PBM and telehealth measures falter in Congress' year-end rush

Lawmakers and advocates are making a last-ditch effort to include pharmacy benefit manger-focused provisions and other legislation in year-end government funding bills, as a flurry of activity targets telehealth measures.

Some of the items under consideration were part of a proposal leaked to lobbyists and reporters last week, including a possible three-year extension of expiring telehealth authorities in Medicare. But PBM legislation was not floated as part of the deal, and proponents inside and outside of Congress are pushing to bring those bills to the forefront.

Related: PBM bill, telehealth extension may ride together in 'lame duck'

"There was wide agreement to be able to do [PBM legislation], and now suddenly it's not happening," Sen. James Lankford (R-Okla.) said. "So that's why we're trying to be able to figure out, how do we actually get this in? We hear that there's conversation on it, but we're not seeing it, so that's why we're pressing it here."

While it is not clear what measures will be attached to a year-end spending bill, a number of healthcare issues are considered to be a very high priority for lawmakers, including extending Medicare's telehealth authority, which is set to expire at the end of the month. Other priorities are stalling a scheduled $8 billion cut in Medicaid funding for safety-net hospitals, mitigating a cut in Medicare payment rates for doctors and keeping Community Health Centers funded.

How long additional policies would last is also unclear, but if lawmakers fail to agree on broader priorities, they would likely last only until March, House and Senate aides said.

Last week's proposal, offered by Republicans for the consideration of House and Senate leaders who are putting together legislation to keep the government funded after the current spending bills expire on Dec. 20, would have been paid for by scrapping pending Medicare regulations that would set minimum nursing home staffing standards and are expected to cost the government about $22 billion to implement. Most Democrats oppose ending the staffing rules.

Negotiations on a possible year-end package are continuing, but the GOP proposal caught some lawmakers by surprise, since a number of PBM legislation sponsors had high expectations that their bills would be among the measures under consideration to fund telehealth extensions.

Rep. Buddy Carter (R-Ga.) held a news conference last Wednesday — the same day the proposal leaked — with Lankford and more than a dozen other lawmakers from the Senate and House in both parties pushing for PBM legislation to pass.

Carter said a telehealth extension he is sponsoring, the Telehealth Modernization Act of 2024, was the most likely bill to carry new PBM restrictions. That bill would extend telehealth authorities in Medicare for two years and extend Medicare's hospital-at-home program for five years. The bill aims to save the government money and pay for the cost of the extensions by barring PBMs from linking their compensation for negotiating drug price rebates to the high list prices of drugs. PBMs would have to charge set fees, instead.

Carter said the bill has broad support, and has already passed two committees in the House.

"All of us understand that telehealth has become an integral part of our healthcare system, but the pay-for for that telehealth will delink the compensation of the PBMs from the price of a drug, and simply pay them a fee. That will save millions of dollars," he told reporters.

"That's why we're calling on leadership, both in the House and in the Senate, during this next three weeks that we're going to be in session, in lame-duck session, to bring these bills to the floor," Carter said. "Let us vote on it, and you see, it's got the support it needs."

The news conference outside the Capitol was called in part to revive the foundering PBM efforts, Lankford said.

Similarly, Sen. Roger Marshall (R-Kan.) said he was discouraged a PBM measure was not in the initial talks.

"I'm shocked that it's not," Marshall said. "We have a package, obviously, that passed out of the Senate Health Committee," he said, referring to the Pharmacy Benefit Manager Reform Act of 2023. The Senate Finance Committee has also passed two bills with PBM restrictions.

Sources familiar with the ongoing negotiations declined to provide specifics, but confirmed the PBM issue was back on the table, if not yet in a formal offer.

The conservative lawmakers got support Monday from a slew of outside groups on the right and the left.

A coalition of left-leaning groups that agree with them on PBMs, led by the American Economic Liberties Project, sent a letter to Senate and House leaders pushing for the passage of PBM legislation.

"Congressional leaders on both sides of the aisle have demonstrated a desire to address the harms stemming from pharmacy benefit managers," says the letter, obtained by Modern Healthcare.

It points to the slew of hearings and legislative markups Congress has held on PBMs, including Republican-led hearings that backed the actions the Biden administration's Federal Trade Commission has taken against the three largest PBMs, CVS Health subsidiary CVS Caremark, UnitedHealth Group's OptumRx and Cigna's Express Scripts.

"While congressional focus on PBMs to date is admirable, if Congress is serious about stopping the national crisis of pharmacy closures and preserving patients’ access to care, members must act now to re-establish a viable business model for independent and chain retail stores alike," the letter says.

A coalition of more than 20 conservative-aligned groups also sent a letter Monday, specifically calling for passage of the Senate Finance Committee's bills.

"They are a down payment on critical spending cuts and regulatory reforms that will be pursued by the incoming Trump Administration," says the letter from groups, including the Center for a Free Economy, the 60 Plus Association and Americans for Limited Government. "These common sense PBM reforms will make government entitlement programs smaller, something the next Congress will be asked to do in budget reconciliation. The time to cut spending is now."

At the same time, the Pharmaceutical Care Management Association, which represents PBMs, has spent millions of dollars lobbying against new restrictions, and touting what it says are success stories for employers and health plan sponsors.

The group says limiting PBMs' methods of compensation will only benefit drug manufacturers, and that despite what lawmakers say, plan sponsors are overwhelmingly satisfied with their benefits.