Middlemen drive up patient drug costs

Insurers use pharmacy benefits managers to tilt playing field

AS LEADERS OF organizations dealing with two of the most difficult chronic conditions to treat – hemophilia and HIV/AIDS – we consistently hear stories about how patients living with these diseases are given the run around by insurers to obtain affordable access to the medications they need to manage their diseases.

It’s an uphill battle; patients are either getting straight out denials, or their insurance company is charging them far more than they bargained for when signing up for coverage. These are some of the same issues legislators currently face as they try to bring new reforms to a bulging health care system in Massachusetts.

Rich Pezzillo

We knew the anecdotes, but we wanted to know more – to hear directly from Massachusetts residents about the issues they face each day at the pharmacy counter. So, we went straight to the source and conduced a poll of nearly 400 of our neighbors.

Here’s what we found:

  • 1 in 5 have seen themselves or a family member denied a prescription;
  • 20 percent have been required to try a medication their insurer dictates, before the medication the doctor ordered will be covered;
  • 62 percent have seen a jump in the cost of co-pays. Only 25 percent of that group had advance notice that their costs would go up;
  • Nearly 63 percent have been surprised by the cost of a hospital bill, despite having insurance.

We know that a patient’s adherence to their medication goes down as insurers put new barriers up. The insurers know it, too. So, it often feels like they do all they can to stop you from picking up that prescription, from casting doubt that what your doctor prescribes is what you really need, if maybe you can skip a dose, so that you can pay that other bill – that’s how they win the game, the game that they are playing with people’s health.

Carl Sciortino

Think about it: Have you ever stood at the pharmacy counter in disbelief at the cost of your co-pay? Or been behind someone in line who had to make a decision whether to foot the bill or leave their prescription on the counter? It’s far too common a scenario that most of us have experienced.

But despite that shared experience, it seems that many of us don’t know about what’s driving that sticker shock. The answer in many cases? Pharmacy benefit managers, or PBMs.

In the same poll we conducted, 75 percent of those asked hadn’t heard of PBMs. So, let’s clear that up. PBMs are middlemen hired by insurance companies to negotiate what drugs will be covered by your insurer and how much you should pay for them.

Seemingly innocuous paper pushers, right? Well, not now. In recent years, these businesses have started to turn huge profits, as they find ways to manipulate the system, and patients to hike their bottom line. And they’ve done so under the radar until very recently, so it’s not surprising that 58 percent polled weren’t aware that the PBMs often increase out-of-pocket costs for consumers by setting higher co-pays.

For them, it’s a numbers game. For many residents, it’s much more than that. It’s the difference between being healthy and being sick. From being able to get out of bed or being too weak to move.

Because despite the fact that Massachusetts consumers are playing by the rules, paying premiums, trying to stay healthy, the insurers and PBMs are re-writing and breaking the rules. And that’s how Massachusetts ends up with more of a healthcare burden.

But here’s what we can do about it. Groups such as ours are fighting for our patients and all Massachusetts residents. These poll participants aren’t part of our organizations, who we know are fighting disease and have significant medical costs. This could be anyone.

We’re calling on lawmakers to add common sense protections as they try to tackle health care reform this summer. Put a safety net in place to keep patients from being forced to try and fail on medications. Protect the sanctity of the doctor-patient relationship. Put patients first and make these Pharmacy Benefit Managers be upfront about how and why we pay what we pay at the pharmacy.

Maybe you were one of the 400 we heard from, or maybe you weren’t. Either way, the time is now to make your voice heard so Massachusetts can fix its insurance problem for the patients who need it.

Meet the Author
Meet the Author
Rich Pezzillo is executive director of the New England Hemophilia Association. Carl M. Sciortino is executive director of the AIDS Action Committee of Massachusetts.