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Congress Must Reform Insurer PBM Practices that Hurt Patients

The Delinking Revenue from Unfair Gouging (DRUG) Act in the Senate would help hold PBMs more accountable and protect patients from the high out-of-pocket costs

By Billy Avelo, September 15, 2023 1:18 pm

Last year Congress passed a bill to allow Medicare to negotiate putting price caps and certain pharmaceutical drugs. While this action may sound like a good idea, there will be unintended consequences for millions of Americans like me who rely on the innovation in the pharmaceutical sector to stay alive.

I have a long history of health issues that have led to extraordinarily high out-of-pocket medical costs. That is why Congress does need to do something to help save patients money at the pharmacy counter. My experiences have also led me to believe our country should be doing more to develop new, more effective treatments for a range of conditions and diseases—preferably without the devastating side effects that I have had to endure over the past several years.

Since September is Cholesterol Awareness Month, I thought my story may help others.  

I have genetically high cholesterol. Despite being in relatively good shape, my high cholesterol led to two heart attacks in 2008 and 2011, at which point I had triple bypass surgery. Not six months after my second heart attack, I was rushed to the hospital as two of three stints had already closed. And on top of all that, I’ve now survived three strokes!

As one can imagine, the medical bills that come with all these conditions have not been easy to manage. Moreover, to help treat my high cholesterol and other conditions, I’ve been prescribed numerous medications that add up to exorbitantly high out-of-pocket costs at the pharmacy. And it certainly didn’t help when I developed severe tinnitus as a result of some of the medications I have to take.

To make matters worse, after being hospitalized for COVID-19 in January 2021, doctors discovered that all of my existing medical issues have led me to develop type 2 diabetes. Now, I must give myself daily insulin shots and take additional medications to control my high blood sugar. Of course, this just adds to the already astronomical out-of-pocket costs of my prescription medications.

I realize lawmakers in Congress can’t do anything to improve my health, but there are things they can do to encourage medical innovation that will help scientists develop more effective treatments for high cholesterol, tinnitus, and diabetes with fewer adverse side effects. There’s also plenty Congress can do to help ease the burden that high out-of-pocket pharmaceutical costs create for patients who rely on prescription drugs to live.  

First, lawmakers in Washington should oppose prescription price-setting policies. While this sound like a good way to control costs, price setting could unintentionally limit access to certain prescription drugs. Even more concerning is the impact these policies can have on innovation. Price setting could restrict the resources  researchers need to keep discovering, developing, and bringing to market life-saving drugs, therapies, and cures.

Second, to help reduce costs while preserving drug innovation, Congress should reform Pharmacy Benefit Managers (PBMs).  Their unfair practices boost their profits while decreasing access and driving up out-of-pocket costs for patients. These little-known but hugely influential groups control 80% of the prescriptions on the market and use that power to dictate exactly when and where patients can access the medications they need.

PBMs can force patient-threatening policies like prior authorization, which can lead to lengthy delays in access to care that can worsen patient outcomes. These insurer-owned groups will also use patient “steering” practices to ensure patients can only pick up their medications at pharmacies they own or with which they are affiliated. All of this cuts costs and boosts profits for PBMs, but at the cost of patient affordability and access.

Fortunately, Congress is considering legislation that could help rein in and reform the abusive tactics and profit-driven practices PBMs use to put profits first and patients last. The Delinking Revenue from Unfair Gouging (DRUG) Act in the Senate would help hold PBMs more accountable and protect patients from the high out-of-pocket costs that can put their vital prescription medications just out of reach. For the good of patients in Nevada and across the country, Congress should pass this much-needed legislation.


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Billy Avelo
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