1. Opinion

How pharmacy benefit managers dictate care | Column

These middle men too often intrude in the decision-making between doctors and patients, a St. Petersburg oncologist writes.

When patients are battling a life-threatening disease like cancer, they want a skilled and qualified physician advising them about treatment plans and the best way to beat this insidious disease. But that’s not always what they get. Sometimes, predatory middlemen called pharmacy benefit managers insert themselves into the decision-making process between the doctor and patient.

As just one example, our team was working with a patient who had metastatic kidney cancer. Both the medical oncologist and urologic surgeon determined that the patient was not a candidate for surgery because of the patient’s other health conditions and the extremely low probability of a cure or any benefit. His doctors instead recommended a specific standard medication approved by the Food and Drug Administration for this condition. However, when the prescription was submitted, the PBM – who is not a physician – denied the request for the specialty medicine and insisted on surgery. The PBM made a medical decision. The appeals process in such a case can take weeks or months, and that’s simply too much time for many cancer patients to wait.

Dr. Michael Diaz [ DR. MICHAEL DIAZ ]

As a medical oncologist, I’ve treated thousands of patients. Unfortunately, I see these situations happen all too frequently. PBMs routinely may delay, deny and obstruct care. This needs to stop.

In another heart-wrenching case, a patient was diagnosed with a rare form of cancer. The physician prescribed an oral chemotherapy medication, a treatment that has been used successfully for several years. However, the PBM would only approve the use of one specialty pharmacy, then deny the claim and insist that the prescription be sent to a different specialty pharmacy. After weeks of going back and forth and dealing with paperwork, and submitting the claim to three different pharmacies, the prescription was finally approved. By then the disease had progressed to the point where he was no longer a candidate for chemotherapy.

While cancer patients are often among the most victimized by predatory PBM policies, the reality is that this broken system affects all Floridians by driving up health care costs for everyone. The mindset of PBMs leads to record-breaking profits but leaves patients in the dust. They direct patients to use the drugs and pharmacies that lead to the largest margins for the PBMs – even if it negatively affects those patients.

Similarly, as a tactic to delay treatments, they require a “fail first” process that often forces patients to use – and fail with – less effective medicines before they can move on to the treatments their physician recommended to begin with.

The bottom line is that it’s the patients and their physicians who should be making these life-altering and potentially life-saving medical decisions – not PBMs.

During the upcoming legislative session, state lawmakers must carefully consider reforms to increase accountability and remove PBMs from the patient decision-making process, particularly for those patients who simply don’t have the time for bureaucratic delays and unnecessary hurdles. These policies are decreasing access to care, can detrimentally impact patients and are increasing costs for Floridians – and it must stop.

Dr. Michael Diaz serves as director of patient advocacy for the Florida Society of Clinical Oncology and is a medical oncologist at Florida Cancer Specialists in St. Petersburg.