Sponsored Insight
When you’re sick, you should be battling your illness — not battling insurance companies and their PBMs.
Three insurance company PBMs control 80% of patients’ medicines, and they act like it. They use their market power to get tens of billions in rebates and discounts on medicine — rebates and discounts that should be going to you.
Middlemen decide what medicines are covered, what medicines aren’t and what you pay for it. Regardless of what your doctor prescribed.
Which leaves you fighting them for your medicines, instead of fighting your illness.
Due to negotiations in the market, in 2021 the prices health plans paid for brand medicines increased by an average of just 1.0%.
But it often doesn’t feel that way for patients because insurers and pharmacy benefit managers have increasingly shifted more health care costs to patients through high deductibles and coinsurance. For services like hospital stays and doctor visits, health plans routinely share the negotiated prices they receive with patients. When it comes to life saving medicines, that often not the case.
In fact, half of commercially insured patient spending on brand medicines is based on the undiscounted list price of a medicine rather than the negotiated net price health plans receive. And commercially insured patients with a deductible have seen their out-of-pocket costs for brand medicines increase 50% since 2014.
Patient assistance programs offered by biopharmaceutical companies can provide a valuable source of support for many commercially insured patients to afford out-of-pocket costs associated with insurance coverage for their medicines. But health insurers and pharmacy benefit managers are using harmful tactics, like accumulator and maximizer programs, to deny patients the benefit of this assistance at the pharmacy.
Middlemen also restrict access to medicines.
In 2022, the three largest PBMs excluded more than 1,150 medicines from their standard commercial insurance formularies. This represents a nearly 1,000% increase in excluded medicines since 2014 and includes medicines that would provide patients needed treatments at lower costs.
Finally, middlemen use utilization management tools, like requiring prior authorization or failing first on other therapies.
This can create significant barriers between patients and the medicines their doctors prescribe. Patients with some of the most serious chronic diseases – autoimmune diseases, allergies and diabetes — and patients from communities of color are more likely to report experiences with these health plan barriers than other Americans who take prescription medicines.
While health care providers like doctors and nurses are there for patients at pivotal moments, hospital administrators often take advantage of the system to pad their bottom lines at the expense of patients. In fact, hospitals are the largest share of health care spending in the United States and are a leading driver of higher costs and premiums for patients across the country.
Voters overwhelmingly support solutions that would help rein in insurers and their PBMs.
An Ipsos survey of over 5,000 insured Americans found that people favor solutions that improve insurance coverage. Fully one-third (33%) rank reducing the burden of deductibles by requiring insurance plans to cover more products and services before a deductible is met among their top two solutions, making it the top desired solution overall. Additionally, 90% of insured Americans want more predictability in their out-of-pocket costs so that they know how much they will pay for things like prescription drugs every month. And 58% of insured Americans would be willing to pay more in premiums if it meant better coverage.
To fix our health care system, we need a robust discussion about the barriers patients face to accessing their medicines and the drivers of health care spending.
Learn more at PhRMA.org/middlemen.