In a Golden Age of Cancer Care, PBMs Are Holding Us Back

*Patient name has been changed

We’re living in a remarkable time for cancer treatment, when a diagnosis no longer disrupts how patients live and work. Unlike years ago, an advanced cancer diagnosis is no longer a death sentence for many. Today, most patients diagnosed with cancer can treat it as a chronic disease, much like hypertension and diabetes. Patients undergoing cancer treatment can go to work, pick their children up from soccer practice, and eat dinner with their families.

This is largely due to oral cancer drugs, which allow many cancer patients to maintain a normal routine and quality of life. These treatments are rapidly on the rise: today, oral cancer drugs account for 25-35% of cancer therapies in development, a number that is projected to grow to 60% in the next few years.

As pharmacy benefit managers (PBMs) have become vertically integrated — with just three organizations dominating 80% of the prescription drug marketplace — cancer patients receiving oral treatment are increasingly forced to endure PBMs’ excessive approval processes and are directed to PBM-owned mail order or specialty pharmacies that refill drugs. These companies, many of whom are owned by or own the largest health insurers, want to control what treatment patients get and how, when, and where they receive it.

As a breast cancer specialist, I’ve witnessed how these middlemen insert themselves between patients and doctors through an opaque system of authorizations, barriers, and fees that delay patients’ access to life-saving treatment.

Last October, I saw my patient Tania*, a 40-year-old woman with metastatic breast cancer that had metastasized to her brain. I recommended that we utilize the oral cancer drug abemaciclib (Verzenio) due to its unique ability to help treat brain metastasis, which many cancer therapies do not treat. After going through her insurance company and PBM for authorization, the pills were denied. I quickly appealed, but the PBM informed us it would take 6 weeks just to be granted a peer review.

During this time, I watched as Tania’s cancer continued to metastasize, and she was soon forced to resort to traditional chemotherapy — a less effective, higher-toxicity treatment plan. Tania had to stop working and even developed two new brain metastases. While I don’t know for certain that Tania would have been better off with abemaciclib, peer-reviewed literature demonstrates that she would have doubled her chances of living without cancer progression and would have experienced less toxicity in comparison with traditional chemotherapy.

My experience with Tania underscores a harsh reality: rather than assist in cancer care coordination, PBMs often cause disjointed, delayed, confusing, and inferior care.

That was just one frustrating example. Let’s examine another.

Doctors frequently modify treatment doses to optimize therapy and control toxicity, sometimes just 1 to 2 weeks after starting treatment. These types of unplanned adjustments are easy to navigate in office-based, medically-integrated pharmacies that serve as a “one-stop shop” for oral cancer therapies, as oncologists can evaluate the patient, check their labs, and make dose modifications prior to the refill.

Yet, PBMs often use their ever-increasing market size and power to divert cancer drugs away from physician dispensing pharmacies. The result is that patients are steered away from the dispensing pharmacy at their community oncology clinic and forced to use PBM-mandated specialty or mail order pharmacies; this may result in delays in prescription delivery, mix-ups, and bureaucratic red tape throughout. By virtually eliminating competition from physician dispensing, PBMs are capturing the prescription drug market — with seemingly little regard for patient care.

PBMs may tell us that this bureaucratic arrangement is a cost-saving measure. Yet, we see no evidence that PBM involvement translates to patient or employer savings. In fact, premiums and out-of-pocket costs continue to rise. The average premium for family coverage in an employer-sponsored plan has increased 47% over the past decade, while patients’ out-of-pocket spending on prescription drugs climbed from 23.8% in 2013 to 25.1% in 2019 (spending fell in 2020, but this was likely due to the pandemic). Further, these abusive practices are used to allow PBMs to control the practice of medicine by removing treatment decisions from providers’ hands.

Thankfully, bipartisan congressional efforts are shining the light of transparency on PBM behavior. In fact, PBM reform is so popular that Sen. Bill Cassidy, MD (R.-La.) and Sen. Bernie Sanders (I.-Vt.) — ideological opposites on many issues — are working across the aisle to pass the Pharmacy Benefit Manager Reform Act (S. 1339), which would ban PBMs’ use of certain predatory tactics, including spread pricing and claw back fees. With widespread bipartisan support, now is the time to add more oversight and transparency to these middlemen.

Cancer and other diseases know no political divide. It’s long past time that we stop PBMs’ destructive behaviors to ensure patients can fully realize the benefits of modern cancer therapies.

Debra Patt, MD, PhD, MBA, is an oncologist specializing in breast cancer in Austin, Texas. She serves in the leadership of Texas Oncology, a large independent community oncology practice that is part of the US Oncology Network, and as vice president of the Community Oncology Alliance.