What You Don’t Know Can Hurt You
Patients are ultimately suffering the brunt of PBM misbehavior. “So many patients can’t afford the medicine they need,” says Dr. Worthing. “One problem is that their copay is based on the list price and not the rebated price—not on the final and lower price paid by the PBM after the kickbacks. The average patient has no idea why this is happening, and they are not sure how to contend with it.”
Going Forward
“Following a landmark decision by the U.S. Supreme Court, we have seen all 50 states pass some type of PBM reform,” says Mr. Cantrell. “Florida has a very strong PBM and drug pricing law that includes a manufacturer reporting requirement. If there is more than a 15% price increase in a calendar year or a 30% increase over three years, then they have to file a report.”
“I want Congress to pass meaningful PBM reform that could drastically reduce drug prices,” says Dr. Feldman. “We need to put an end to the days of a $10,000-a-month drug being preferred while the $350-a-month drug is excluded from the formulary. Patients will save a substantial amount of money if we can delink PBM compensation from the list price of the drug, taking away the incentive to choose higher priced drugs. This would allow formularies to be constructed on the doctor/patient relationship, safety, efficacy and lowest price—not highest kickback. Ideally, I would like all PBMs to be regulated as a public utility.”
“We absolutely must delink the price of the drug from the size of the rebate,” agrees Dr. Blumstein. “In addition, we will continue working on legislation mandating that the rebate savings are passed through to the healthcare system and/or to patients. Many states have legislation directing that a certain percentage of the rebate will be passed through. This is taking a long time, but the fact that we are getting so much attention means that people are beginning to know the behind-the-scenes dealings of the PBMs.”
“Although incremental, reform is moving well,” adds an optimistic Dr. Worthing. “ATAP is working closely with multiple patient groups, which is terrific because there are so many more patients than doctors! Rheumatologists and patients are linking arms, going to their state capitals and raising their voices.”
“There is truly strength in numbers,” says Dr. Feldman. “We are so grateful to have the ACR, the voice of rheumatology and various state organizations on board. Along with our patients, we are moving the needle on rectifying a million wrongs brought on by this corrupt system.”
