This is a bad explanation. To be sure, I think the system is intransparent and full of middlemen needlessly taking margin. But this explanation is naive and effectively incorrect. The way this really works takes some brain to understand though.
- For generic drugs, the pharmacy contract between PBM and insurer is based on an annual "effective rate" that is a percentage of AWP (let's say it's AWP minus 85%). AWP is "average wholesale price", but it's really list price, it's not an average nor is it wholesale, it's just what's reported by the manufacturer to an insurer's data vendor.
- The PBM makes the insurer whole at the end of the year if they undershoot the discount. I.e., if at the end of the year the insurer's claims are AWP -84%, they will cut a check for 1% of the aggregate AWP.
- This means it doesn't matter to the insurer how any given prescription drug claim is priced, because if they make one drug more expensive they have to make other drugs less expensive.
- This particular drug has a wild discrepancy between its actual acquisition cost (which keeps going down) and its list cost, which leads to this perverse seeming result.
- BUT! That result doesn't make the insurer or the PBM any more or less money because our contractual arrangement isn't tied to the actual acquisition cost.
- Could we run the whole system on actual acquisition cost? Sure, but you'd just end up underwriting all the new contracts in such a way that the insurer and the PBMs and the pharmacies would still make the same amount of money, we're just allocating it differently at a drug level.
- In other words, this guy picks one random drug where the list price to acquisition delta is large; but the entire system runs only on baskets of these drug deltas, and if you squeezed on this one end, it would just pop out elsewhere. It's like Walmart negotiating a set of prices with one manufacturer, say, Nestle, for all of Nestle's products that they purchase from them, only to then say "but you gave that one obscure cocoa cheaper to Kroger". To which Nestle would say, sure, but you still came out ahead of Kroger because I gave you all those other discounts, so you can't look at it in isolation.
That is NOT to say that drug pricing might be too high; or that certain drugs are ineffective relative to their pricing; or that there are too many middlemen; or that it should take a computer science degree to figure out how this works.
Perhaps the one lesson here is that simple truths in healthcare are often simple, and also wrong