Louisiana patients rely on Congress to clear pharmacy middlemen who block access to care

Prescription drugs behind the counter of a pharmacy in Edmonds, Washington. (Getty Images)

With more than 2.9 million Louisiana patients living with at least one chronic illness, access to a prescribed treatment plan is essential to manage symptoms. However, middlemen, known as pharmacy benefit managers (PBMs), are making it harder for Louisiana patients to get the care they need by raising costs and creating unnecessary medication access barriers for patients and providers. 

As CEO of Pontchartrain Cancer Center, I’ve witnessed firsthand the real-life consequences that Louisiana patients and their families can experience when they are unable access the treatments they need as a result of PBM practices.

PBMs work between health insurance companies to negotiate medication discounts on behalf of the health plans they represent. These middlemen have an outsized impact on how much treatments can cost at the pharmacy counter with little transparency and oversight – just three PBM companies control nearly 80% of the entire prescription drug market. 

Based on negotiated pricing and rebates, PBMs can dictate which drugs appear on the list of prescription drugs covered by a health insurance plan, what the out-of-pocket costs are for each, and what patients and providers must do to gain access to medications. Additionally, PBMs are not required to be transparent about the rebates they acquire, leaving patients to continue paying higher out-of-pocket costs for critical treatments. 

 As a result, PBMs have become one of the most influential stakeholders in the health care industry, dictating which medications a patient can access without a medical license or experience in prescribing medicine. 

After a two-year investigation, the Federal Trade Commission recently found that PBMs can significantly influence what drugs are available to patients and at what cost, while racking up profits for themselves.

 While PBMs are putting necessary care out of reach for patients, chronic illnesses continue to disproportionately impact our state. Louisiana has higher rates of cancer than the national average, nearly 15% of Louisianians are living with diabetes, and seven of the 10 leading causes of death in Louisiana are chronic illnesses. 

Treatment of these conditions requires consistent medications to manage symptoms. But when a patient’s out-of-pocket costs become too high, a patient is more likely to abandon their treatment plan, which can lead to even higher costs down the line, such as emergency room visits or even more severe medical complications. 

For cancer patients who must adjust to managing their illness, PBM practices put undue stress on the patient and their family as they have to consistently navigate hurdles that PBMs institute.

 It’s long overdue for PBMs to be held accountable – their business practices are contributing to higher costs for consumers, new barriers for providers and are putting additional strains on our health care system. Under the current PBM business model, a PBM’s revenue is directly tied to drug’s list price, meaning pharmacy middlemen are directly motivated to increase health care costs for Louisiana patients. On average, for every $1 in negotiated savings, medication list prices increase by $1.17, according to University of Southern California research.

Requiring PBMs to share savings they receive from medication cost negotiations with patients and de-linking PBM compensation from the list price of a medicine would bring patients immediate relief from high costs they’re being confronted with at the pharmacy counter. Louisianians and patients across the nation are relying on their legislators to address high health care costs and middlemen in the health industry, with 78% believing that insurance plans should be required to share negotiated savings with patients and 75% favoring increased transparency over PBM practices, based on a National Association of Community Pharmacists poll

I’ve witnessed the strain PBMs are putting on patients, families, and our health system here in Louisiana. PBM reform already has strong bipartisan support, and members of Congress must heed the concerns of patients, providers and stakeholders across the country by prioritizing efforts to increase transparency and oversight of PBMs.

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