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Is United the fox guarding OptumRx’s hen house?

Insurers and pharmacy benefit managers are both tasked with keeping a watchful eye on medication spending. But are the incentives lining up? A recent investigation into UnitedHealthcare’s PBM OptumRx has us wondering.

Remember how a few months ago we wrote about how pharmacy benefit managers (PBMs) are huge benefactors for profit growth within insurers (ahem, Anthem)? Well, it’s becoming a trend that keeps ascending for other insurers, including United. For us, it’s also a major red flag – and the situation in Mississippi is the perfect example of why.

For context: PBMs are groups that manage all prescription benefits on behalf of insurers and employers. They are supposed to be the do-gooders, providing oversight when it comes to overprescribing or overfilling medicine, all in an effort to lower costs and streamline the process. What’s opaque, though, is whether they’re actually playing that role. United, among other insurers, seem to see more profit gain than patient benefit, and states like Mississippi seem to be catching wise.

According to the Clarion Ledger, the Mississippi State Auditor’s Office is looking into whether OptumRx is overbilling the state for prescription drugs. The PBM has made $250 million off their Medicaid services in Mississippi since 2017, and the investigation follows a $55 million settlement with Centene over the same set of allegations. There’s no public evidence of wrong-doing, but it does makes us feel a little at ease to hear that the Mississippi State Auditor’s Office has launched an investigation into OptumRx —but where will it lead? We’re hoping for more governance and oversight of insurers and PBMs alike.

Insurer PBMs like OptumRx act like heroes, claiming to reduce drug costs and frustration for its members. But there is no cape or glory in this story. Little do members know that United owns the PBM – and plenty of providers, to boot – and increasing healthcare costs continue to benefit shareholders’ bottom lines.

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