Question of the Week — Should Pharmacy Benefit Managers (PBMs) be allowed to deny patients access to essential life-saving drugs prescribed by their doctor?
As described in a recent article in The Fresno Bee, thousands of patients nation-wide have been denied access to essential life-saving medications by pharmacy benefit managers (PBMs) under the guise of ensuring that patients receive the most appropriate and cost-effective treatment.
PBMs are the quintessential “middlemen” in the healthcare system, standing between patients and their physicians on one side, and insurers and drug companies on the other. They were originally intended to help advocate for the interests of patients and reduce drug costs. But recent evidence strongly suggests that PBMs have had the opposite effect. Large health insurers and pharmacy companies now own and control the largest PBMs. For example, CVS Health owns Aetna, which controls CVS Caremark; Cigna owns Express Scripts; and UnitedHealth Group owns Optum Rx. Consequently, PBMs now create drug formularies for particular insurance companies—the PBMs’ own parent corporations—which have a financial interest in delaying or denying care to the sickest patients.
PBMs also receive “sweetheart deals” from drug manufacturers in the form of rebate agreements. These rebates are sometimes pocketed by the PBMs and their parent corporations, and not passed along to patients. Moreover, the financial incentives inherent in rebate agreements influence PBM and health insurer drug treatment approvals. Patients and the physicians who care for them suffer the consequences. Instead of receiving the drug that is the best treatment in the opinion of the patient’s treating physician, patients receive the drug that will generate the most rebates—and highest profits—for the PBM and drug company. Several bills are pending in Congress to curtail the conflicts-of-interest inherent in the PBM industry. Unfortunately, even if enacted, these legislative steps may come too late for many patients.
Whistleblowers within PBMs, pharmacies, health insurers, and/or drug manufacturers with knowledge of kickback or other illegal arrangements between these healthcare entities can greatly assist patients and physicians, and protect government healthcare programs like Medicare and Medicaid, by filing a complaint under the False Claims Act. If you are a whistleblower with such information, please contact us.