Why are drug prices so high? Mass. should press for answers.

The way prescription drugs are paid for and reach consumers is complicated and opaque, involving drug manufacturers, pharmacy benefit managers, wholesalers, insurers, and pharmacies. Attempts to control costs have devolved into finger-pointing between the pharmaceutical industry and pharmacy benefit managers, which are companies that act as middlemen between insurers and manufacturers.

“It’s like having a conversation with your kids when they come to you telling you it’s Sally’s fault the vase broke, and Sally said, ‘no it’s not, it’s Joey’s fault,’” said state Senator Cindy Friedman, Senate chair of the Legislature’s Joint Committee on Health Care Financing.

As lawmakers attempt to rein in costs, the first step should be transparency — prying loose more information from Sally and Joey, in other words. Lawmakers should make pharmaceutical companies, pharmacy benefit managers, and wholesalers subject to the Health Policy Commission’s cost trends hearing — as hospitals and insurers already are. If they fell under the commission’s purview, each player in the drug industry would be required to submit cost information to the commission and testify at a public hearing. While the added transparency would not in itself control costs, it would let health policy analysts understand where the excessive costs are in the system so the commission or Legislature could take steps to rein them in. Gathering the information and making public what can be released without compromising companies’ competitiveness would go a long way toward illuminating a debate that is now dominated by contradictory claims from each side.

Pharmacy benefit managers — the largest ones being CVS Caremark, Optum Rx, and Express Scripts — are employed by insurers to negotiate prices with drug manufacturers and determine which drugs insurers will cover. Ideally, PBMs would control costs by using their market power to negotiate lower drug prices and ensure that when there are multiple drugs to treat a condition the customer has access to the least expensive drug more cheaply. One paper published by the National Bureau of Economic Research estimated that PBM services add $192 billion annually in value to society compared to a world where drug manufacturers fully control prices.

However, the money PBMs save does not necessarily go to consumers. Each major PBM is owned by an insurer, and PBMs both recoup enormous profits themselves and return savings to those insurers. The three major PBMs are all part of companies that made the top 15 on this year’s Fortune 500 list of US revenue producers.

PBM contracts often disadvantage independent pharmacies. Todd Brown, executive director of the Massachusetts Independent Pharmacists Association, alleged that PBMs “purposely keep the system complex” and “manipulate it for their benefit at the expense of everyone else.”

Additionally, the way PBMs profit creates incentives for insurers to prioritize higher cost drugs. Typically, a drug manufacturer gives the PBM a discount or rebate from the drug’s list price, often a percentage of the price, in exchange for being placed in an insurer’s formulary with strong insurance coverage. That means the higher the cost of the drug, the more the PBM earns. PBMs can also exclude lower cost drugs from insurance coverage.

State Representative John Lawn, House chair of the Committee on Health Care Financing, called PBMs “mob-like.” “They control the whole game,” he said.

But PBM representatives say pharmaceutical companies are focusing on them to distract from the core problem, which is high drug prices. They say drug companies abuse patent law to limit competition and unnecessarily hike prices of essential drugs.

“The pharmaceutical industry supports policies designed to shift blame, eliminate the only check on their otherwise unlimited pricing power, and keep prescription drug prices high to further boost their profits,” said Katie Payne, a spokesperson for the Pharmaceutical Care Management Association, which represents PBMs.

While wholesalers have rarely been part of the conversation, these huge companies, which ship drugs from manufacturers to pharmacies and operate cooperatives through which independent pharmacies bargain with PBMs, are another important player.

A variety of regulations on PBMs are being discussed on Beacon Hill and Capitol Hill. Generally, these proposals would change the way PBMs are compensated or require that drug discounts obtained by the PBM flow through either to the patient or the insurer.

Other proposals state lawmakers are considering would provide government review of high-priced drugs or cap co-pays for particular drugs.

A vital first step in understanding the consequences of any of these proposals is to increase transparency on what role each segment of the industry plays in ever-increasing drug prices.

When Massachusetts lawmakers created the Health Policy Commission a decade ago, the biggest drivers of health care spending were hospitals and insurers, so the commission was charged with addressing those sectors. There was little interest in taking steps that might have harmed the biotech and pharmaceutical companies that are integral to the state economy. But since then, pharmaceutical prices have continued to grow and encompass a larger part of the health care ecosystem. That is not necessarily a bad thing. If a breakthrough drug prevents surgery, that helps patients. But that shift means it is more important to scrutinize pharmaceutical spending, eliminate unnecessary spending, and make sure the money that is spent benefits health care consumers.

Drug companies point out that they are regulated on a federal level. But several states, including Washington, Minnesota, and Maine, have passed laws requiring state-level data collection and transparency in drug pricing. Massachusetts should follow suit.

Correction: An earlier version of this editorial misstated the amount the average commercial insurer paid on pharmaceuticals in 2021, according to the Health Policy Commission. It was $1,196 per member per year.

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