Comment: Meddling by prescription ‘middlemen’ needs to end

By Raymond Miller / For The Herald

Patients often get an unwelcome shock after visiting their local pharmacy: their usual medications have been switched out for something other than what their doctor prescribed.

This can be a stomach-dropping moment for someone who has become stable on their current therapy. This isn’t what their doctor had prescribed, and they don’t know anything about this new brand. Most folks are told, incorrectly, that their medicines are interchangeable with similar products. Switching out patient medications without consultation with a doctor is ethically dubious and can cause serious and persistent setbacks in a patient’s course of care.

Unfortunately, this is the experience of thousands of patients who visit their pharmacies each day because of interference from pharmacy benefit managers (PBMs). Dubbed the “middleman” of the medical system, pharmacy benefit managers were initially conceived as negotiators to create savings and process pharmaceutical claims. Over time, however these benefit management companies have taken advantage of their place in our health care system to inflate prices, enhance corporate profit margins, and keep patients on the hook for out-sized charges.

Today, just three PBMs control more than three fourths of the market: CVS Caremark, Express Scripts and OptumRx. These companies consistently rank among the most profitable in the country, which comes as no surprise after seeing the influence they have on the market. Pharmacy benefit managers use their inflated market share to exploit our health care system, distort competition, drive up patient costs and reduce therapeutic choices for patients and their doctors. They harm our health care system and patients by interrupting treatment decisions made by patients and their doctors. This method of changing a patient’s medicine without their consent is called “non-medical switching,” as PBMs change out medication types to boost profits and increase patient cost-sharing at the pharmacy counter.

Many legislators agree: It’s time to put patients above profits. More than ten states, including Washington state, have successfully sued to recover damages from PBMs for overbilling state Medicaid programs. This is a big step forward for PBM reform, despite the structural issues that allow for predatory insurance formularies — the lists of drugs insurers cover — to persist.

This call to action comes from the top down: We recently saw the U.S. Senate hold a hearing on the dangers that PBMs pose to patients by monopolizing markets and driving up drug prices. Legislators seem to have prioritized PBM reform this session, but hearings alone are not enough. Unfortunately, patients will not see meaningful improvements in prices or access without tackling the stranglehold that PBMs have on the market. The less control that pharmacy benefit managers have over prescription medication markets, the more savings go back to patients directly.

Luckily, Washington’s federal lawmakers have already been leading federal bipartisan PBM reform efforts. Sen. Maria Cantwell, D-Wash., has been meeting with clinicians, pharmacists and patient advocates to promote her own reform bill, the Prescription Pricing for the People Act, which would ban practices like “spread pricing,” where a PBM charges significantly more than what they pay for a drug, and then pocket the difference. Senate Finance Committee Chair Ron Wyden, D-Ore., championed the Creating Transparency to Have Drug Rebates Unlocked (C-THRU) Act, which would require a percentage of PBM profits on drug sales to be passed along to patients at the point of sale. As a patient adversely impacted by benefit managers, I can confidently say that these reform must remain a federal priority for the 118th Congress.

Washington state legislators are also prioritizing PBM accountability in Olympia. A cross-section of bipartisan legislators including Sens. Ann Rivers, Annette Cleveland, Patty Kuderer, and Manka Dhingra have introduced initiatives to address prior authorization restrictions for already-vulnerable populations, working to reduce the burden of cost-sharing requirements for patients at the pharmacy counter.

The time for reform is now: No one should have to worry about a third party inserting itself in a relationship between a doctor and a patient. As they exist today, pharmacy benefit managers do very real harm to patients. These middlemen must be accountable for time and money lost at the pharmacy counter and the detrimental impacts they visit on patients through non-medical switching.

Raymond Miller is a United States Air Force and Vietnam veteran. A Marysville resident, he is the president and Founder of Vets Place Northwest-Welcome Home and works with veterans to help them secure their benefits.