How PBMs Are Undermining Physician Autonomy and Patient Care
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Pharmacy Benefit Managers (PBMs) significantly impact physicians’ decisions regarding patient care, often to the detriment of both. According to a recent report from the House Committee on Oversight and Accountability, PBMs play a major role in driving up drug costs and getting involved in patient care for their own financial benefit. This is especially concerning for physicians, as they often find that their treatment decisions are undermined by the formulary preferences of PBMs, leading to delays in treatment and increased administrative burdens.
For example, when PBMs mandate the use of specific biosimilars, physicians often face hurdles in obtaining prior authorizations, delaying crucial treatments for patients like Savannah, a case study patient with ulcerative colitis. The report highlights that PBMs’ complex and opaque practices, including spread pricing and inadequate reimbursement for essential drugs, threaten the financial viability of medical practices, especially those providing infusion services. This forces practices to choose between absorbing financial losses or directing patients to specialty pharmacies, further delaying care.
The House Committee’s findings underscore the need for significant reforms to ensure that PBMs do not continue to place profits over patient care, allowing physicians to make treatment decisions based on medical necessity rather than cost considerations. The goal is to restore the focus on patient well-being and the physician-patient relationship, which is increasingly compromised and strained by the current system.
PBMs Are Stacking the Deck Against Patients and Independent Physician Practices (Cohen, M.D, MedPage, 8/11).
The Role of Pharmacy Benefits Managers in Prescription Drug Markets (A report from the House Committee on Oversight and Accountability, 7/23).
