Last year, Sen. Richard Blumenthal (D-CT) provided vital services to patients suffering from serious illnesses. He chaired a Senate hearing on the role pharmacy benefit managers (PBMs) play in the price and availability of much-needed medicines.
At that hearing, Senator Blumenthal said the largest PBM, which controls the medicines available to millions of Americans, is excluding hundreds of medicines from its formularies, so patients can’t take them. I pointed out that they have blocked access.
Since that hearing, PBM’s grip on our health and well-being has grown stronger. Out-of-pocket drug costs are out of reach for far too many people, and this system will help find the best drugs for PBM financial returns, even if they are not the ones doctors deem best for treatment. is configured for patient use. our terms.
When it comes to these business brokerage practices, it’s time for Congress to turn its investigation into concrete action.
This is of great concern and urgency for people living with serious and complex diseases such as HIV/AIDS and cancer. Our body chemistry is not identical, and certain drugs work better in some patients than others, and conversely can cause harmful side effects in some patients. Affordability and availability of these treatments is important when professionals decide the best drug or combination of drugs to treat severe illness.
PBM was initially responsible for making it happen. They were negotiators who worked with multiple health insurers and public programs such as state Medicaid programs and used their accumulated purchasing power to take advantage of favorable prices from pharmaceutical companies. However, over time, the industry has undergone significant consolidation and now only his trio of multi-billion dollar companies control 80% of the prescription market. Unfortunately, they are using that power for their own benefit, not for patients and consumers.
In 2014, only 109 prescription drugs were excluded from one or more PBM formularies. By 2022, that number has increased to 1,156. The number of drugs excluded is increasing each year. These are drugs that PBM has determined are not covered by insurance and patients must pay full list price or use drugs recommended by PBM. It is no exaggeration to say that few people can afford the full price of specialty medicines.
why did this happen? One reason is that PBM has created a reimbursement structure in which the higher the list price of a drug, the more profit it makes through management fees and rebate deals. As such, drugs that do not generate favorable revenues for intermediaries are likely to be excluded from formularies, limiting the treatment options available to patients. This anti-consumer environment has so far evaded solutions because PBM business practices are so complex and incredibly opaque.
It is imperative that Congress act, even on a scale that has been too biased toward corporate interests. Bipartisan legislation introduced by Senators Maria Cantwell (D-Washington) and Chuck Grassley (R-Iowa) will force these companies to be more transparent about their actions, It will put an end to deceptive and harmful pricing practices. This law is good, even if more needs to be done to ensure that the discounts and rebates that PBMs negotiate with pharmaceutical companies are not just shared with consumers and converted into profits. It’s a start.
Today there are people in our state who are suffering from serious illnesses and cannot get the medicine they need. This is completely incomprehensible in our society. Senator Blumenthal and others have helped focus on where the issues of drug access and affordability lie. Now is the time to do something about it.
John Merz is CEO of Advancing CT Together/Hartford.