Posted on June 28, 2022 in: Professional Practice
The Columbus Dispatch - Powered by Dow Jones·
Darrel Rowland | US | June 26, 2022·12:00am
After overcoming a communications snafu, the agency that provides health coverage for Ohio's poor and disabled seems on a glide path to throwing out controversial pharmacy benefit managers accused of gouging Ohio taxpayers and pharmacists.
But a key question remains: Will those PBMs ever pay a price for possible illegalities over the past several years? After six months of investigating, state Medicaid Director Maureen Corcoran says she's still not sure the agency will ever get to the bottom of complex machinations by PBMs on the price and access of prescription drugs for some 3 million of Ohio's most vulnerable.
"Our work is not done," she said. "I knew it would be extraordinarily complex."
But Corcoran said she is neither clear about the investigation's next step, nor whether the problem can be resolved.
Ohio Attorney General Dave Yost also is probing the issue in what appears to many as a rival effort.
"We can't comment on an ongoing investigation," said Bethany McCorkle, Yost's communications director. "With that being said, AG Yost has been a national leader in holding PBMs accountable. It has been a top priority, and he has not abandoned his work in that warehouse."
'Clawbacks' saturate Medicaid
A key focus of the twin probes is the practice of "clawbacks." That's when PBMs "claw back" money from a pharmacy on a prescription that was filled weeks or even months earlier.
The PBMs say they merely are carrying out provisions of "effective rate" contracts to which pharmacies or their representatives had agreed. Pharmacists say that the near monopoly of PBMs – the three biggest control 80% of the business – result in take-it-or-leave-it contracts that heavily favor the middlemen in the drug chain.
Corcoran said her agency has discovered that controversial contracts allowing clawbacks "are pervasive through the Ohio Department of Medicaid's system."
Because those clawbacks take place after Medicaid has closed the books on a drug transaction,millions of dollars that went to PBMs are left unaccounted for by the agency, she told the legislature's Joint Medicaid Oversight Committee last fall.
That shortcoming means that Medicaid drug spending data that Ohio – and likely most, if not all other states – report to the federal government is falsely inflated. Since those totals typically are used to calculate how much taxpayers must pay for the program, funded by the state and federal governments, Americans across the country are likely being overcharged because of the PBM tactic, Corcoran acknowledged.