Patients would benefit from reforms to pharmacy benefit managers’ abusive practices

12 April 2023

For cancer patients and others diagnosed with terminal illnesses, access to innovative, cutting-edge drug treatments can mean the difference between life and death. I speak from firsthand experience, having first been diagnosed with breast cancer nearly 15 years ago.

A year after completing what my doctor’s thought would be my final round of treatment, I was told my cancer had metastasized to my lungs. Unable to get into any clinical trials for up-and-coming treatments, I had resigned myself to the reality that I could be living out the final days of my life and accepted the suggestions of the experts to live those days to the fullest.

Now, a decade and half later, I am proud to be one of the longest-living triple negative breast cancer patients with no evidence of returning disease at this point. This did not happen by chance, but because I was approved for a newly developed treatment. In short, my life was saved by medical innovations and advancements.

While some consider them an easy target for scorn, pharmaceutical companies are able to bring new drugs to market thanks to the hard work and dedication of scientists and researchers who strive to find cures for patients like me who face even the bleakest of diagnoses. However, their work relies on preserving an environment that encourages and supports robust innovation and investment in developing such vital treatments.

As local lawmakers here in Nevada to our federal representation in Washington, D.C., seek to implement policies that could help lower out-of-pocket costs for patients and consumers, they must be careful not to rely on government-led price control policies. The intent may be good but setting the prices for prescription drugs could negatively impact the accessibility of certain treatments and medications on the market today. Worse, these kinds of policies threaten treatment research and development by restricting the resources scientists need to develop next-generation medications and cures.

As someone who owes her life to a new, life-saving treatment, preserving the pathway to medical innovation is a deeply personal matter to me. If policymakers truly want to help patients reduce out-of-pocket expenses, they should shift their focus to pharmacy benefit managers, or PBMs.

Anyone who is well acquainted with the ins and outs of prescription access knows that PBMs are the health care intermediaries who control more than 80 percent of the medications available on the market today. They are essentially able to dictate when and where patients can receive their needed medications, and yet they operate with such loose regulatory oversight that they are virtually unaccountable for their practices.

For example, PBMs negotiate discounts and rebates on prescription drugs that they are then supposed to pass on to patients at the pharmacy in order to help reduce out-of-pocket costs. However, they are usually just able to keep these rebates for themselves in order to boost their bottom line, all while forcing patients to continue paying higher out-of-pocket costs.

Additionally, the prior authorization policies PBMs use can lead to lengthy delays in patients accessing their physician-prescribed medications. For cancer patients and others living with terminal disease, these kinds of delays can cause more than a mere inconvenience; they can significantly worsen patient outcomes, leading to needless complications, disease progression, and even death.

While I understand the need to address high out-of-pocket costs, I also know that government price-setting will not help address these concerns and will threaten the innovation that patients like me rely on. State and federal lawmakers should instead focus their energy on reforming the abusive practices PBMs use to profit off of vulnerable patients.

Maura Bivens is a triple negative breast and metastatic cancer symptom-free patient from Las Vegas. She is a former improvisational comic and nail salon owner, and has a third-degree black belt. After losing countless friends to cancer, she became a patient advocate on the advice of her doctor, who told her the best thing she could do to honor them was share her story.

The post Patients would benefit from reforms to pharmacy benefit managers’ abusive practices appeared first on The Nevada Independent.

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