Patients Before Monopolies

The fundamental problem in pharmacy is that the payment system is corrupt.

On April 13, I gave a speech at the Huntsman Center here in Salt Lake City. I want to share my speech and then comment briefly on what has happened since. Here’s the text of my speech:

“The Broligarchs are at war with people that work for a living. I’m a pharmacist. Here’s some ways that war plays out in my world.

I work at Jolley’s Compounding Pharmacy, which my grandpa started over 70 years ago, making us the third oldest pharmacy in Utah. I graduated from East High School. Salt Lake City School District, like many other employers, uses CVS/Caremark as their pharmacy benefit manager. Last year, CVS convinced the district that they’d save money by forcing all of the teachers to go to CVS/Pharmacy for any prescription refills. This means that I, an East High School graduate, cannot be paid to care for the teachers that taught me the math and chemistry I use every day.

This Monday, I billed a claim to CVS/Caremark, and CVS said they would pay me $0.35 to dispense a month’s supply of seizure medication, and then they’d take back $0.30 for the service of processing the claim on their computer. After my staff filled the prescription, and I checked to make sure it was safe and appropriate, my coworker delivered that seizure medication to our patient’s home. For that level of care, we were paid a whole nickel.

On Friday, I went to our drive up window and talked with a woman about her new prescription for Losartan. She was worried about taking it - this was her first chronic medication, but her systolic blood pressure has been as high as 195 recently, so I talked with her about the dizziness that sometimes happens when starting blood pressure medicine, how to manage her diet to reduce her blood pressure, and to reassure her that this medication will help her stay healthy for years to come. We talked for about 15 minutes. Her PBM, OptumRx paid nothing for that service, and told me to collect a $6.63 copay from her. The Mississippi Board of Pharmacy recently audited OptumRx, which is the PBM division of United Healthcare, and found that they paid their own pharmacies 27 times as much as they paid mom and pop pharmacies for antibiotics.

As a result of this corrupt self-serving behavior by Fortune 10 companies, just since January of last year, 3178 pharmacies have closed nationwide. Hundreds of thousands of Americans now have to drive more than 30 miles to the nearest pharmacy or hope that mail order arrives on time and undamaged. You may have noticed that there aren’t pharmacies in IHC clinics anymore - just empty shells where they used to have a pharmacy.

The empty shell of the old Intermountain Health Salt Lake Clinic Pharmacy

During the last Congress, the Senate Finance Committee unanimously passed legislation that would have reformed some of the worst of these Pharmacy Benefit Manager abuses. In December, it was included in the budget package, and I started to get hopeful that pharmacists would see change. And then Elon Musk started tweeting that the bill was too long, and that hope died. The next day, Elon tweeted “What is a Pharmacy Benefit Manager?”

You should be able to go to the doctor of your choice, not just the clinic that your insurance company owns. You should be able to go to the pharmacy of your choice, not just CVS. It should be illegal for CVS to be in charge of paying pharmacies while BEING the biggest pharmacy, and United Health to be in charge of paying doctors while employing more than 100,000 doctors. We need to Break Up Big Medicine. If you agree, go to breakupbigmedicine.com and join my fight.”

That was April 13, 2025. In December 2024, Elizabeth Warren, Josh Hawley, Diana Harshbarger and Jake Auchincloss introduced the Patients Before Monopolies Act (PBM Act), which would ban PBMs (and their parent companies) from owning pharmacies and vice versa.

On April 14, 2025, 39 State and Territory Attorneys General sent a letter to Congress requesting that they pass a bill similar to the PBM Act, prohibiting PBMs from owning pharmacies. On April 16, 2025, Arkansas Governor Sarah Huckabee Sanders signed HB1150 into law, which prohibits companies with a PBM in their ownership structure from obtaining pharmacy permits from the state board of pharmacy, effective 1/1/2026.

On May 13, the Senate Judiciary Committee held a hearing about PBMs. Four separate Senators explicitly called for the outlaw of PBMs owning pharmacies. MO Senator Hawley had a heated discussion on the topic with PCMA’s JC Scott. HI Senator Hirono cited her experience as an antitrust lawyer stating that you can have all the transparency you want, but a structural reform is needed. NJ Senator Cory Booker described the vertical integration of PBMs and pharmacies as “not a scam” but “corporate violence.” LA Senator Kennedy used a rather colorful analogy to say that we should outlaw PBMs from owning pharmacies. On May 14, Representative Chuy-Garcia also called for a ban on PBM-pharmacy vertical integration.

Patient advocates and pharmacists have been far too timid about the types of reforms that they ask for in the past. “Ban spread pricing!” “Let pharmacists prescribe 2 specific drugs!” “ Ban copay accumulators!” “Make Medicare define reasonable and relevant reimbursement rates.” The PBM Act and similar bills get at the structural corruption in the pharmacy reimbursement system. Because PBMs own pharmacies, they are able to manipulate pricing in what I describe as a “cream skimming” scam. PBMs deflate the Maximum Allowable Costs (MAC) and dispense fees that they are willing to pay for the vast majority of commonly prescribed medications, and INFLATE the MACs of rare “specialty” products, and then convince employers to employ a “exclusive” deal for obtaining those specialty products. This very behavior is the topic of multiple lawsuits against employers for violating their fiduciary duty under ERISA. I recently had a fascinating discussion with a former PBM executive who described to me the method by which these “specialty exclusive” deals are obtained - during a multiple-hour-long implementation meeting in which hundreds of decisions about formulary, cost sharing and pharmacy network are made with the employer on a zoom call with the PBM, the question of “do you want a specialty exclusive deal” is posed deep in the meeting, at which point all but the most attentive and sharp employer representatives have started to have their eyes glaze over at all of the decisions to be made, and they are primed to agree with all of the default options.

Given the financial harm to employers and their employees by this tactic, the solution of “ban PBM-pharmacy co-ownership” feels long overdue. The incentive to create a pricing scheme with inflated margins for rare drugs and suppressed pricing for common drugs disappears if you ban PBM-pharmacy co-ownership (and secondarily ban spread pricing). Why would you, as a PBM, reimburse a competitor $0.35 for carbamazepine and your own pharmacy $6,229 for teriflunomide (cash price of ~$32 per the JP Morgan suit) in the absence of a self-dealing PBM-pharmacy relationship?

While I’m on the subject, the existence of different “Maximum Allowable Costs” for different pharmacies for the same exact drug for the same patient on the same day is an insult to the english language. If a MAC is a “maximum” for me, it’s the “maximum” for my competitors too. It’s an incredibly widespread practice and it makes me feel crazy. I have plenty of publicly available evidence of this that I will likely make the topic of an upcoming rambling.

The best analogy I can come up with for the PBM-specialty pharmacy co-ownership that drives at least 28% of prescription drug revenues in the US is in real estate. Most homebuyers use a buyer’s agent to assist them in purchasing a house and negotiate down the sales price. Imagine a buyer’s agent that attempts to sell you THEIR OWN home. Their incentives would be fundamentally against yours - it’s far worse than if they were both the buyer’s and seller’s agents, they are the seller! You would not trust their analysis of what the home costs. And yet, that’s the basic scheme of PBM-pharmacy co-ownership. The PBM is ostensibly the buyer’s agent for the employer/health plan and the members of the health plan, and simultaneously they are the primary or even sole pharmacy selling the most expensive prescription drugs.

This charade of corporate violence against the public cannot be allowed to continue. Congress must pass the PBM Act into law as soon as possible - it’s good public policy to put Patients Before Monopolies.