Most people have never heard of pharmacy benefit managers, the businesses that negotiate prescription drug coverage for health insurers. But they could play an outsized – and unwelcome – role in treatment decisions.
Just ask Allen Meadows, MD, an allergist in Montgomery, Alabama.
Asthma Inhalers’ Pricing Paradox
“Many doctors feel frustrated by medication switches that are forced upon patients by pharmacy benefit managers,” Dr. Meadows says. “The change is almost never in the patient’s best interest.”
Sometimes patients are forced to take a more powerful and expensive drug than necessary. Other times, patients are switched to a medication that is “equivalent,” except that one is more lucrative for the pharmacy benefit manager.
These companies make their money off of the rebates they negotiate with pharmaceutical companies. Higher-priced drugs yield higher-dollar rebates. So pharmacy benefit managers may design prescription drug coverage to drive patients to more expensive medications, even if they don’t need them.
Asthma offers a startling example. Powerful and expensive inhalers designed for the most severe cases can cost patients less out of pocket than the less expensive inhalers that are better suited to their milder symptoms. In some cases, pharmacy benefit managers push patients toward an inhaler that costs hundreds of dollars while blocking access to an alternative that costs a fraction of the price. The higher sticker price isn’t usually an issue because the pharmacy benefit managers negotiate for large rebates, which often lead to a lower out-of-pocket price for patients and a bigger profit for them.
The situation also complicates the physician-patient relationship. Health care providers usually have a clear idea of what’s best for the patient.
The Hidden Costs of Middlemen
Pharmacy benefit managers bill themselves as cost savers for the health care system. But these middlemen’s upside-down rebate schemes put doctors in the impossible position of choosing between their patients’ physical and financial well-being.
Protecting patient-centered care requires a return to treatment decisions that are made by health care providers and patients, not by profit-minded pharmacy benefit managers.