Pharmacy benefit managers (PBMs) under the microscope for their role in high drug prices have often cited their reportedly slim profit margins as evidence that they do not drive up costs. The three leading PBMs, which control about 80% of the prescription drug market, have historically reported profit margins of 4% to 7%, among the lowest in the healthcare industry.
A new white paper from the USC Schaeffer Center for Health Policy & Economics demonstrates that these slim margins are dramatically influenced by the accounting practices PBMs elect to employ. The paper also shows how efforts to assess PBM profits have become more challenging after these companies merged with healthcare conglomerates that own other players in the pharmaceutical supply chain.
States in recent years have advanced or considered numerous measures seeking to increase PBM transparency, and Congress is currently pursuing legislation to reform PBM practices. The Federal Trade Commission, meanwhile, continues to scrutinize PBMs after accusing leading firms of inflating drug costs through strategies like rebates, markups and preferential treatment of affiliated pharmacies.
"Accounting practices make it difficult to judge the health and efficiency of the PBM market, particularly as dominant firms have become part of larger, more complex companies," said lead author Karen Mulligan, a research scientist at the Schaeffer Center. "Greater financial disclosure requirements for PBMs are needed to develop a better picture of how PBMs make money and the extent to which these practices may raise costs for consumers."
How accounting choices drive margins
PBMs sit at the center of the pharmaceutical supply chain, acting as intermediaries that pay pharmacies and negotiate rebates with drug manufacturers on behalf of insurers. PBMs retain transaction fees and a portion of manufacturer rebates while passing along payments between manufacturers, insurers and pharmacies.
Historically, PBMs have included these "pass-through payments" in financial reporting. This may also include the share of rebates sent directly to the insurer. While allowed under professional accounting guidelines, this practice may add hundreds of billions of dollars to PBMs' reported revenue or expenses without affecting their actual earnings. This obscures key determinants of PBMs' profitability, including the role of rebates, fees and other payments.
Using a simplified example with typical transaction fees and rebates, the white paper illustrates how accounting choices can produce vastly different profit margins for a hypothetical drug listed at $360. If pass-through payments were reported as revenues or expenses, the PBM's margin would be 10% – or slightly higher at 13% if manufacturer rebates passed to the insurer were not reported. However, the margin jumps to 87% if pass-through payments were not reported at all. (See Figure 5 in the white paper.)
Vertical integration in the healthcare industry has further blurred PBMs' financial picture. In the past decade, the three dominant PBMs have become part of diverse healthcare corporations that also own insurers, specialty pharmacies and group purchasing organizations (GOPs) that negotiate discounts.
Under this structure, payments between the PBM, insurer and the specialty pharmacy become internal transfers invisible to the public. Using the same hypothetical $360 drug as the previous example, the white paper shows how the publicly reported profit margin can be half of what's recorded internally, as dollars are shifted to other units within the PBM's parent company. (See Figure 6.)
Transparency reforms should illuminate revenue streams
The researchers suggest that policymakers consider requiring PBMs to exclude pass-through payments from financial reporting, as regulators have done for intermediaries in other industries.
Policymakers should also consider reforming financial reporting requirements so that healthcare conglomerates provide separate reporting for each distinct business unit, rather than allowing PBM operations to be combined with other units like specialty pharmacy. Further, requiring disclosure of internal transfers and pass-through payments in these companies would provide clarity about what's driving profits.
"True transparency requires greater visibility into profit flows hidden inside increasingly complex corporate structures," said co-author Darius Lakdawalla, chief scientific officer at the Schaeffer Center and the Quintiles Chair of Pharmaceutical Development and Regulatory Innovation at the USC Mann School. "Building a more efficient and sustainable pharmaceutical supply chain starts with a better understanding of where dollars are flowing."
