Over the last generation, pharmacy benefit managers (PBMs) have assumed greater and greater roles in our prescription drug system. Originally they were merely supposed to manage drug benefits, but now they manage pharmacy benefit plans, negotiate with drug companies, and decide what drugs patients will get and from where they will get this. In many cases they now interfere with treatments and attempt to dictate what physicians can and cannot do. A recent paper by the Community Oncology Alliance, the third in a series of papers, examines the impact that PBMs have on cancer patients and how they harm patient care.
The stories are harrowing. One patient was diagnosed with renal cell carcinoma and his doctor prescribed him a special oral medication. The oncology clinic sent a prescription for the medicine to the PBM-mandated specialty pharmacy, but the pharmacy wanted additional information, delayed sending the medicine for almost forty days, causing his cancer to worsen.
Another patient with multiple myeloma, was being denied the medication needed for her treatment, and a worker at the clinic called the PBM to sort things. She spoke to five different representatives at the PBM, none of which understood her situation. The last representative even discouraged her from making the call and trying to get the medication approved. Only when she threatened to contact Medicare and the Maryland Insurance Commissioner's office and complain about the unprofessional handling of this case did the PBM relent and assign her a case worker.
There are many other examples. PBMs delivered medicine late, delivered the wrong doses, failed to notify doctors of issues with medication, and demanded that cancer patients follow pointless procedures even when they desperately needed medicines. And these problems aren't limited to cancer drugs. PBMs claim that they provide excellent service and reduce drug costs, and that the above instances are just a few bad apples. But since the PBM market lacks transparency, accountability, and consumer choice, it is very difficult to find out if they are correct. And the limited evidence available shows that PBM abuses are serious and widespread.
North Dakota passed a law earlier this year requiring increased PBM transparency and seeking to correct these abuses. But the Pharmaceutical Care Management Association (PCMA), the main lobbying group for PBMs, did not support this law. Instead, they have sued and asked the courts to declare the law unconstitutional.
This paper is further evidence that PBMs need stronger regulation and oversight, especially so cancer patients can be protected and get the medicine they need. We hope that additional information on these abuses will come to light, and that policymakers will pass laws to fix this problem.