PBM: Unmask the Villains of Healthcare’s High Costs

Marion Mass, M.D. and Christina Dewey, M.D.

Would you like to lower healthcare costs, restore quality and improve choice? Yes? Then you MUST learn about Pharmacy Benefit Managers (PBMs).

If you look on the Fortune 500 top 12 companies, you will find three companies who own PBM. Dig deeper, and you’ll discover these companies are CVS  health, who owns the PBM CVS Caremark, United Healthcare who owns the PBM Optum Rx, and Cigna, who owns the PBM Express Scripts. These three PBM control 85% of the prescription drug market, and are the biggest revenue generators for their parent companies. 

For example, when the insurance company Cigna, purchased Express Scripts in 2019, their revenues tripled. Take a peek under the hood of CVS Health, and you will discover that CVS’s  PBM CVS Caremark is, to put it frankly, its prize cash cow, its biggest source of revenue.  Moo.  

Until recently, many Americans had no idea what a PBM was, and blamed insurance and pharma and physicians for the high cost of care. The truth is much more complicated, and those making the money don’t want you to pull the mask off the villain of high healthcare costs.  They aim to prevent  the Scooby Doo denouement and keep Americans from discovering the biggest, richest, most devious villains in the healthcare space are the PBM.

Some really important clues to why we should suspect that the PBM are villainous profiteers:

–    The PBM and insurance companies now own one another, and some, like the CVS Health empire, also own pharmacy chains

–    The PBM controls the pharmaceutical companies, by creating the formularies, aka the list of medications that the insurance companies will “cover”. Physicians play no part, nor have any say in  this choice.

–    The PBM can collect legalized kickbacks, called ‘rebates’ from pharmaceutical companies because the PBM were granted an exemption from the anti-kickback statute in 2003 by GW Bush’s HHS secretary. This anti-kickback exemption allows pharmaceutical companies to simply pay for placement on the formulary.  Americans are not necessarily getting the best medication, but the best med a legal bribe can buy.

–    There is no transparency for these kickbacks (aka rebates) but sources have revealed that in 2020, the total amount of kickbacks approached $200 BILLION (yes with a B).

–    PBM like CVS Caremark are now facing charges of preventing elderly Medicare patients, including those with End Stage Kidney Failure from access to affordable life sparing medications.

–    In multiple states, PBM have been found to be helping themselves to Medicaid money… not a small helping, either: In Ohio alone, the PBM subsidiary of Centene as well as CVS and Optum were pocketing $244million per year.


–    The big PBM that own pharmacies, like CVS are utilizing shady practices to put trusted Mom and Pop pharmacies out of business.    


–    In an NBC News exclusive with Cynthia McFadden, the PBM mail order pharmacies were found to be delivering ineffective medications.  One young pediatric patient with cystic fibrosis was hospitalized after wasting away because of medications delivered by PBM giant Express Scripts, whose agent pooh poohed the concerns of the patient’s mother.

Do you need to hear more? 

Yes, you need to understand who is granting more favors to the behemoth companies responsible for the maleficent behavior noted above.

Let’s look at several recent congressional bills in chronological order of passage. 

The Affordable Insulin Now Act was passed by the House and Lingers in the senate

Although those who support the bill  claim to have lowered the cost of insulin, Lloyd Dogget, a Texas Democrat correctly stated that the bill does not lower the cost of insulin by even a penny.  He’s correct.  It lowers the co-pay, but the uninsured, and those who pay insurance ( whether they be employer or independent purchaser)  will continue to pay the full bloated cost of insulin, 80% of which is flowing to the PBM via kickbacks and fees.  In other words, this bill simply ensures that the taxpayers keep paying the PBM in the form of kickbacks.

Worse yet, the bill grants a delay of the rebate rule for PBM.  The rebate rule was an Executive Order introduced in 2020 and demanded that the kickbacks (aka rebates) would flow to the patient at the point of sale and not the PBM and the insurers.  PBMs are continually telling Americans that they pass on the rebates, yet when the rebate rule was suggested, they have threatened to increase Medicare premiums as soon as the rule is enacted. 

Congress has discovered they can pull the entirely disingenuous accounting sleight of hand of delaying the rebate rule (in other words, allowing the PBM to keep collecting their kickbacks and not forcing them to pass on to patients) and thereby claiming that they are saving money by preventing Medicare premium increases. To put another way, the PBM’s and Insurers are playing Chicken with the rebate rule by threatening Medicare premium increases, and the Congress-people that delay the rebate rule are taking the bait.  I suppose that makes them lower than chickens in the game.  Perhaps they are simply chicken….. oh, never mind. Maybe they simply don’t understand.

The insulin Bill was not the first time Congress  delayed the rebate rule.  Apparently they did it in the infrastructure bill, too.  Howard Dean, a physician and former presidential candidate called them on it in Newsweek, even pointing out that the rebate rule was solid, and potentially the best thing to come from the Trump Presidency. 

Based on the above, we ought to let that insulin bill die and come up with a real way to lower insulin costs.

The recent Gun Bill Passed by the Senate and House and signed into law sneaked in a gift to PBMs.

Why on earth would a bill on guns contain another delay in the rebate rule, yet another gift to the PBM industry?  The same faulty accounting gimmick of using the rebate rule delay as a pay for.  Unbelievable.  Senators Chris Murphy, D-CT and John Cornyn, R-Tx are mum about who put the PBM poison pork into the gun bill.  Interestingly, Murphy’s top donor is the law firm that helps CVS negotiate mergers.  And Cornyn is a top taker from Vizient, a hospital Middleman Group Purchasing Organization.

Good news at last!  PBM reform in the Mental Health Package

Thankfully, some good news exists. .  Some colossally INCREDIBLE news:

HR 7666, the bipartisan mental health bill introduced by Frank Pallone, D-NJ, and Cathy McMorris Rogers –R, Wa passed the house this week with 400 yay votes.

Some of us were really yelling ‘Yay’ when we discovered splendid section 602, quietly added by Rep Michael Burgess (R-Tx), mandating   big time TRANSPARENCY for big PBM/Insurers with shocking penalties of $10K per day for non-compliance.

Requiring  PBM transparency will save $2BILLION/10 years, paying for the bill.  Billion with a ‘B’.  As Mental health and substance abuse medications are largely overpriced due to PBM kickbacks, this provision absolutely belongs in the bill.

Americans will receive  some wonderful services  with this bill for Mental Health and Substance Use Disorders. Full detail can be found in the bill,  but here is a screenshot of some of the high points

WE CANNOT STOP… we must make sure the mental health bill passes in the senate WITH PBM reform Intact

Please CALL and EMAIL  both of your US Senators ASAP, (find their numbers and email contact links  here ) and tell them to PASS  the Senate version of HR 7666 with the Burgess amendment to bring PBM transparency and accountability intact.  Ask  your friends to call.  Ask your neighbors to call. Ask everyone in your circle and beyond. Tell YOUR Senators you now know the PBMs are behind the ever increasing healthcare costs and it’s time for Congress  to listen to we the people and not the profiteering villainous Pharmacy Benefit Managers! 

Drs. Mass and Dewey are proud to be pediatricians for over 20 years each and fierce advocates for patients and physicians!

Dr. Mass, graduated from Duke Medical School and trained at Northwestern. She has practiced in the Philadelphia area. She’s a cofounder of Practicing Physicians of America And leadership in Free To Care .

Dr. Dewey attended Loyola University Stritch School of Medicine . She did a year of surgery internship then two years of pediatric surgery research before training in Pediatrics at University of Minnesota. She is founder and CEO of Peds Mama Doc and has published in multiple outlets

Speak on Trump’s Order on Price Transparency in Health Care by 1/29

PPA is encouraging that physicians and others comment to Health and Human Services regarding the Trump Administrations’ most recent Price transparency rule found here.

 This proposed rule complements a previous rule requiring hospitals to post their actual prices online and requiring insurers to disclose (in easy-to-understand format) the prices they now negotiate in secret with hospitals and other providers. The effect would be to enable patients to have some idea before they receive care of what they could end up owing to a provider after the care is delivered and the insurer has issued an Explanation of Benefits (EOB) showing what portion of the cost has been covered. This is a step toward pricing sanity in a more-competitive healthcare marketplace because it supports informed shopping by consumers of medical services. The intent is to enlist and boost the power of consumers in driving down prices.

It is crucial for physicians and patients to comment, as the insurance and hospital industry have come out in full force supporting the now hidden prices that have allowed these two industries to profit themselves while gouging Americans.   This is especially true of the most consolidated hospital systems and dominant insurance companies who use opacity combined with their respective market shares to continually drive prices up.  They simply have no incentive to lower prices. 

PPA’s full comments are below.  You are welcome to copy and paste them in part or whole.  When commenting, adding your personal story regarding how patients are hurt by opaque prices.  

For ease, you can consider copying and pasting a personalized form of these italicized comments: firmly support the current efforts to bring the prices of medical services and procedures into the open and to make those prices easily accessible to our patients—in short, to replace price opacity with price transparency.

Noting that in the proposed rule, HHS also requested comments regarding how to enact transparency of quality, I request transparency in the level of the training attained by those who deliver care, and full disclosure of conflicts of interests of any person or organization the government relies on to define or implement quality in health care.

SUBJECT: CMS-9915-P, Comment on the Proposed Rule Mandating Price Transparency

Ending price OPACITY in favor of price TRANSPARENCY is critical to driving down the costs of all forms of medical care in America.

Practicing Physicians of America (PPA)—a non-profit organization representing thousands of physicians, and a part of the Free-to-Care Coalition, now comprised of 37,000 physicians and 3 million citizens—declare their firm support for the proposed rule requiring insurers to reveal the prices they negotiate with all providers of medical care.

Why Transparency is So Sorely Needed

Each day, the thousands of physicians represented by PPA see the pain in the pocketbook of our patients. We see their foremost concern when they seek medical care. What will this cost?

We have observed our patients incurring higher out-of-pocket costs for health insurance (which ought NEVER to be confused with actual healthcare) that outpace their wage increases and threaten the financial viability of their households. 

More than ever before, the patients we treat in our offices are looking for an accessible, easy-to-understand way to shop for the medical services they need and to control their medical expenses. They would like also to see the exposure and defeat of the hidden forces that drive the relentless rise in premiums in response to excessive costs routinely obscured under the third-party payer system that has dominated American healthcare for close to 50 years and been an engine of our stratospheric rates of inflation in the cost of healthcare.

Price opacity, which has enabled forms of price gouging, has produced the environment we see today in which one in five Americans have had medical bills turned over to collection agencies.

This country desperately needs informed consumers of medical services who have choices at their disposal. Price opacity abets ignorance. Price transparency would vindicate the axiom of Francis Bacon: Nam et ipsa scientia potestas est. (Knowledge is power.) The informed consumer who is capable of making choices in a free marketplace that has been disciplined by competition is the only reliable force for driving down deductibles, premiums, and other costs. 

Do the lobbyists of the health insurance and corporate hospital industries resist calls for the end of opacity and the introduction of transparency? Of course they do. They’ll move heaven and earth to keep the good thing going that has fattened their coffers at the expense of the American patient. Those administrator-heavy industries drive inflation in healthcare by every means our current system has legitimized.

Consider the following.

For certain services and procedures provided on an inpatient basis, hospital charges grew by 42% over the eight-year period from 2007 to 2014.

Similarly, for hospital-based, outpatient care involving the same services and procedures, charges increased by 25%.

The charges for the same services and procedures provided by independent physicians grew by only 6% over the same eight-year period.

Those figures are drawn from a study of insurance claims data by the Health Care Cost Institute that has been the subject of reports in the last year.

Meanwhile, as the resources of the American consumer of medical care are relentlessly squeezed, the profitability of the health insurance industry is a picture of robust financial health

The health insurance and corporate hospital industries benefit from the price opacity that has become the sine qua non of the wildly inflationary, third-party payer system that has dominated the landscape of American healthcare for a half-century.

This scandalous gravy train operating under cover of law and public policy must be halted. Transparency is the brake to do the job. 

Those who enact national policy via regulation need to think FIRST of the needs of American patients and to tell the lobbyists of the health insurance and corporate hospital industries that they will no longer be permitted to be the dominating, decisive voices in the room.

On Quality

In inviting comment, the Departments have raised also the question of how Americans can shop on an informed basis for medical care of high quality that is affordable.

Yes, quality can be hard to define and quantify… although most people recognize it when they see it and can distinguish differences in quality when they experience them.

PPA offers this counsel. If the Departments are contemplating a forum of stakeholders to explore the question of quality in healthcare, it would be essential that any such forum be composed of the full range of stakeholders, most heavily represented by patients and the physicians who deal with them directly and personally.

When it comes to physicians, a “quality forum” should include not only physicians employed by corporations but also independent physicians.

When it comes to hospitals, a “quality forum” should include not only the urban, the regional, the large, and the corporate, but also the smaller, the rural, and the independent.

In addition, the representatives of stakeholders participating in any such forum on quality must be required to declare the interests they represent. The interest of the wider public, American patients—who seek to maintain their choices while simultaneously looking for relief from the high costs related to the medical care they receive and the insurance they carry as a hedge against catastrophic costs—  must be protected from the special and narrow interests that have greatly profited under the current inflationary, increasingly consolidated, increasingly corporatized system that has sprung up and flourished under a system of opacity.

“Quality” as a Function of the Practitioner’s Training 

As shown by surveys over the last decade, one measure for enhancing patients’ recognition of quality would be mandating transparency regarding the level of training acquired by medical practitioners. As the numbers of nurse practitioners and physician’s assistants have grown over a period that has seen some states allow nurse practitioners to “practice” as the functional equivalent of physicians, patients have experienced increasing confusion over who is delivering their care.

There is a vast gulf between the minimum 15,000 hours of clinical experience needed to become a physician and the 500 or 1,000 clinical shadowing hours needed to qualify as a nurse practitioner, or the 2,000 clinical hours required of a physician’s assistant. Given the obvious disparity in-depth and quality of training for these levels of medical practitioner, patients deserve to know the degree of training experienced by their caregivers, and they deserve the freedom to seek care from practitioners of their choosing.

Requiring hospitals and clinics to post prominently the levels of training of all practitioners is a simple step toward transparency. It will minimize confusion and strengthen the ability of the American patient to identify quality. 


Regarding Transparency. PPA firmly supports the current efforts to bring the prices of medical services and procedures into the open and to make those prices easily accessible to our patients—in short, to replace price opacity with price transparency.

Regarding Quality. We counsel that the Departments, in addressing the question of quality, whether by a forum or some other means, seek input from a range of stakeholders, and most particularly from patients and physicians. The Departments must be acutely conscious of the interests and agendas that inform what stakeholders have to say. The Departments should also never lose sight of the inescapable reality that any regulatory mandates on information-gathering that can be predicted to add to the administrative overhead already encumbering the practice of medicine in the United States will be at odds with efforts to create a freer, more-competitive marketplace in which prices can be first be expected to stop rising, and then proceed to fall.

Lastly, PPA calls for transparency in the level of the training attained by those who deliver care.

Speak by Jan. 17 on Pres. Trump’s Executive Order Regarding NP and PA Unsupervised Practice

It’s time for physicians to answer the call for comment on the effect of Section 5 in President Trump’s Executive Order (EO), “Protecting and Strengthening Medicare,” of October 3, 2019.
Section 5 of this order calls for eliminating supervision by physicians of mid-level providers of medical care—nurse practitioners (NPs) and physician assistants (PAs).
More than that, it calls for pay parity (more accurately, “reimbursement parity”) among the same groups by Medicare.
Eventually all third-party payments for care would be leveled (flattened) across physicians, NPs, and PAs, regardless of their clinical training.
Pay parity and elimination of supervision will raise the cost of Medicare, accelerate the corporate takeover of healthcare, deepen the physician shortage, decrease competition in the healthcare sector, and multiply dangerous instances of patients being treated by someone with a fraction of the training received by a physician.
PPA explains this in detail in comments sent to CMS Administrator Seema Verma. To read those comments, see below.
Send comments in an email to PatientsOverPaperwork@cms.hhs.gov and addressed to Administrator Verma by Friday, January 17, 2020,  using the phrase “Scope of Practice” in the subject line.
Comments need not be lengthy. You may copy, paste, and personalize the italicized text shown above. You may consider including a personal story, if you have one, regarding the issues raised by an expansion of the scope of practice for mid-level providers of medical care.
Physicians, it’s time to speak up for your patients and for the value of the training that has defined you!

Administrator Verma:

This e-mail is in response to the call for comment on the effect of Section 5 in the President’s Executive Order (EO), “Protecting and Strengthening Medicare,” of October 3, 2019, with special reference to the issue of Scope of Practice (SOP) and associated pay parity.

To a very great extent, the President’s order has the support of the Practicing Physicians of America (PPA), an organization representing thousands of physicians, and a part of the Free-to-Care Coalition, now comprised of 37,000 physicians and 3 million citizens.

However, PPA objects to Section 5 of the order.

Section 5, although never explicitly mentioning the Nurse Practitioner (NP), will expand the scope of the NP’s role in the American system of delivering medical care.

In what we say next, we do not wish to be misunderstood. The NP is an important member of a medical team, but the team must be led by someone with far greater clinical training and experience. It is simply impossible to equate the 1,000 clinical hours of an NP’s training with the 20,000 clinical hours of a physician’s training.

Physicians are sometimes criticized for raising this point because it is assumed that their motivation is nothing more than the protection of their turf. In fact, our concerns are far more-securely grounded and serious than that, and require evaluation on the merits.

Actual experience and the accumulating data on the gradually expanding scope of the NP’s role in the American healthcare system paint a troublesome picture.

Impact of Overutilization

As a collective workforce, NPs have been criticized for:

Over-authorization of unnecessary procedures;
Over-prescription of medications, including opioids.

At the very least, those tendencies point ultimately to increases in costs, a fiscal impact that is the very opposite of the presumed intent of Section 5.

Impact Favoring the Corporate Takeover of American Healthcare

The increasing corporatization of American healthcare is an undeniable fact that has no demonstrable benefit whatsoever toward restraining inflation and reducing costs in that sector of the economy—a sector that, to the detriment of the general public, is increasingly dominated by special interests, the lobbying dollar, and the campaign contribution.

The largely consolidated hospital industry. These corporate entities, already home to more than 50% of the nation’s physicians, will be incentivized to replace more and more of those physicians with less-expensive practitioners who have significantly less training.

Pharmacy chains. The large chains are already deploying “health hubs” in their brick-and-mortar stores. In some cases, these chains own Pharmacy Benefit Managers (PBM) and insurance companies and have already become anti-competitive, vertically merged behemoths. What is to stop them from exploiting the alignment of interests that are inherent within a vertically merged, integrated entity, and draining even more money from the public’s pocket, not only from increased sales of prescriptions and over-the-counter goods, but also from increased profits through the PBMs they own?

Increasing consolidation and quasi-monopolization that continue to create a less-competitive marketplace are inconsistent with the restraint of inflation and a reduction in costs.

Impact on the Deepening Shortage of Physicians

Another, presumably unintended, consequence of Section 5 will be to deepen the already-critical physician shortage.

Section 5’s call for parity of compensation for services will mean that a corporation that employs physicians will have no economic inventive to retain them because the corporation will receive the same amount for a patient’s time with an NP as it will for the same patient’s time with a physician. The NP, however, will be available to the corporate employer at far less cost than a physician.

The long-term effects will be inescapable.

The rate of attrition among physicians will accelerate.

Fewer young adults will step up to replace them because it will make no sense to incur the high tuition of medical school and undergo the years of training that follow.

We will experience shortages among the ranks of well-trained physicians that go far beyond the tens of thousands already expected.

Impact in Fostering a Less-Competent Workforce for Delivering Medical Care

As taxpayers, we must speak against the absurdity of the government spending equal Medicare dollars for the services of highly trained physicians on one hand and on the other hand the same services (or what may appear superficially to be the same services) from practitioners who have a mere fraction of the physicians’ training and expertise.

Even among older NPs, there is dismay over the declining standard of training now being received by younger NPs via diploma-mill programs that are eager to churn out “graduates” with less training, sometimes conducted largely online.

A Cameo Illustrating the Problem

Not long ago, I met a four-month-old patient and his frantic father, a veteran, whose wife was deployed overseas. Less than 18 hours before, an NP in a large, pediatric hospital had sent the child home, despite obvious symptoms of a bowel obstruction, a surgical emergency. The child was now extremely ill and in great danger. Fortunately, this child was transferred to an ICU setting in time and was able to recover after being treated properly.

Nearly every physician I know can tell at least one such story—and sometimes more than one—from personal experience.

Section 5 will accelerate the replacement of physicians with NPs. In turn, that will multiply occurrences like the one described above. It is unavoidable that the outcomes will, in some cases, be tragic.

Impact Overall

While we understand that the executive order of October 3, 2019, was meant to push back against proposals of “Medicare for All,” Section 5—with its provisions for an expanded scope of practice for non-physicians and pay parity—will have the particular impact of reinforcing the trend in American healthcare toward corporatization, consolidation, and quasi-monopolization.

The large, special interests will complete the process of turning medicine into big-box operations, with low quality and little discipline from a marketplace in which competition thrives.

Decreased competition is never a prescription for restraining and reducing costs.

Decreased competition means that the choices available to all will shrink; and it will be the choices of the underprivileged that will shrink the most. Factor in the consequences of “pay parity” and it will not be long before ALL AMERICANS are paying more. The foreseeable consequence of higher costs in healthcare will certainly be increased public support for a “Medicare for All” system—the very outcome the executive order was meant to avoid.

A Call to Remove Section 5 from the EO

For the reasons cited above, the Practicing Physicians of America call for Section 5 of the EO to be removed. Its implicit expansion of the scope of practice for a less-qualified workforce and its provision for pay parity among professionals of vastly different levels are threats to America’s health and the ability of a competitive marketplace to discipline the pricing of services.

Our Recommendation of a Better Path

The Practicing Physicians of America ask that all federal measures be aimed at strengthening the eroding foundation that, historically, has been responsible for the high quality of American healthcare.

Foster competition.

Increase choices for the public.

Sections B and C of an annotated white paper I was honored to help write in the spring of 2019 offer innovative models for charity care and for expanding access to health care. As a solution to the deepening shortage of physicians, we offer Section D (“Reverse Our Physician Shortage”)

That paper inspired the growth of the Free-to-Care Coalition mentioned above.

The physicians of the Coalition stand ready to speak for our patients and for our profession.


Marion E. Mass, M.D.
Co-founder, on behalf of Practicing Physicians of America