Peter Mihalick: Congress Can Stop Pharmacy Benefit Managers From Manipulating Patients

Millions This is Americans Prescription medications are often used to treat their ailments. According Polling was done by the Kaiser Family FoundationAbout sixty percent of adults report that they take at least one prescription medication. A quarter of them take four or more prescription medications. MeanwhilePharmacy benefit managers (PBMs), which are responsible for managing the health of pharmacy patients, are making it easier for them to do so. Americans At risk from schemes to divert copay assistance money from patients and a lack thereof.

Spending Health care spending is on the rise. The Hill Report on December 15, 2022, “U.S. spending on health care grew by 2.7 percent to reach a total of $4.3 trillion in 2021, or around $12,900 per person, according to new figures from the Centers for Medicare & Medicaid Services (CMS).” That The 2020 report shows that the same costs went up by 10.3 percentage. Any Activities that increase the cost of healthcare are costly because the cost of care is rising at a faster pace than inflation.

Pharmacy Benefit managers are middlemen, which is unique to the United States – These are the ones who negotiate the terms between drug manufacturers and insurance companies for prescription drug coverage. Because they are compensated on complicated mechanisms like manufacturer rebates, PBMs have been able to monopolize the market for life-saving medications. This This means that PBMs are more likely to prioritize drugs with higher rebates in their coverage formularies than drugs with lower list prices. This would be more transparent and advantageous for the patient. Three PBMs – CVS, Express Scripts, and OptumRx – control 80% of the market.

Patients Copay assistance is often offered by drug manufacturers to help people pay their out-of-pocket expenses. This People with chronic diseases such as HIV, arthritis, multiple sclerosis and multiple sclerosis typically receive assistance to offset the high price of specialty medications and medications that are not generic. Copay Patients need assistance to ensure that they adhere to their doctor-prescribed medications.  Patient It is important to keep your positive outcome in mind.

However, in recent years, PBMs and the insurers have been attacking copay assistance – but only when it does not benefit their bottom line. Complex schemes set in place by PBMs, called copay adjustment programs, prohibit copay assistance from counting towards a patient’s deductible or out-of-pocket maximum, even when the insurer or PBM keeps the money. These schemes threaten patients’ access and adherence to medications and place an unaffordable out-of-pocket financial burden on patients.

According To polling done by Kaiser Family Foundation, roughly 30% of people haven’t taken their medicine as prescribed due to costs. And It only gets worse when out-of-pocket expenses rise. According To a study IQVIA found that 61% commercially insured patients refused to fill their prescriptions if their out of pocket costs exceeded $250.

The Companies that use copay adjustment programs are often not seen by policymakers or patients. This allows them to avoid scrutiny. And Some go one step further. SaveOnSP is a partner of PBM Express ScriptsFor example, telemarketing is used to convince patients to sign up for copay assistance programs in order to receive their medication. Programs like this leave patients between a rock and a hard place: if they enroll, their prescriptions are covered, but the copays don’t count toward their annual deductible and out-of-pocket limit, leaving them exposed when they need other health care. If If they decide not to enroll, their specialty medication will not be covered by the insurance plan.

Some State legislators took action to protect vulnerable patients as well as to resist PBMs. In 15 states Puerto RicoCopay adjustment programs are now banned.  Using A recent Supreme Court Many states are now exploring other options to make prescription drugs less expensive and reduce the PBM industry’s reach.

AdditionallyLegislators Capitol Hill Patients are also important to us. The HELP Copays Act, H.R. H.R. 5801, bipartisan legislation to outlaw maximizer adjustment and copay accumulator systems, is likely be reintroduced in new Congress. 

In This is an example. Republicans Can seize the top spot in health care policy by taking a stand for PBMs and their policies. By Stand up for the vulnerable Americans And taking a stand against patient aid diversion programs Republicans Have the chance to show their commitment to ensuring that all are included Americans Access to the care they require and make a positive difference for patients across the country.

Peter Mihalick Former legislative director and counsel to the former Reps. Barbara Comstock, Virginia Republican, Rodney Blum, Iowa Republican.