In today’s world, cancer is no longer the death sentence it once was. Thanks to advancements in cancer treatment, patients can now lead relatively normal lives while undergoing therapy. Oral cancer drugs have played a significant role in this progress, allowing patients to maintain their routines and quality of life. However, the increasing dominance of pharmacy benefit managers (PBMs) in the healthcare system has created barriers and delays in accessing these life-saving treatments. This article explores the detrimental effects of PBMs on cancer care coordination and the urgent need for reform.
PBMs, which now control 80% of the prescription drug marketplace, have inserted themselves between patients and doctors, disrupting the treatment process. Their excessive approval processes and ownership of mail-order and specialty pharmacies force cancer patients to follow their predetermined treatment pathways. This control over treatment decisions limits patient choice and hampers access to the most effective therapies. By prioritizing their own profit margins, PBMs undermine the well-being of patients.
The story of Tania*, a breast cancer patient, illustrates the devastating consequences of PBM interference. Tania’s metastatic breast cancer had spread to her brain, and her oncologist recommended the oral cancer drug abemaciclib. However, the PBM denied authorization, leading to a lengthy appeals process. While waiting for the approval, Tania’s cancer continued to progress, and she had to resort to less effective traditional chemotherapy. The delay caused irreversible damage to Tania’s health and quality of life. This case highlights how PBMs impede timely access to potentially life-saving treatments.
PBMs not only obstruct treatment initiation but also disrupt ongoing therapy. Oncologists often need to modify treatment doses based on patient response and toxicity levels. This flexibility is crucial for optimizing therapy and reducing side effects. However, PBMs steer patients away from physician-dispensing pharmacies, where dose modifications can be conveniently made, to their own mandated specialty or mail-order pharmacies. This shift causes delays, mix-ups, and bureaucratic hurdles that hinder the continuity of care. Patient well-being should take precedence over corporate interests.
PBMs claim that their involvement reduces healthcare costs, but evidence suggests otherwise. Premiums and out-of-pocket expenses continue to rise for patients and employers. Over the past decade, family coverage premiums in employer-sponsored plans have increased by 47%. Furthermore, patients’ out-of-pocket spending on prescription drugs has also seen an upward trend. PBMs benefit financially from their monopolistic control over prescription drug distribution, while patients and employers bear the burden of escalating costs. This system is unsustainable and demands reform.
Recognizing the need for change, bipartisan efforts have emerged to address PBM practices. The Pharmacy Benefit Manager Reform Act (S. 1339), supported by Senators Bill Cassidy and Bernie Sanders, aims to ban predatory tactics employed by PBMs, such as spread pricing and claw back fees. The widespread bipartisan consensus indicates the urgency of bringing transparency and oversight to these middlemen. Patients undergoing cancer treatment deserve access to the most effective drugs without unnecessary obstacles.
PBMs’ pervasive influence in the healthcare system has negatively impacted cancer care coordination. Their control over treatment decisions, excessive approval processes, and restrictions on physician-dispensing pharmacies have led to disjointed and delayed care. The escalating costs borne by patients and employers further emphasize the urgency for PBM reform. Transparent and accountable practices are essential to ensure patients can fully benefit from advancements in cancer therapies. It is time to prioritize patient well-being over corporate profits and put an end to the destructive behaviors of PBMs.
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