Quality, innovative, individualized care is key to beating a cancer diagnosis. As an oncologist for almost 20 years, my goal has always been just that — to walk beside my patients through their entire cancer journey while offering a personalized treatment plan to give them the best chance at survival.
Over the past two decades I’ve seen oncology care change dramatically. Although we still can’t cure or prevent all cancer, technology has advanced in terms of both early detection tests and late-stage treatment options. Unfortunately, it’s becoming more difficult to prescribe lifesaving medications and therapies that will help our most vulnerable patients in their fight against cancer. The root of the problem lies with drug pricing middlemen in our healthcare system. Their unfair practices are threatening access to high-quality patient cancer care and increasing the financial and administrative burdens on both patients and doctors.
Dr. Douglas Flora
These pharmacy benefit managers, or PBMs, are driving up the cost of medications and threatening the patient/doctor relationship. While PBMs will tell you they are improving access to care by negotiating lower prescription drug costs, the truth is that PBMs are overcharging patients for much-needed medications, underpaying the pharmacists who dispense these prescriptions, and then keeping the difference to increase their profit margins — a practice called “spread pricing.”
A 2020 study by the American Society of Clinical Oncology shows that the cost of oncology drugs is growing at a faster rate than any other class of prescription drugs. In fact, the cost of new medications routinely exceeds $100,000 – and that’s typically for just one medication. Patients often require a combination of multiple medications to manage their condition so, as you can imagine, things can get very expensive, very quickly.
In addition to the outsized role PBMs play in determining the cost of prescription drugs, PBMs also implement “utilization management” strategies to create more barriers to care and insurance headaches. Things like prior authorizations, step therapy (when the patient has to try, and fail, on a PBM-preferred drug before having access to medicines prescribed by their doctor) and non-medical drug switching too often dictate which medications can be prescribed and create unneeded delays in patient care.
The American Cancer Society Cancer Action Network reported in 2019 that 34 percent of patients had to wait for insurance approval of cancer treatment and that utilization management policies resulted in treatment delays and increased stress for patients. Given that delays in cancer care can lead to poorer health outcomes, these issues must be addressed.
Even worse, I’ve seen firsthand how some patients are forced to pick and choose their medications or skip a refill, simply because they cannot afford their regular prescription medications under the current system. The COVID-19 pandemic has only exacerbated the problem due to job and health insurance loss and delays in routine care. All of this is bad for public health.
PBMs claim to provide value to patients but instead are just inserting themselves between the patient/doctor relationship to protect their bottom line instead of the well-being of patients.
It’s time to take steps to rein in the middlemen. It’s one way that we can ensure the quality, innovative, individualized care needed to save more lives from cancer. Because at the end of the day, a patient shouldn’t have to worry about whether supply chain and pricing manipulations will affect their ability to survive. Their only worry should be their health and staying strong to win their fight against cancer.
Dr. Douglas Flora is the Executive Medical Director of Oncology Services at St. Elizabeth Healthcare and serves on the Board of Directors for the Kentucky Society of Clinical Oncology.
The vast majority of PBM UM programs are based on reducing variation from the standard of care. Standards that are establish by medical bodies made up of his peers. Reducing variation from the accepted standard will produce quality care, improve patient outcomes and reduce costs, although it seems he is not concerned with the last benefit of these programs.
We all must accept the fact that there are limited resources. While cancer is a terrible disease we can not forget the patient with more pedestrian conditions that also deserve to access to care. Because of this, it is important that the potential for waste is reduced. Just this week a UM program initiated by Araya ( a PBM) that limits first fills of expensive chemo meds to a two week therapy saved one of their clients $20,000 because the patient did not tolerate the medication ad discontinued after a few days. If the prescribers orders had been blindly followed, the extra medicine would have gone to waste.
With regard to patient cost, this is determined by the health plan and in some cases the benefit level the patient chooses. PBMs determine what tier a medication is placed, the health plan determines the contribution.
When it comes to price, again this is not determined by the PBM, this is set by the drug manufacturer. The confusion between the Average wholesale price set by the manufacture and what is paid by the plan is created by the rebates programs, patient assistance programs, and wholesaler arrangements all under control of the manufacturer.