The New York Times reports:

In 2017, the drug industry middleman Express Scripts announced that it was taking decisive steps to curb abuse of the prescription painkillers that had fueled America’s overdose crisis. The company said it was “putting the brakes on the opioid epidemic” by making it harder to get potentially dangerous amounts of the drugs.

The announcement, which came after pressure from federal health regulators, was followed by similar declarations from the other two companies that control access to prescription drugs for most Americans.

The self-congratulatory statements, however, didn’t address an important question: Why hadn’t the middlemen, known as pharmacy benefit managers, acted sooner to address a crisis that had been building for decades?

One reason, a New York Times investigation found: Drugmakers had been paying them not to.

For years, the benefit managers, or P.B.M.s, took payments from opioid manufacturers, including Purdue Pharma, in return for not restricting the flow of pills. As tens of thousands of Americans overdosed and died from prescription painkillers, the middlemen collected billions of dollars in payments.

The details of these backroom deals — laid out in hundreds of documents, some previously confidential, reviewed by The Times — expose a mostly untold chapter of the opioid epidemic and provide a rare look at the modus operandi of the companies at the heart of the prescription drug supply chain.

The P.B.M.s exert extraordinary control over what drugs people can receive and at what price. The three dominant companies — Express Scripts, CVS Caremark and Optum Rx — oversee prescriptions for more than 200 million people and are part of health care conglomerates that sit near the top of the Fortune 500 list.

The P.B.M.s are hired by insurers and employers to control their drug costs by negotiating discounts with pharmaceutical manufacturers. But a Times investigation this year found that they often pursue their own financial interests in ways that increase costs for patients, employers and government programs, while driving independent pharmacies out of business. Regulators have accused the largest P.B.M.s of anticompetitive practices.

The middlemen’s dealings with opioid makers reveal a lesser-known consequence of this pay-to-play system: Seemingly everything — including measures meant to protect patients and curtail abuse — can be up for negotiation. [Continue reading…]