Access to medication is an issue for many Americans, even if they have commercial or government health insurance. Availability and affordability are affected by formulary restrictions and increasing patient cost-sharing based on list prices of drugs.
While pharmaceutical manufacturers obviously play a key role in this system, there is an entity that until recently has stayed under the radar—pharmacy benefit managers (PBMs)—that may be more important in getting the proper medicine to patients, according to Madelaine Feldman, MD, FACR, of The Rheumatology Group, New Orleans, LA, and President of the Coalition of State Rheumatology Organizations.
During a session from 9:00 – 10:00 am Tuesday in Room W178b, PBMs & Providers: Superior Patient Care Through Transparency, Dr. Feldman will discuss how PBMs interface with payers, providers, and manufacturers, and how PBMs impact drug pricing and patient access to medications.
“The rebate/price concession system controls the formulary and, in particular, the preferred list of specialty medications,” Dr. Feldman said. “It is this control of the formulary that gives PBMs the power to decide what drugs our patients have access to, where they can obtain the needed medications, and how much patients will pay for their medicines.”
This system, she said, leads to utilization management tools, such as step therapy and non-medical switching, that disrupt the doctor-patient relationship, incentivize higher list prices, and potentially stifle innovation.
“Education of patients, physicians, legislators, and regulators of how the drug supply channel works is the first step to reforming a system that interferes with the doctor-patient relationship, limits access to medications, and creates perverse incentives to increase list prices of medications,” Dr. Feldman said.
There are litigation and reform efforts at the state and federal level to create system transparency, she said, noting that the Department of Health and Human Services and the Food and Drug Administration are aware of the issues and are currently considering actions such as removing safe harbor for PBMs under the federal anti-kickback statute.
“It’s not clear how the recent decision of the Department of Justice to allow CVS Caremark to buy Aetna and Cigna to buy Express Scripts will affect the system, but it is feared that it will only serve to make a hazy system even more opaque,” Dr. Feldman said.
Also in this session, Brent Clough, co-Founder and CEO of Trio Health, La Jolla, CA, will talk about how his company is working to bring more transparency to the drug supply channel. Using a proprietary technology platform, Trio Health collects and analyzes retrospective observational data on patients to provide insight into how the various stakeholders—physicians, pharmacies, and payers—impact the performance of patients.
“Our US health care ecosystem comprises patients, pharmaceutical companies, payers, pharmacy benefit managers, physicians, and pharmacies that have competing interests in the realm of drug innovation, drug pricing, and access to care,” Clough said. “There is an obvious tension between drug companies that want to maximize drug profits to fund drug innovation, and payers that want to manage expenses, the latter by limiting access to care. Most often, it is the patient who loses when these competing forces are not in equilibrium.”