recent developments in Alzheimer’s disease treatment, including the approval of two new drugs, are bringing hope to those affected by the disease. Have questions? Submit them here, and my colleague Laurie McGinley will address them during a live chat Monday.
Why independent pharmacies are calling for PBM reform
There’s ongoing debate over the role that pharmacy benefit managers — widely known as PBMs — play in the high cost of prescription drugs in the United States.
Working on behalf of insurers, the industry middlemen help manage prescription drug benefits and negotiate prices consumers pay at the pharmacy counter. During this session of Congress, lawmakers from both parties have scrutinized PBM’s business practices, and preliminary findings from a Federal Trade Commission investigation raised concerns that major PBMs may be squeezing independent pharmacies for profit — an allegation that the industry’s top lobbying group disputes.
To learn more about the issue, I spoke with Anne Cassity, senior vice president of government affairs at the National Community Pharmacists Association. Our conversation has been edited for length and clarity.
Health Brief: What is the state of the nation’s independent pharmacies?
Cassity: It’s a very challenging time. In 2023, we lost nearly one independent pharmacy per day, and we’re on track for a similar number of closures this year.
A significant factor is the vertical consolidation in the industry. The largest insurers now own the largest PBMs, or vice versa, and they control our reimbursement rates and determine which patients can use our pharmacies.
Meanwhile, all the major PBMs own mail-order pharmacies, and one even operates one of the country’s largest chain drugstores. This means that an independent pharmacy can do everything right, but the payments it receives are controlled by an entity that also happens to be a direct competitor.
Health Brief: What business practices used by PBMs do you see as driving these issues?
Cassity: Three PBMs represent about 85 percent of insured lives, so they have a chokehold on the marketplace. As a result, they offer independent pharmacies “take it or leave it” contracts that are very hard to turn down.
Health Brief: What is at risk for consumers if these pharmacies close?
Cassity: The top concern is patients’ ability to access medications, with the biggest impact in rural areas. For example, in Nebraska, there’s a whole side of the state where there are only one or two pharmacies, and that’s problematic if someone doesn’t have a vehicle or public transportation. Mail order also might not work for everyone, because certain medications that people get may be sensitive to temperatures.
Health Brief: Which measures in Congress on PBMs does your association support, and why?
Cassity: We’ve been really focused on payment reform for public health programs. A lot of independent pharmacies’ business comes from Medicare and Medicaid, and those patients are often vulnerable, so it’s important that they continue to have access to face-to-face health care.
One of our top priorities is Medicaid Managed Care payment reform, which was included in a larger price transparency package that the House passed in December. The bill would eliminate spread pricing [when PBMs charge insurers more than they pay pharmacies] and require that pharmacies be paid the national average drug acquisition cost plus the state Medicaid dispensing fee. PBMs would be limited to a transaction fee.
Our second priority is to bring some fairness to Medicare Part D. We support a provision in the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act, reported out of the Senate Finance Committee in December, which would require the Centers for Medicare and Medicaid Services to define reasonable and relevant contract terms and enforce them. This would create some parameters around what PBMs can offer.
Health Brief: Do you see this as a policy issue ripe for bipartisan action?
Cassity: I can’t think of another issue in this Congress that has received more bipartisan, bicameral support. Lawmakers have done 18 months of substantive work on this issue, and it would be tragic if these reforms aren’t included in some sort of lame-duck package and finalized this year.
Agency alert
CMS unveils 2025 quality ratings for Medicare Advantage plans
The Centers for Medicare and Medicaid Services released 2025 quality ratings for private Medicare health and prescription drug plans in advance of the open enrollment period set to kick off next week.
Just 40 percent of Medicare Advantage plans that include prescription drug coverage received an overall rating of four stars or higher for 2025, down from 42 percent in 2024, 51 percent in 2023 and 68 percent in 2022.
Key context: The agency rates plans on a scale of one to five stars, evaluating factors such as how effectively network providers manage member health care, member satisfaction and overall plan administration. Higher-rated plans will earn larger bonus payments from CMS in 2026, significantly affecting their bottom line.
Election watch
Poll: Abortion rising as a top issue for young women voters
New this a.m.: Four in 10 women voters younger than 30 cite abortion as the most important issue influencing their vote in this presidential election, nearly double the percentage from when the same group was surveyed in June, according to KFF, a nonpartisan think tank.
The special follow-up poll measures how the electoral landscape has shifted since President Joe Biden exited the race and Vice President Kamala Harris secured the Democratic nomination. KFF found that Harris holds an advantage over former president Donald Trump on who women voters trust to do a better job deciding abortion policy, with 58 percent favoring her compared with 29 percent for him. Harris also outperforms Biden in the matchup, who received 46 percent support when the group was polled during the summer.
Speaking of the election …
Health care has long been a powerful and polarizing issue in the race for president. In the latest podcast episode of “Post Reports,” Dan Diamond joins host Martine Powers to cut through the current political noise and break down what a Trump or Harris presidency could mean for health care.
You can listen to their conversation here.
On the Hill
Cassidy investigates gender-affirming medical treatments for minors
The top Republican on the Senate health committee is launching an investigation into major medical organizations that endorse puberty blockers, hormone therapy and other treatments for children and adolescents with gender dysphoria.
Sen. Bill Cassidy (R-La.) sent letters to the World Professional Association for Transgender Health (WPATH), American Academy of Pediatrics (AAP) and Endocrine Society requesting details on how these groups developed their recommendations and care guidelines, including the people involved and the scientific evidence considered. They have until Oct. 24 to respond.
A closer look: In his letters, Cassidy cited an April report commissioned by England’s National Health Service, which found “remarkably weak evidence” supporting the benefits of gender-affirming medical interventions for young people.
The report has been cited by some clinicians and conservative lawmakers to support restrictions on treatments for transgender minors in the United States, but it has also faced sharp criticism. That includes a July analysis from researchers at the Yale School of Medicine and other institutions, which argued that it “obscures key findings, misrepresents its own data, and is rife with misapplications of the scientific method.”
The view from the Endocrine Society: “Our Clinical Practice Guidelines are developed using a robust and rigorous process that adheres to the highest standards of trustworthiness and transparency as defined by the National Academy of Medicine,” a spokesperson said in a statement. Neither WPATH nor the AAP responded to a request for comment.
Infectious disease
CDC flags drug-resistant cluster of mpox cases
On our radar: U.S. health officials have identified 18 mpox cases caused by a variant resistant to tecovirimat, widely known as TPoxx, the only antiviral treatment available to accelerate recovery, according to a new report from the Centers for Disease Control and Prevention.
The cases, reported between Oct. 6, 2023, and Feb. 15, 2024, involve patients across five states who had never taken the treatment. The study’s authors said the actual number of cases is likely higher because not all mpox infections are genetically sequenced to identify the variant responsible.
Why it matters: The CDC has warned that overuse of TPoxx could promote resistance and recommended limiting its use to high-risk patients. The study authors said the findings underscore the importance of adhering to the agency’s guidance and called for more genetic surveillance to determine whether the resistant variant is still circulating in the United States.
In other health news
- In 2023, an estimated 15.5 million U.S. adults had an attention-deficit/hyperactivity disorder diagnosis. About a third take stimulant drugs to manage it, nearly 72 percent of whom reported difficulty filling their prescription because the medication was unavailable, according to a new CDC study.
- The Advanced Research Projects Agency for Health launched a new initiative aimed at identifying probiotic strains that can prevent or rapidly treat deadly lung infections before they take hold or develop antibiotic resistance.
- Teva Pharmaceuticals has agreed to pay $450 million to settle allegations that the drugmaker violated an anti-kickback statute and the False Claims Act, the Justice Department announced. Teva did not admit wrongdoing.
Quote of the week
“When my staff and I got into the office, we talked about our situation. We were crying, but we huddled together and just took care of our patients.”— Beth Hanrahan, 64, a primary care physician who practices in Clearwater and lives in a small island community in South Pasadena, on Hurricane Helene.
Health reads
Sugar rush
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