“I think this is a great step in the right direction. I think patients — particularly those struggling with very high deductibles and costs associated with prescription drugs or high coinsurance rates associated with very high price drugs — stand to benefit significantly from this announcement,” said Rena Conti, a health economist at the University of Chicago.
As people have struggled with high prices for drugs, including insulin for diabetes and the lifesaving EpiPen, there has been heightened scrutiny of the complicated mechanics of drug pricing. Drugmakers set the list prices of drugs but grant secret rebates to pharmacy benefit managers who negotiate on behalf of insurers and employers.
Because of the lack of transparency in the industry, a raging debate has developed over the extent to which those rebates are being passed on to insurers, employers and consumers, with pharmacy benefit managers saying they produce savings and drug companies arguing that rebates aren't trickling down to patients. The most concern has focused on consumers in high deductible plans, who get stuck paying the high list price — even though their plan receives a discount.
“Today’s announcement by UnitedHealthcare is a prime example of the type of movement toward transparency and lower drug prices for millions of patients that the Trump Administration is championing,” Health and Human Services Secretary Alex Azar said in a statement.
The United States' largest pharmacy benefit manager, Express Scripts Holding, allows clients to share rebates with consumers at the point-of-sale, but has not seen uptake of the plan design. Express Scripts negotiates drug prices on behalf of employers or insurers, which can choose whether to pass on rebates or use those savings to lower premiums more broadly.
“Most prefer to use the discounts from rebates in other ways that benefit all of their members since not all medications are rebated,” spokeswoman Jennifer Luddy said in an email.
CVS Caremark, another large pharmacy benefit manager, said that it provides more than 90 percent of the rebates it negotiates to clients. CVS has offered an option to pass on rebates at the point of sale since 2013. At the moment, about 12 million members are enrolled in plans with this kind of benefit design.
“For clients who do not choose to apply rebates at the point of sale, they may instead opt to use rebates to lower overall member health benefit costs by reducing deductibles, premiums or co-pays for all members,” CVS spokeswoman Christine Cramer said in an email.
In theory, passing rebates to consumers could increase premiums for everyone else, but UnitedHealthcare spokesman Matthew Wiggin said that the company expected a minimal effect. Conti said that it was not readily apparent what effect the change could have on premiums, but was skeptical that it would have much of an effect.
George Hill, an analyst at RBC Capital Markets, wrote in a note that the move was more of a public relations move than a structural change to how pharmacy benefit managers (PBMs) work.
“We expect other health plans to follow suit working with their PBM partners, and for this news to have little actual impact (if any at all) on the PBM space,” Hill wrote.