Many of the patients I treat as a registered nurse working in home healthcare have either been recently discharged from the hospital or need ongoing medical care.  All are homebound due to mobility limitations, their age, or their specific conditions. Often, they face higher healthcare costs than your typical patient and may require ongoing access to one, if not multiple, prescription medications.

For these vulnerable patients, the restrictions and profit-driven policies that insurers and their pharmacy benefit managers (PBMs) use to control prescription drug access have a particularly damaging impact. Congress needs to help reform PBMs to strengthen patient access and reduce the high prescription costs that can make it more difficult for many patients to receive the medications and treatments their doctor prescribes. 

Far too often, I’ve watched my patients navigate overly restrictive PBM policies designed to help these insurer-owned groups increase profits at the expense of timely access to care. PBMs’ harmful policies can force patients to try different drugs other than the one they were prescribed and essentially prove that they do not work before finally being approved for the specific medication they need.

In a best-case scenario, these practices create more work and an additional layer of frustration for patients, especially those who rely on home healthcare services. Many of these people already have enough trouble accessing pharmacies and need assistance picking up their prescriptions. Having to do so multiple times because PBMs would rather cut costs by forcing patients to jump through hoops than cover the treatment they need, is just another unnecessary barrier to care.

However, their practices can have even more harmful outcomes, particularly for patients battling a range of chronic diseases or conditions. Not only do patients forced to go through these arcane protocols face an increased risk of side effects, but by delaying access to more effective treatments, they may even face further disease progression. This should go without saying, but patients’ health and well-being should come before PBM profits.

It’s bad enough that PBMs are undermining access to care at the pharmacy; however, PBM abuse doesn’t end with these practices. Behind the scenes, these healthcare middlemen are abusing their role as intermediaries between insurers, drug manufacturers, and pharmacies to profit from prescription drug savings that could help reduce the cost burden for patients.

During their formulary negotiations with drug manufacturers, PBMs often collect significant prescription drug rebates and other discounts that could—and should—be passed down to patients at the pharmacy to help ease their out-of-pocket expenses. However, because they operate with such little transparency and accountability, PBMs will often share just a tiny portion of these savings with patients and use the rest to increase their already high profits. 

As a result, millions of patients are paying more out of their own pockets just to help keep PBMs as profitable as possible. That is especially hard for patients who are no longer able to work and live on a fixed income, which includes many of the home healthcare patients I treat.

PBMs should not be able to get away with most of the things they do to restrict patient access and inflate prescription drug costs in the name of higher profits. Lawmakers in Congress should work together to pass PBM reform that addresses unfair PBM policies and provides patients with more of the prescription medication cost savings they need.