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Pricing patients out of health: Urgent need for PBM reform

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Special to the Daily Californian

OCTOBER 17, 2023

Patients across California are still waiting for Congress to pass legislation that would reform the harmful practices of insurers and Pharmacy Benefit Managers (PBMs) who boost their profits at  the expense of prescription drug access. Although our lawmakers appeared to be making strides on the issue earlier this year, the momentum to achieve real results seems to be slipping away along with the rest of the legislative calendar. As a San Francisco resident, living costs are already high enough. Necessary prescription medications should not add further financial burdens to Californians.

Failing to pass comprehensive legislation would deal a devastating blow to patients and families who struggle with high out-of-pocket costs and reduced access. As someone dependent on  prescription medication, I have a vested interest in the implementation of meaningful health care reform.

Like thousands of others across California, I need to be able to access the doctor-prescribed medicines that work best for me. Unfortunately, knowing that there are powerful, largely unregulated middlemen out there who want to capitalize on my vulnerability is concerning.

I worry that one day, I will be told I can no longer access my doctor-prescribed medications and have to take something else less effective, or face exorbitant out-of-pocket costs for the original treatment. Visiting the pharmacy counter shouldn’t be a situation where patients have to be nervous, but insurers and PBMs often don’t give us a choice.

Even with highly expensive monthly premiums and steep deductibles, insurance coverage seems to dwindle and we are still saddled with crippling co-pays. To make matters even more complicated, this industry often invokes other restrictive policies like prior authorization  methods and fail-first therapies to ensure they can make the most money off of patients. These actions can result in significant delays or outright denials of lifesaving medications and can put  their customers’ health at immediate risk.

In lockstep with insurance companies and these anti-patient policies, PBMs can also push “patient steering” rules which require a customer to pick up their medication at their affiliated,  large-chain pharmacy. Even if it is more convenient for me to pick up a medication at my local hometown pharmacy, my PBM might not give me a choice and instead force me to pick up my prescription tens of miles away. This practice furthers their bottom lines even more and puts their greed above their customers’ health needs.

Another major problem caused by PBMs are the rebates and discounts they take from patients. PBMs serve as the intermediaries between drug manufacturers and insurance companies, and they negotiate savings for medications. While that sounds helpful in theory, in practice, PBMs end up pocketing a small amount of these rebates for themselves and saddling patients with higher out-of-pocket expenses. Instead of passing along helpful discounts on medications, they keep the savings and continue to serve their own financial interests.

Until substantive legislative and regulatory changes are made, patients will continue to face harmful delays, increased out-of-pocket costs and time wasted by navigating complex insurance and PBM policies.

Our lawmakers on Capitol Hill know how important this issue is to Californians, and many of them have signed onto important reform bills like the HELP Copays Act and the Share the Savings with Seniors Act. But these efforts only go so far, and with no immediate vote scheduled for any of these bills or larger packages in either the House or Senate, I worry we will run out of time.

Patients need their lawmakers to take this call to action seriously. They should work together to pass a bipartisan solution that will reform insurance companies and their PBMs, thereby ensuring that the health and well-being of customers comes first — rather than the success of investors.

One such example is the Delinking Revenue from Unfair Gouging (DRUG) Act, which has only been introduced in the Senate so far. Senator Padilla should help pass the DRUG Act out of the Senate, and our California Representatives should introduce and pass a similar companion bill in the House. Patients cannot afford to have Congress kick the can down the road on this issue any longer.

The clock is ticking for Congress to pass health care reform bills. We cannot afford to have action delayed any longer.

Abigail (Abby) Malin is a UC Berkeley graduate who currently works in San Francisco. Contact the opinion desk at [email protected] or follow us on Twitter.

OCTOBER 17, 2023