What it means: If Fiedler is right, all of the fuss about PBM laws might not end up having much impact on employers' health plans.

Policymakers could soon be focusing more on costs and pricing strategies at the pharmaceutical manufacturers.

The backdrop: PBMs help self-insured employer plans, insurers and other payers manage their prescription drug benefits.

Critics have accused the big PBMs of pushing up the full list prices of drugs to maximize the size of the discounts they negotiate and their discount-based compensation.

Critics have also accused big PBMs of crushing pharmacies, by steering patients to the PBMs' own mail-order pharmacies.

The Pharmaceutical Care Management Association, a group for PBMs, has argued that most of the hostility its members face is the result of drug manufacturers' and pharmacies' anger about the PBMs' successful efforts to narrow the manufacturers' and pharmacies' profit margins.

The hearing: Most of the House members and witnesses at the hearing blasted the big PBMs.

Related: Benefits group CEO stumps for PBM bills at House hearing

Fiedler agreed that lack of competition in the PBM market and PBMs' reluctance to provide clear, detailed, easy-to-understand reports on their activities does cause major problems.

"By some estimates, the three largest PBMs control almost four-fifths of the market," Fiedler said.

PBMs' lack of clear, detailed reporting hurts employers' ability to shop for new PBMs for their self-funded health plans, he said.

"Switching PBMs is also challenging, since it requires a plan's enrollees to adapt to new formulary rules and pharmacy networks," he said. "As a result, PBMs wield market power that they can use to demand prices in excess of their costs."

Antitrust regulators could probably help by keeping the big PBMs from acquiring other PBMs, Fiedler said.

But Fieldler suggested that many popular strategies for reining in PBMs seem likely to have neutral or bad effects.

Some House bills would prohibit PBMs from collecting certain kinds of compensation, such as fees tied to the size of the drug price discounts they negotiate, in an effort to keep PBMs from pushing up the full list prices of the drugs just to maximize their own revenue.

One problem is that limits on discount-based compensation might weaken the PBMs' efforts to bargain for lower prices, Fiedler said.

Even if the PBMs continued to bargain hard for lower prices, restrictions on types of compensation would likely have little effect on the PBMs' profits or overall drug prices, because the PBMs would simply maintain their compensation levels by increasing other types of fees, Fiedler added.

Fiedler also warned against thinking of breaking up the big PBMs as an easy solution.

"When they're going up against the manufacturers, the big PBMs have more leverage," he said. "I think that's just the reality of this market."

Fiedler said that his best guess is that breaking up the big PBMs would save consumers money, but "I don't think the evidence we have on that question is perfect."

Similarly, he said, predicting how efforts to keep PBMs from steering patients to their own captive pharmacies will work is difficult.

"I think there are instances where it's legitimately more efficient for a PBM to deliver drugs through its own pharmacy," he said. "It may also allow the PBM a way around the market power held by some outside pharmacies."

Fiedler was more optimistic about the impact of bills that could require PBMs to send employers and other customers detailed reports. But he pointed to forecasts showing that transparency requirements would save only about $900 million per year early on, with the impact shrinking over time.

"PBMs' pre-tax profits totaled about $18 billion in 2023," Fiedler noted.