Drug Price Caps Are the Wrong Solution for Patients
By: Colorado BioScience Association Date: 07/29/2024
Patients say Upper Payment Limits (UPLs) won’t make their medicines more affordable. Colorado’s Prescription Drug Affordability Board (PDAB) hasn’t listened.
Colorado’s PDAB was created to review the impact of prescription drug costs on Coloradans. The PDAB may address affordability by setting a UPL on certain prescription drugs or recommending other ways to lower drug costs.
In only ten months, the PDAB has completed affordability reviews on five drugs and started a process to set UPLs for the three they deemed “unaffordable.” However, the PDAB has not investigated why drugs cost as much as they do, how each member of the supply chain contributes to drug costs, or evaluated what impact UPLs will actually have on patients. Brushing aside a chorus of concerns that drug price caps are the wrong solution for patients, the PDAB has charged forward to be the first in the nation to implement this experimental program. Yet, they don’t have a clear understanding of the real impacts of their decisions on patient out-of-pocket costs, on access disruptions, or on investment in innovation.
Throughout the PDAB’s work, patients and patient advocates have been vocal about how UPLs won’t actually lower patients’ out-of-pocket costs for their medicines. They have also said they are concerned about the unintended consequences of UPLs for access and innovation, and that they are frustrated with the PDAB’s refusal to truly listen to or dialogue with patients.
Patients: Drug Price Caps Won’t Help Me
The PDAB’s decisions to deem drugs “unaffordable” for Colorado consumers and to initiate rulemaking to set UPLs for those drugs have been scrutinized by patients and many other impacted stakeholders. They have been described as rushed, informed by limited patient input and flawed data, and lacking a clear understanding of why some patients are having difficulty accessing or affording drugs.
Patient and patient advocate Tiffany Westrich-Robertson, who spoke on behalf of the International Foundation for Autoimmune and Autoinflammatory Arthritis (AiArthritis), raised concerns that the Board hadn’t done enough to engage patients and find out why some said affordability was a problem, in an interview with the Denver Post, saying, “I am extremely, extremely concerned.”
Tiffany also delivered impassioned public comment at the PDAB meeting on July 3, 2024, where her frustration and fear were palpable.

Tiffany Westrich-Robertson, AiArthritis (00:44:34 – 00:46:40):
– “…The only testimonies that really matter are those who fit the pre-planned narrative to find the drug unaffordable and apply a UPL. That being said, I am assuming your decision to apply a UPL has already been made prior to today and that this comment period is merely a formality.”
– “…setting a UPL on one or two drugs in the same class will do one of two things: it will either patients will not lose access—if it is their drug, they won’t see any savings because they won’t be passed on to the patient, but those of us in alternative therapy classes—the other 90% of Colorado patients—will be nonmedically switched off of their miracle drug.”
– “…As you move forward in this process, I sincerely hope that biased, pre-planned narratives come to a halt and that patients, patient organizations, and not only patient consumer representative groups that are funded by payers and anti-pharma foundations are invited as equal and valued partners in the conversation for our authority, expertise, and real lived experience and the data we bring to the table.”
PDAB Members Admit They Don’t Know How Drug Price Caps Will Impact Patients
PDAB members admit they don’t know:
- How UPLs will work
- What impact they will have
- Who UPLs will help or hurt
At the same PDAB meeting where Board members voted to initiate the UPL rulemaking process for two drugs, PDAB members also discussed many outstanding questions about UPLs, as the imposition of UPLs will be a first-of-its-kind mandate.

– PDAB Chair Dr. Gail Mizner: “…it’s been pointed out multiple times that we don’t know for certain what the effects of setting an upper payment limit will be, but my hope would be that in fact it would move the drug to a lower tier and make it more accessible to Coloradans.” (00:52:12 – 00:52:39)
– PDAB Member Dr. Amy Gutierrez: “…how our decision is going to lead to a net cost reduction for patients I think is still kind of an unknown for us…” (00:56:30 – 00:56:39)
It has become increasingly clear that the PDAB does not have answers to critical questions, nor do they have a clear understanding of the extent to which those questions cannot be answered. There has been very little investigation into how each member of the complex pharmaceutical supply chain impacts how patients access their medicines, and the price patients ultimately pay for them. There has been even less evaluation of how the implementation of a UPL would actually work in that complex system and the unintended consequences it would likely cause.
As the Colorado PDAB moves toward a UPL rulemaking process, “hope” or “unknown” factors cannot be the basis for the PDAB’s actions.
Even Though UPLs Are the Only Tool the PDAB Has, They Must Still Determine Whether UPLs Will Actually Accomplish Their Goals
Just because the legislature directed the PDAB to consider setting UPLs, doesn’t mean UPLs will actually benefit patients.
PDAB Member Dr. Sami Diab acknowledged that “we are operating under [Senate] Bill 21-175, which doesn’t give us all the tools to really help the consumers of Colorado afford their drugs, so the upper payment limit is our tool.” (00:57:14 – 00:57:32 of recording)
Before selecting an ill-informed and rushed dollar amount at which to set a price cap, the PDAB must thoughtfully investigate and get clear answers to so many more fundamental questions about the impact of UPLs:
- What impacts will there be on patients?
- Will patients actually pay less?
- Will there be any access interruptions along the supply chain?
- Will investments into the research & development of new drugs be stifled?
- How will insurers and pharmacy benefit managers (PBMs) operationalize UPLs?
- Will they change benefit designs to lower patients’ out-of-pocket costs?
- How will drug formulary and tiering decisions be altered?
- How will they use any savings generated?
The need for a deeper discussion and investigation has been strongly reinforced by the March 2024 report titled, “Health Plans Predict: Implementing Upper Payment Limits May Alter Formularies and Benefit Design But Won’t Reduce Patient Costs.” The report was based on research conducted by the Partnership to Fight Chronic Disease.
This report concluded:
“This research offers early indication that some payers in Colorado and other states with PDABs and UPLs have not prepared extensively for implementation of UPLs. States implementing and considering PDABs with UPL authority should consider potential impacts on plan benefit design and other downstream consequences for patient cost sharing, provider reimbursement, and access to care. Most importantly, states should take note that payers believe UPLs are likely to alter how patients in these states will be able to access their prescriptions and they do not believe UPLs are likely to reduce patients’ costs.”
For states implementing PDABs with UPL authority, the report suggests that stakeholders: “Consider and pursue other affordability measures with a greater impact on reducing patient costs, such as copay caps, copay accumulator and maximizer bans, and requiring rebate pass-throughs to consumers at the pharmacy counter.”
PDAB Members Raise Questions About the Role of PBMs and Insurance Carriers in Increasing Drug Costs
Although the PDAB cannot enact affordability measures other than UPLs, the PDAB is empowered to make policy recommendations to the legislature on other affordability measures to reduce drug costs for Colorado consumers. In its 2023 annual report to the General Assembly, the PDAB failed to make any concrete recommendations about other tools that would be more effective at reducing patients’ drug costs.
However, they did acknowledge that, “Patients and patient advocacy groups have brought to the Board’s attention their concerns regarding carrier policies which lack transparency and increase patient costs and delay access to critical prescription drugs.” They also stated that “the Board is concerned about the role that pharmacy benefit management firms (PBMs) play in increasing the costs of prescription drugs.”
These questions were raised around the same time the Federal Trade Commission(FTC) released an interim report titled “Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies.” This “scathing” report “blasting” the business practices of “prescription drug middlemen” highlighted how PBMs, “who are at the center of the complex pharmaceutical distribution chain,” “wield enormous power and influence over patients’ access to drugs and the prices they pay.” We share more about this important report and the increasing scrutiny of PBMs in our blog FTC Blasts PBMs in New Report.
We’re glad that questions around the roles of insurance carriers and PBMs were discussed more during the July 3rd PDAB meeting and that PDAB members highlighted the need to better understand payers and PBMs. The PDAB’s July 3rd discussion shined a spotlight on, as PDAB member Dr. Justin VandenBerg put it, the “lack of transparency…within the PBM world” and the need for the PDAB to “better understand what’s really going on in the background” in order to draw conclusions about even the status quo, let alone about how a UPL would be operationalized in the system and ultimately impact patients.
Drug Price Caps Are the Wrong Solution for Patients
Imposing UPLs on drugs without understanding their impacts is risky and irresponsible.
While the Colorado PDAB has moved forward with its process, another state has pressed pause on its charge to address drug affordability.
Oregon’s PDAB recently “voted to pause the affordability reviews for 2024 so the board can review, assess and possibly improve the criteria and methods used to assess and select drugs for potential affordability reviews in 2025, using a refreshed data set.” We applaud the Oregon PDAB for recognizing its limitations and slowing down.
During the Colorado PDAB’s July 19th meeting, PDAB staff said they don’t want stakeholders to think they’re going to “rush forward” and indicated that, to the degree Board members “want to delay future things,” “we will absolutely do that,” adding that we can “anticipate that this delay…will probably impact the upper payment limit rulemaking timeline.”
PDAB Chair Dr. Gail Mizner agreed: “We want to take the time we need to do this properly and thoughtfully and with as much input and data as we can gather, so that’s what we’re going to do.”
Patients and stakeholders will be watching closely to see whether the Colorado PDAB’s actions align with its stated intentions to not “rush forward” and to take the time and steps necessary to truly carry out its charge “properly and thoughtfully” and with “as much input and data as [they] can gather.” The PDAB cannot achieve its goal of helping Colorado patients access effective, affordable medicines without fully studying and understanding the implications of its decisions and the economics of the entire drug supply chain. Moving forward recklessly to set artificial drug price caps could have devastating consequences for thousands of chronically ill Colorado patients who rely on these medications to treat life-altering symptoms of debilitating medical conditions.
Learn more about how Colorado’s “Efforts to Control Prescription Drug Pricing Harm Collaborative Work to Advance Patient Care with Health Innovations.”