BILLIONS: Is ICER Enabling Illegal PBM Rip-off Racket?

  • by: Robert Goldberg |
  • 05/11/2016

 If you give someone the tools they use to commit a crime, are you also responsible? 

Consider the following news item from Reuters about pharmacy benefit managers and their rebate contracts with drug companies: 

U.S. probes contracts between drugmakers, pharmacy benefit managers
“The U.S. Attorney's Office for the Southern District of New York is investigating contracts between drugmakers and companies that manage prescription benefits, according to regulatory filings… When drugs are knocked off their formularies, patients may have to pay full price for them. PBMs often keep or dump a product depending on whether they can obtain favorable pricing.”
As I have noted PBMs get and distribute about $110 BILLION in rebates each year.  That’s a trillion over a decade.  ICER plays, or seeks to play a role in setting prices and determining what products PBMs choose and insurers pay for that is central to enlarging and maximizing rebates.   And the PBMs are working closely with ICER to develop the price and access parameters of the contracts the  U.S. Attorney for the Southern District of New York is investigating:
“ICER’s new program will make a huge difference by providing what is sorely needed: an independent, trusted source of information about new drugs,” stated Steve Miller, MD, Chief Medical Officer of Express Scripts, the nation’s largest pharmacy benefits manager. “I believe many payers and policy makers will find this information of critical importance as they evaluate the new drugs, and we look forward to using it to help us improve the ability of patients to get access to new, innovative drugs at a price the system can afford.”
PBMs are also looking to ICER’s Steve Pearson to find reasons to pay less for cancer drugs depending on their indication. As a recent article noted: “ Express Scripts is using data from ICER, as well as the DrugAbacus, to inform its indication-based pilot.”
As I have noted before, indication pricing, based on average response and on a QALY measure reflecting PBM profit motives, can endanger patients and discourage companies from investing in treatments for the most difficult to treat tumors.  More generally, first in class or first ever drugs to treat the most severe conditions -- particularly rare diseases --  are likely to show modest benefit on average.  Such medicines will never meet ICER's devalued QALY measure. 
The most recent example is ICER has already determined that most new multiple myeloma drugs approved to treat patients whose disease has returned are NOT cost effective, even at 90 percent of the list price of the drug.
People with myeloma will bear moral, economic and clinical consequences that ICER ignores and the media barely mentions.   So two days before ICER meets to approve the report’s (foregone) conclusions I will be releasing a white paper that measures these essential values.
One important point to consider:  ICER recommendations would lead to drug companies forking over billions in rebates in exchange for putting these drugs on their formulary.   It does NOT mean that patients will get access.   It does mean that ICER is enabling the rebate ripoff scheme that the US attorney is investigating.  It may not be cutting the deals but ICER is supplying the PBMs the justification for the rebate enterprise.   


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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