Reduce red tape preventing access to medicines


A 6-year-old boy with asthma sees his doctor, who prescribes a daily inhaler. His grandmother picks him up from the pharmacy and learns that he is not covered by insurance and will cost her $300 a month, so she calls the doctor’s office for help. A nurse spends 45 minutes on the phone with an insurance company and 30 minutes filling out forms to obtain coverage for this necessary medication. Finally, after a few days, the insurance company grants coverage, but it is too late. The patient had to be hospitalized for a severe asthma attack.

I am that nurse. I work in a clinic at a large children’s hospital and this patient, and countless others like him, are all too familiar to me. They have health insurance. A trained provider prescribes them effective and well-researched medications. Yet these patients either cannot afford the drugs they need or cannot get them in time.

This situation is not inevitable. Rather, it is the result of a particularly pernicious aspect of our for-profit healthcare system: pharmacy benefit managers (PBMs). They administer prescription drug benefits on behalf of health insurance plans and prioritize profits over patient care.

The stated goal of PBMs is to control the cost of prescription drugs by negotiating with pharmaceutical companies and creating formularies – a list of acceptable and covered drugs – that prioritize the most clinically and economically effective drugs. for patient conditions. However, the reality that PBMs create for patients and the healthcare system achieves the opposite. Narrow PBM formularies often only include one or two options for a particular drug, limiting patient and provider autonomy.

Additionally, PBMs typically develop these formularies not by identifying which drugs have the greatest impact on patient outcomes, but rather based on the magnitude of cost reductions that PBMs negotiate with pharmaceutical companies. Rather than being able to use the drug chosen by their health care provider, patients are forced to accept a drug selected by a for-profit entity that knows nothing about their medical condition and personal circumstances.

To bypass the PBM formulary and get the drugs they need, patients and providers must go through a pre-authorization process. Prior authorizations involve submitting an explanation as to why a patient needs a particular medication instead of the one PBM has chosen for them.

Submissions require a phone call, fax, or use of a cumbersome online portal, and patients must wait days, sometimes weeks, for a response from a PBM. In many cases, PBMs require patients to have tried and lack therapy on their preferred medications before granting the medication that the patient and his provider have chosen.

Prior authorizations waste time and money: A recent survey of physicians found that providers and their staff spend an average of 13 hours a week filling them out instead of devoting that time to direct patient care. Almost all of them (93%) had patient care delayed by the prior authorization process. A third of providers say waiting for prior authorization resulted in a serious adverse event for their patients, just like this little boy with asthma whose lack of access to medication led to a medical emergency and hospital visit .

Meanwhile, PBMs’ use of formularies and split pricing—in which they charge payers or health plans more money for drugs than they pay pharmacies for those drugs—makes them record profits, which rose from $25 billion to $28 billion between 2017 and 2019. It is essential to protect patients by curbing the greedy practices of PBMs.

To do this, we need legislation that empowers the federal government to directly negotiate drug prices with pharmaceutical companies. This idea is hugely popular among Americans: A recent poll shows that 77% of Republicans, 89% of Independents and 96% of Democrats support the federal government negotiating lower drug prices.

Earlier this week, the Senate passed the Reducing Inflation Act, which allows the federal government to do so for the first time for a number of drugs under Medicare. This legislation is far from perfect and it does not go as far as it should to curb the profit motive that has nothing to do with health care, but it is a solid first step in the battle against pharmaceutical greed and PBM.

We must build on this momentum and encourage our legislative leaders to extend these rules to Medicaid and private insurance plans, and to continue to remove the red tape and financial barriers that prevent people from accessing the medicines they need. need. We cannot afford PBMs to waste our time and money when people’s health is at stake.

Lela Kanter, MSN, RN, CPN, is a registered nurse at Children’s National Hospital and a student nurse practitioner at the Catholic University of America.

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