In recent years, cancer treatment has undergone remarkable advancements, transforming what used to be a death sentence into a chronic illness for many patients. Thanks to the development of oral cancer drugs, individuals diagnosed with cancer can now lead normal lives while undergoing treatment. These drugs have become increasingly prevalent, accounting for 25-35% of cancer therapies in development and projected to reach 60% in the coming years. This progress has allowed patients to continue working, taking care of their families, and participating in daily activities without major disruptions.
The Rise of Pharmacy Benefit Managers
Unfortunately, the rise of pharmacy benefit managers (PBMs) has introduced new challenges in accessing cancer treatments. These PBMs, which now dominate 80% of the prescription drug marketplace, have established a vertical integration that gives them significant control over patients’ treatment options. Cancer patients undergoing oral treatment increasingly face excessive approval processes imposed by PBMs, who often direct them to PBM-owned mail order or specialty pharmacies for medication refills. This consolidation of power enables these companies, many of which are owned by or own large health insurers, to dictate the treatment patients receive and how, when, and where they receive it.
As a breast cancer specialist, I have witnessed firsthand the detrimental effects of these middlemen on patient care. The convoluted system of authorizations, barriers, and fees imposed by PBMs creates delays in accessing life-saving treatment. I recall the case of a patient named Tania*, a 40-year-old woman with metastatic breast cancer that had spread to her brain. Based on her specific condition, I recommended a unique oral cancer drug called abemaciclib (Verzenio) that has shown promise in treating brain metastasis. However, after going through the insurance company and PBM for authorization, her request was denied.
The Consequences of Delayed Treatment
The appeals process proved to be a time-consuming ordeal, and it would take six weeks just to undergo a peer review. As Tania waited, her cancer continued to progress, and she was eventually compelled to undergo traditional chemotherapy, which has lower efficacy and higher toxicity. The delay in accessing the preferred treatment had severe consequences. Tania was forced to stop working, and her condition worsened with the development of additional brain metastases. While we cannot say for certain if abemaciclib would have had a different outcome, scientific literature suggests that Tania would have had better chances of living without cancer progression and experienced fewer toxicities compared to traditional chemotherapy.
Tania’s case serves as a stark reminder that rather than facilitating cancer care coordination, PBMs often contribute to disjointed, delayed, confusing, and inferior care. This is just one of the many frustrating examples that highlight the negative impact of PBMs on patient outcomes. Another common challenge arises when treatment doses need to be adjusted to optimize therapy and control toxicity. In-office, medically-integrated pharmacies can readily accommodate these modifications, offering a seamless experience for patients. However, PBMs exert their influence to divert cancer drugs away from physician dispensing pharmacies towards PBM-mandated specialty or mail order pharmacies. This redirection leads to prescription delivery delays, potential mix-ups, and bureaucratic hurdles that impede patients’ access to timely treatment.
An Illusion of Cost Savings
PBMs may argue that their involvement is a cost-saving measure, but the evidence suggests otherwise. There is no clear indication that PBM practices result in savings for patients or employers. Premiums and out-of-pocket costs continue to rise, with family coverage premiums increasing by 47% over the past decade. Additionally, patients’ out-of-pocket spending on prescription drugs as a percentage of total spending has also increased. These practices not only fail to deliver cost savings, but they also grant PBMs undue control over the practice of medicine by undermining healthcare providers’ treatment decisions.
Acknowledging the destructive behaviors of PBMs, bipartisan congressional efforts have emerged to address the need for reform. The Pharmacy Benefit Manager Reform Act (S. 1339), sponsored by Senator Bill Cassidy and Senator Bernie Sanders, aims to ban certain predatory tactics employed by PBMs, including spread pricing and claw back fees. The broad bipartisan support for this legislation indicates a growing recognition of the detrimental effects of PBM practices on patient care. Now is the time to introduce more oversight and transparency to ensure that patients can fully benefit from the advancements in modern cancer therapies.
Cancer does not discriminate based on political beliefs, making it imperative to prioritize patient well-being over corporate interests. By shining a light on PBM behavior and advocating for reform, we can strive to create a healthcare system that prioritizes patient access to timely and effective cancer treatments. It is time to break free from the grasp of PBMs and ensure that cancer patients receive the care they deserve.
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