As the costs of specialty drugs continue to rise and patient access to them becomes more challenging, physicians are increasingly called on to argue for treatments supported by medical evidence but difficult to access due to decisions outside their control. Medicine as big business is not new. However, the growing influence of pharmacy benefit managers (PBMs) highlights the clashing priorities between a profit-driven business model and a care-driven medical model.
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Explore This IssueAugust 2021
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Many PBM practices, including formulary construction, copay accumulators and non-medical switching, affect the cost of, and access to, specialty drugs and can have detrimental effects on patient care (see Table 1). Yet these decisions are made far from clinical settings, often without input from providers.
Rheumatologists are on the front lines of this conflict given the importance of specialty drugs, particularly biologic agents and biosimilars, in the treatment of rheumatic conditions and the administrative hoops providers have to jump through to prescribe these drugs for their patients.
“Rheumatologists understand very well that most of the medications we prescribe are going to be subject to prior authorization and step therapy,” says Angus Worthing, MD, a rheumatologist at Arthritis & Rheumatism Associates, Washington, D.C. “But I’m not sure everyone knows these things are mainly a profit scheme for PBMs and can increase the incentive to raise drug prices.”
Dr. Worthing serves as vice president of the Alliance for Transparent & Affordable Prescriptions, a coalition of providers and patients that works to address PBMs’ impact on drug costs and patient access to affordable care. Understanding how PBMs negotiate drug prices and formulary access is critical, he says, given the impact these negotiations have on downstream practices, such as prior authorization and step therapy.
Unlike physicians, whose professional oath and duty are to make decisions in their patients’ best interest, a PBM has a fiduciary duty to the corporation it works for: “The first rule for any corporation is to make money for its shareholders,” says Harry L. Gewanter, MD, FAAP, MACR, clinical associate professor of pediatrics, Children’s Hospital of Richmond, Virginia Commonwealth University. “No matter what PBMs or payers say, any care patients get is a secondary side effect.” Dr. Gewanter works closely with the Biologics Prescribers Collaborative, an organization that promotes the safe use of both originator and biosimilar biologic medications.
A major problem with PBMs and insurers is the lack of transparency in negotiations regarding which drugs are placed on a formulary and which tier the medication is on. Dr. Gewanter underscores that the list price, or wholesale acquisitions price, used for negotiations with PBMs does not accurately reflect the net cost to PBMs after price concessions they receive in the form of rebates and discounts or the cost patients see. “Unlike medical charges, where patient copays are based on the negotiated net price, patients’ pharmacy copays are based on the list price—[not the PBM’s negotiated cost],” he says.