ICYMI: When middlemen get in the way, it’s the patients who lose

While the U.S. health care system continues to change in fundamental ways, patient concerns about accessing and affording their medicines remain. In fact, PhRMA’s recent Patient Experience Survey found that out-of-pocket costs are the top health care issue with 57% of Americans reporting that they worry about them.

I spoke with Elise Labott, adjunct professor at American University, at The Washington Post’s Global Women’s Summit during the segment, “No More Middlemen: Protecting Medicine Access and Affordability,” to unpack the role of middlemen in our health care system.

Middlemen have grown to play an outsized role in how patients access health care. Just 3 pharmacy benefit managers (PBMs) control 80% of the market. And increasingly, they are part of large integrated health care companies that own not just a PBM, but in some cases an insurer, pharmacies and physician practices.

Meanwhile, insurance companies and PBMs, not doctors, decide what medicines are covered and shape how much patients pay at the pharmacy counter. Importantly, PBMs make their money through rebates and fees that are predominantly tied to the list price of a medicine. And because in most cases PBMs do not pass along the net savings they negotiate with manufacturers to patients, people pay more.

Insurers and PBMs also rely on utilization management tools, like prior authorization and fail first requirements, which may prevent or delay access to medicines for patients. As the use of utilization management increases for treatment of some diseases, the burden of navigating these requirements falls disproportionately on women who make 80% of the health care decisions on behalf of their families.

Whether they are charging fees tied to the price of medicines or steering patients towards pharmacies that deliver higher profits, middlemen are using their power over the market to drive behavior that serves their interests, not patients.Reforms that would drive transparency and more patient-centric decision-making in the U.S. health care system are within reach. We need to address the role of PBMs.

Read more at PhRMA.org/Middlemen