Drug companies set drug prices and over the last eight years those list prices have increased by more than 200%. If not for us, our clients and patients would be left to pay those costs. Drug makers set prices and we exist to bring those prices down to ensure patients can access the drugs they need and the payers can afford them. We use every tool in our arsenal to do it and are constantly innovating new ways to bring costs in line and create greater patient access. We did that with hepatitis C and we are doing the same with diabetes, inflammatory conditions and other key therapeutic areas. And last year we limited our clients' total impact to a 2.5% increase in unit cost in a year where brand inflation was 11%. One of the commonly cited issues related to the PBMs is the lack of transparency. Profit margins are very low, but it's common for revenue to be booked on drugs which were never in-hand for the company, but only negotiated for. It is murky, because some drugs do go through mail-order services and are actually sold directly. This lack of transparency has led many to question whether PBMs are actually taking a much larger cut than what would be constituted as 'fair,' which would be a contributor to higher drug costs. Although the company line is always that PBMs drive value and lower prices for the customers, without additional color on the issue they can continue to be considered part of the problem. Because of this, legislators are attempting to force the companies into providing additional disclosures regarding rebates. As for the PBMs, the fear is that additional disclosure could harm the ability to negotiate for the lowest possible price. It will be interesting to see how it plays out, and the future of the industry as it stands today is not certain. On the last earnings call, ESRX CEO discussed the rebates and margins to an extent. In 2016, ~89% of all rebate dollars were sent directly to the customers. However, some customers prefer to keep 100% of the rebates, some do rebate-sharing with other concessions and some don't take any but look for other reductions in pricing. Therefore, profit margins are on a case by case basis by customer and dependent on many different factors outside of just rebates. This makes it difficult to say definitively either way whether ESRX is taking profits at the expense of the consumer. Another major issue that has been holding down ESRX is the potential upcoming loss of one of its major customers.
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