Patient Care Access News

How to Improve PBM Practices to Boost Patient Access to Care

ASCO published a set of recommendations for PBMs that would improve patient access to care and cancer treatment.

patient access to care

Source: Thinkstock

By Sara Heath

- Pharmacy benefit manager (PBM) companies need to retool their strategies to improve cancer patient access to care, according to a recent position paper published by the American Society of Clinical Oncology (ASCO).

The paper, published on August 31, asserted that many current PBM practices limit patient access to care and have many inefficiencies that can eventually increase out-of-pocket patient costs. Being that medication costs serve as some of the biggest expenditures in cancer care, this is a considerable issue, ASCO stated.

“Examples are emerging of PBM practices that may place patients at risk of life-threatening complications,” ASCO President Monica M. Bertagnolli, MD, FACS, FASCO, said in a statement. “There’s no doubt that the high cost of cancer care is a major burden on patients and the healthcare system, but efforts to address the problem shouldn’t come at the expense of quality patient care.”

A PBM is a third-party drug administrator. These companies, which include the likes of Express Scripts, OptumRX, and CVS Caremark, were initially created to quell drug costs and simplify the prescription filling process.

“PBMs were originally created to serve as third-party administrators of pharmacy claims, but now leverage their market power to obtain lower prices on drugs,” ASCO said in its paper. “Employers and other plan sponsors also use PBMs to outsource the complicated work of designing and maintaining formularies to those with more specialized expertise.”

READ MORE: Patient Groups Advocate Patient Access to Care in Drug Blueprint

But PBMs are no longer fulfilling those needs and may be presenting more issues than solutions, ASCO stated. Because of consolidated market power – the three biggest PBMs control 85 percent of the market – and other industry forces, PBMs are making it harder for some patients to receive their treatments. Cancer patients especially are feeling the burden of PBM practices.

“Although PBMs have the potential to generate cost savings for payers and plan sponsors, it is not clear those savings necessarily accrue to patients,” the paper explained. “Stakeholders have been challenged in achieving detailed understanding of this issue because of the proprietary and confidential environment in which PBMs operate.”

An analysis of general PBM practices revealed areas for improvement, ASCO said. For example, prescription filling errors can put patient outcomes in jeopardy, as well as create drug waste. Incomplete prescription filling can duplicate patient copays.

In some cases, PBMs alter treatment doses without consulting a patient’s provider, or create delays in care because of prior authorization requirements.

These issues stem from the numerous restrictions PBMs have, ASCO contended. “Gag clauses,” for example, bar pharmacists from notifying patients of less expensive drug options that could lower patient financial responsibility for their medications.

READ MORE: Drug Formulary Exclusion Lists Reduce Patient Access to Treatment

PBMs sometimes require patients to use mail-order services instead of a dispensing pharmacist. And “brown bagging” or “white bagging” mandates require oncologists to prescribe a chemotherapy drug that has not been prepared in their facility.

These protocols can hinder patient access to care, as well as patient outcomes, ASCO said.

ASCO recommended PBMs and payers ensure that changes to treatment for cancer patients only be made after sufficient consulting with a providing oncologist. The organization also suggested gag clauses be prohibited and that PBM Pharmacy and Therapeutics committees include pharmacists and providers.

The organization also called on CMS to regulate parts of PBM practices.

CMS should use its authority to require PBMs to give detailed accounts of remuneration fees and to “instruct contractors and PBMs to discontinue application of current Star performance ratings and related DIR claw backs on oncology dispensing physicians and practice-based pharmacies, instead relying on measures and standards that are more appropriate to the specialty,” ASCP said.

READ MORE: What Providers Should Know to Improve Patient Access to Healthcare

The agency should also enforce the “Any Willing Provider” provision of Medicare Part D, meaning PBMs must allow qualified, in-office oncologists to dispense medications. CMS may consider use of the JW modifier, a tool which ASCO said is used to determine drug waste stemming from incorrect prescribing. Data from the JW modifier should be made public.

Supporters of PBMs state that these companies save employers, payers, unions, and government programs billions of dollars in prescription drug spending. PBMs are also beneficial for standardizing drug prescribing, which is essential for patient safety, supporters say.

ASCO acknowledged those benefits, stating that PBMs do have an important role to play in healthcare. However, improvements are needed to perfect these company practices.

“Promoting delivery of high value care to every patient with cancer is central to ASCO’s mission,” the organization concluded. “ASCO understands and shares concerns about escalating costs and their impact on patients—and we have been actively engaged in addressing that issue. However, strategies for controlling cost must not compromise oncologists’ ability to provide the right care, at the right time, for all their cancer patients.”


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