When I sit down with a patient for that important conversation about which medication he or she should take, both of us are focused on getting the best results possible. That's what patient-centered care is all about.
But my patient may not realize that invisible third parties are trying to undermine our decision-making. And they are focused solely on their own bottom lines. They don't understand patient-centered care, much less practice it, yet they have the power to override what my patient and Idecide.
These uninvited third parties are pharmacy benefit managers, or PBMs. The
companies are hired to negotiate drug prices on behalf of insurers. Oftentimes, they also administer the prescription drug plans for insurers and self-insuring corporations.
It sounds innocuous enough. But in reality, these companies run a $400 billion a year market by routinely delaying, denying or switching patients' medications to maximize profits. Never mind that those medications were carefully selected by doctors like me to address patients' individual medical needs.
Pharmacy benefit managers often claim they're lowering drug prices for patients, but that's not necessarily true. Too often, they're using the drug rebate system to instead enrich themselves - undermining patient care in the process.
Through the rebate system, drug companies vie for favorable health plan coverage age by offering rebates to the pharmacy benefit manager. When pharmacy benefit managers collect the rebate money, they keep a portion for themselves and pass the rest along to the insurance company.
But there is no requirement that patients share in this windfall. The rebate system can actually create a perverse incentive for companies to raise drug prices to offset higher and higher rebates. When patients' out-of-pocket costs are based on their medication's list price, they end up paying more, not less, as a result of the pharmacy benefit managers' negotiating.
Meanwhile, doctors find that their informed choice of medication comes second to what the pharmacy benefit manager prefers.
Getting coverage for a drug other than one preferred by the pharmacy benefit manager is not easy. Extensive paperwork and delays may ensue as doctors work to get prior authorization from the health plan. This can involve days or weeks of rejections, appeals and negotiations, with no guarantee of approval. Patients may also face step therapy, which requires them to endure a series of ineffective but insurer-preferred drugs before getting the drug prescribed by their doctor.
Assuming a patient does finally get coverage, the drug's "non-preferred" status usually means higher co-pays. That can make it prohibitively expensive for the patient.
Equally frustrating, a patient with a chronic condition like diabetes, arthritis, asthma, or mental illness can be suddenly forced to switch from a medication that's worked well for years. Why? Because the pharmacy benefit manager has found a better deal on a different medication.
Beyond dollars and cents, pharmacy benefit managers' tactics cost patients heavily in anxiety and quality of life. They also undermine the fundamentals of patient-centered care, especially the doctor-patient relationship.
A one-size-fits-all system that treats patients like pawns may boost profits for big health insurance companies. But when those profits come between patients and doctors, the cost is far too great.
In a year where the Florida Legislature passed over 33% more bills on average than the last three legislative sessions, lawmakers failed to grant one hearing to several PBM-related legislative proposals that would have increased transparency and consistency for Florida's patients. In 2022, lawmakers must put patient-centered care first by evolving the way pharmacy benefit managers do business in the state of Florida. ¦
- Dr. Catherine Nina Kowal is a rheumatologist based in Naples, with more than 21 years of practice. Dr. Kowal is a past president of the Collier County Medical Society, and serves on the Board of Governors for the Florida Medical Association.