Oncology patients at serious risk with Congress’ drug pricing plan

As Congress works to lower health care costs, we reach a critical point in our nation’s debate over what consumers must pay for prescription medicines. The current Senate budget reconciliation package is hyper-focused on bringing down drug prices. Unfortunately, the legislation is short-sighted, and ignores a key remedy that would help lower out-of-pocket costs for medicines. 

The reconciliation package does not include reforms for pharmacy benefit managers – or PBMs – something many lawmakers, including Ohio U.S. Sen. Sherrod Brown, have been working on in recent years. Sen. Brown and colleagues are working to apply the knowledge that has been uncovered in recent years about abusive PBM practices, to develop better public policies that will lower drug costs for patients. 

PBMs are a key part of the drug supply chain. Three PBM companies control more than 75% of the market and these companies continue to modify business practices in a manner that generates more revenue for them – rather than lowering patients’ out-of-pocket costs.

In 2018, The Columbus Dispatch started a deep dive into PBM practices. The Dispatch, Ohio Capital Journal and other news outlets continue to report on the ways PBMs drive up costs for large public payers such as Medicaid, engage in unfair and unpredictable reimbursement practices that put many independent pharmacists out of business, and increase out-of-pocket costs for patients.

Ohio news media investigations exposed the practice of “spread pricing” which revealed that PBMs took in around $225 million more from the state than pharmacies were reimbursed for their services to Ohioans using Medicaid benefits.

Oncology providers increasingly deal with a health plan practice called “white bagging,” which occurs when a plan requires patients to get their cancer medication from a mail order, or specialty pharmacy, owned by or affiliated with that plan’s PBM. This form of pharmacy steering can seriously disrupt patient care.

Patients who are forced to use a PBM mail order or specialty pharmacy must now wait for medicine to come from that source, rather than allowing the oncologist, who may have the needed drugs in stock and ready for use, to go ahead with immediate treatment. 

Oncology providers around the country can describe the extreme frustration, not just with the delay in patient care, but the drug waste that occurs because of white bagging policies.

The behavior of PBMs now has the attention of the Federal Trade Commission, whose members recently voted to launch an investigation into some PBM practices. Given this investigation, and the recent exposure in the news media and other pharmacy trade public policy analysts, officials at the state and federal level are much better informed about the role PBMs play in driving up drug costs. 

Congress should be doing everything possible to ensure that patients can afford their medications and receive treatment in a safe and timely manner. This requires a more thorough package that prioritizes policies such as copay caps for chronic conditions and reforms to PBM practices.

For oncologists and cancer practices around the country, who have been leading efforts to point out PBMs’ impact on patients fighting cancer – we expect better.