In a presentation entitled The PBM Has No Clothes: A (Public Sector) Proposal Is More Transparent Than You Think, Steffanie Mathewson, Esq, principal, Mathewson Research, described how the Freedom of Information Act (FOIA) and state sunshine laws make it easier for stakeholders to view and understand the strategic direction of major PBMs.
In a presentation entitled “The PBM Has No Clothes: A (Public Sector) Proposal Is More Transparent Than You Think,” Steffanie Mathewson, Esq, principal, Mathewson Research, described how the Freedom of Information Act (FOIA) and state sunshine laws make it easier for stakeholders to view and understand the “strategic direction” of major PBMs. Her findings also report that 60% of RFP requests are for commercial purposes.
The FOIA (Title 5 of the United States Code, Section 552) provides any person the right to request and receive access to non-confidential records/documents maintained by federal agencies or local governments. It also includes groups such as Medicare contractors and, growingly, PBMs. Similarly, the Sunshine Act promotes transparency and access by requiring manufacturers of drugs,
medical devices, and biologicals that participate in US federal healthcare programs like Medicare or Medicaid to report certain payments and items of value given to physicians and/or other entities such as teaching hospitals.
Mathewson says some PBMs’ RFPs show the growing cost and spending in specialty drugs. There is a trend transparency, and the FOIA provides a good way to obtain proprietary info from PBMs—this includes metrics, advertising, processes, plans for products, and the list goes on. “It’s a major driver in spending,” she said. “It’s just really important to monitor and see what’s happening. The implication will have reverberating effects.”
Mathewson says, based on the teachings of Michael Porter, the essence of competition is simple and evident in pharmaceutical manufacturers , PBMs, and specialty pharmacy. “The basic point is, information is power and data is power,” Mathewson says. “Transparency is about sharing power, shifting power from 1 site of control.”
It’s not just government entities that are held to the laws; in fact, there are several nonprofit groups that also must release their information. It depends on each state’s rules regarding who has to comply with the laws. She adds that “It’s one of the best windows or ways to legally obtain price-containing data of PBMs and PBM competitors—it’s powerful [and] cost-effective.”
The Push for Fair Pricing and Reform in Pharmacy Benefit Management
April 3rd 2025Amid growing legislative pressures and industry debates, pharmacy benefit managers (PBMs) are exploring new strategies to enhance transparency, reduce patient costs, and navigate the evolving healthcare landscape.
Read More
The Importance of Examining and Preventing Atrial Fibrillation
August 29th 2023At this year’s American Society for Preventive Cardiology Congress on CVD Prevention, Emelia J. Benjamin, MD, ScM, delivered the Honorary Fellow Award Lecture, “The Imperative to Focus on the Prevention of Atrial Fibrillation,” as the recipient of this year’s Honorary Fellow of the American Society for Preventive Cardiology award.
Listen
Using AI-Driven Strategies to Optimize Specialty Drug Costs, Manage Polypharmacy
April 2nd 2025As health care costs continue to rise, artificial intelligence (AI)-driven solutions are emerging as a powerful tool for managing specialty drug spending and polypharmacy risks, as showcased in recent research presented at the Academy of Managed Care Pharmacy 2025 conference.
Read More
Promoting Equity in Public Health: Policy, Investment, and Community Engagement Solutions
June 28th 2022On this episode of Managed Care Cast, we speak with Georges C. Benjamin, MD, executive director of the American Public Health Association, on the core takeaways of his keynote session at AHIP 2022 on public health policy and other solutions to promote equitable health and well-being.
Listen
How Recent Federal Policy Changes Are Shaping Managed Care Pharmacy
April 2nd 2025Federal legislative and regulatory changes are reshaping pharmacy practice, with key challenges in government funding, pharmacy benefit manager reform, and health care policy shifts—topics explored by experts at the Academy of Managed Care Pharmacy's annual meeting.
Read More
The IRA’s Unintended Consequences for Drug Pricing and Coverage
April 2nd 2025The Inflation Reduction Act (IRA) may be restricting Medicare Part D formularies, increasing patient costs, and stifling pharmaceutical innovation, experts warned at the Academy of Managed Care Pharmacy 2025 annual meeting.
Read More