The spread.

This editorial highlights how the business of pharmacy benefit managers (PBM) is heavy on the “benefit.” These third-parties are designed to serve as middleman patient advocates, negotiating prices and easing access, but the pharma market was just too ripe. Now we are left with a handful of Walmart PBMs (think: Express Scripts) who rival Big Pharma itself. The first government analysis of PBM practices demonstrate some real missed opportunities to lower health care costs, such as “spread pricing” where PBMs charged Medicaid as much as double what it reimbursed pharmacies. The difference was of course pocketed for their services. Further elucidated was another, dare we say more shocking, practice coined “gag clauses” where PBMs forbid pharmacists from telling patients if an out-of-pocket payment would be less expensive than using insurance (i.e., cutting the middleman). TBL: Healthcare reform must extend to the middleman. | Royce, JAMA 2019