There may be growing analysis into pharmacy advantages managers (PBMs).

The American Medical Affiliation (AMA) launched a report Monday displaying little competitors amongst PBMs and vital vertical integration with well being insurers. It comes as Congress considers measures towards PBMs and the Federal Commerce Fee investigates them.

“The decision for higher regulatory oversight of PBM enterprise practices is overwhelmingly welcomed by physicians as a test on potential anticompetitive hurt ensuing from low competitors and excessive vertical integration within the PBM business,” AMA President Bruce A. Scott, MD, stated in an announcement. “The findings of the brand new AMA evaluation deserve consideration as Congress and the administration proceed their work to guard sufferers and make sure that prescribed drugs stay reasonably priced and accessible. The AMA urges cautious monitoring and, when obligatory, intervention of each horizontal and vertical integration to make sure competitors within the PBM and medical health insurance markets.”

The AMA’s evaluation was based mostly on 2022 information from industrial and Medicare Half D drug plan enrollees. It discovered that the 4 largest PBMs have a 70% market share of the PBM market. When taking a look at rebate negotiations, CVS Well being has a 21.3% market share, OptumRx has 20.8%, Categorical Scripts has 17.1% and Prime Therapeutics has 10.3%.

Moreover, the report discovered that 82% of PBM markets are extraordinarily concentrated on the regional drug plan stage.

The evaluation additionally discovered that PBMs have excessive vertical integration with well being insurers. Nationally, insurers which are vertically built-in with a PBM cowl 72% of business or Medicare Half D enrollees. When trying on the prescription drug plan stage, roughly 70% of enrollees are coated by a payer that’s vertically built-in with a PBM. Nevertheless, this varies by area, as some are virtually totally vertically built-in and a few have minimal vertical integration.

The AMA additionally experiences the market shares of the ten largest prescription drug plan insurers nationally, damaged down by industrial, Medicare Benefit prescription drug plans, and standalone prescription drug plans. UnitedHealth Group is the market chief within the industrial and Medicare Benefit prescription drug plan markets, with 13% and 28.2% shares, respectively. CVS Well being is the biggest insurer within the standalone prescription drug plan market, with a 25.6% share.

The Pharmaceutical Care Administration Affiliation (PCMA), an advocacy group for PBMs, took challenge with the methodology the AMA used for the report.

“Sadly, the AMA's methodology, by specializing in PBMs within the Medicare market, doesn’t assist the report's conclusion,” Greg Lopes, a PCMA spokesman, stated in an electronic mail. “Greater than 70 full-service PBMs function within the healthcare markets. It’s unfair to imagine that the AMA offers an correct image of your entire healthcare system. The underside line is that the PBM market is dynamic, various, and continues to develop. PBMs fluctuate in measurement, geographic footprint, and repair choices, making a market with a wide range of choices for well being insurers, employers, unions, authorities applications, and different well being plan sponsors.”

In July, the FTC additionally revealed findings on PBMs in an interim report. It defined that after a long time of mergers and acquisitions, the PBM house has turn into extraordinarily concentrated. It discovered that the six largest PBMs — CVS Caremark, Categorical Scripts, Optum Rx, Humana Pharmacy Options, MedImpact and Prime Therapeutics — handle about 95% of all prescriptions crammed within the U.S.

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