The status quo of the American health care system is doing damage to families and businesses in real time.
Pharmacy Benefit Managers, drug purchasing “middlemen,” were originally conceived to lower drug costs and streamline patient access to affordable care. Over time they have quietly accumulated power and influence since their inception and now dictate the medicines patients have access to and the price they pay for them. Today, three PBMs oversee nearly 80% of prescriptions written in the U.S. and use their market power to dictate the terms by which patients can access the medication they are prescribed. PBMs determine which prescriptions are available on an insurance formulary, how much patients pay out-of-pocket at the pharmacy counter to access those prescriptions, and how much a pharmacist is reimbursed for the services they provide to a patient.
The negative impacts of PBMs on our health care system are widespread and growing. Rising rates of insurance claim denials, burdensome prior authorization requirements, and long administrative delays to process prescriptions are now fixtures of our PBM-dominated health care system. Fortunately, Sens. Ron Wyden, D-Ore., and Mike Crapo, R-Idaho, have reintroduced comprehensive PBM reform legislation, the PBM Price Transparency and Accountability Act, which seeks to bring long-overdue reforms to health insurance industry practices that drive up costs for patients, employers, and public payers like Medicaid and Medicare. The legislation would break the vicious cycle of cost-shifting onto patients and the community-based clinicians that serve them.
It’s become impossible for clinicians to provide quality care while navigating a gauntlet of administrative hurdles that keep patients from accessing their prescribed medication. Doctor’s offices commonly employ entire staff teams to fight claims denials and appeal unfair payment decisions. Every hour a doctor spends wading through red tape is time not spent caring for patients.
The ethical obligation of physicians to advocate for patient welfare is stymied by a system that prioritizes short-term financial gains at the expense of patient experience and access to care. This situation underscores the need for systemic reforms to close the loopholes that allow PBMs to override patient-doctor decision-making. Enough is enough.
To address these issues, patients and physicians must engage in advocacy efforts that push for reforms to realign financial incentives around the provision of high-quality, affordable care. This includes challenging restrictive PBM policies that increase insurance claim denials, advocating for fair reimbursement models that allow community providers to keep their doors open, and supporting legislative action to increase oversight and transparency throughout the pharmaceutical supply chain.
The common sense guard rails proposed by PBM Price Transparency and Accountability Act will protect resources for communities experiencing high out-of-pocket cost burdens and ensure that our health care system prioritizes patients over profit margins. The conversation around health care reform must move beyond headline-grabbing policies and focus on creating a sustainable model that prioritizes patient outcomes over profits for intermediaries. It’s long past time to address the root causes of high drug costs and advocate for more equitable access to essential treatments for patients.
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Karen Ferguson, of Spokane, is founder of Our Stories Rx.