Medicare and its beneficiaries aren’t the winners in the behind-the-scenes rebate game played by drug makers, health insurers, and pharmacy benefit managers, according to a paper published Tuesday in JAMA Internal Medicine.

The paper, which dives into the complex and opaque world of Medicare drug price negotiations, finds that rebates may actually drive up the amount Medicare and its beneficiaries pay for drugs — especially for increasingly common high-priced drugs — and it offers some solutions.

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