It is Time for Policymakers to Protect Patients from Predatory Practices of Insurers and PBMs

It is Time for Policymakers to Protect Patients from Predatory Practices of Insurers and PBMs

Policymakers often talk about protecting patients against the predatory practices of insurers and PBMs. It is about time for state and federal legislators to support such legislations to ensure that ONLY patients benefit from such patient assistance programs and to stop PBM and insurers from profiteering on the backs of patients.

The following is a snippet of a 1/15/23 article written by Dr. Robert Popovian (American Council on Science and Health advisor) and Louis Tharp for Healthcare Business Today,

Although per capita patient out-of-pocket (OOP) spending on prescription medications has dropped, averages are deceiving. In the U.S., a modest percentage of patients are burdened with unsustainable OOP biopharmaceutical spending. These are the patients who depend on brand-name medicines that have no generic or biosimilar equivalents. The primary contributor to the OOP burden is the changing of pharmaceutical benefit design. Such evolution from fixed-cost co-payments to percentage-based coinsurance and the expansion of high-deductible plans has dramatically increased the OOP share of drug costs paid by those patients. 

In addition, pharmacy benefit management companies (PBMs) and insurers have devised a payment model in which patients do not directly benefit from multi-billion-dollar concessions, rebates, and fees collected by PBMs and insurers from biopharmaceutical companies. In contrast to physician or dentist visits, where a patient’s coinsurance or deductible is based on lower prices negotiated by the insurer, patients’ shares of medication costs are based on the inflated list price. Subsequently, biopharmaceuticals are the only segment of the health system in which patients do not realize the benefit of lower prices negotiated on their behalf.

Over the past several years, biopharmaceutical companies have offered assistance to eligible patients to help offset OOP costs. The monetary value of these manufacturers’ patient assistance programs (PAPs) places the pharmaceutical companies among some of the largest U.S. charities. To devalue PAPs, PBMs and insurers have instituted accumulator and maximizer programs. These initiatives prohibit the patient assistance funds provided through pharmaceutical companies from counting toward the insured individual’s deductible or maximum OOP spending. Consequently, accumulator and maximizer programs force patients to double-pay. The insurer and PBM collect the patient assistance funds provided by the biopharmaceutical industry meant for the patient, while patients must continue making OOP payments until they meet their maximum requirements. Simply put, PBMs and insurers increase profitability on the backs of patients.

2 Responses

  1. Its changing and not for the better.,as the person stated above.Its almost like the insurance company for profit are dictating what we can and cannot have,,obviously,,,,and not based on the medical needs of the patient,,hell ,”let em die off,”’Wasn’t it here,Steve said there are literally nazi death squads now, dictating who lives and dies based upon insurers???When my primary and i were fighting for a MRA,, for the thoracic spine,since blood thinner made my physical pain worse back there,,she put it threw and Head of radiology denied it,,Then she came back w/this ,”they” might let u get one of the gastro,,but i don’t need one on the gastro,i reponded,,,who the hell are these ,”theys”,,she wouldn’t answer,,,are these theys,the same ones who forcible put a shrink in ,”meeting,” on patient,u never agreed to??With the forced combining of mental/medical via Kaiser permante??Are thee insurance ,”stake holders,”the theys??maryw

  2. Speaking of insurers….I had the most bizarre phone call from my health insurance company last week. I’m on my state’s version of Medicare, & have been trying for over a year to get from them the name of a dentist or oral surgeon that’s in network. I’ve gotten dozens* of names from their website & over the phone, & NOT ONE was actually in network. One guy left practice 10 years ago. I called a few weeks ago to ask why they were incapable of providing accurate information about what providers were in their own network: they basically said, “it’s not our problem, keep calling the names on the site or the ones we give you” (the names that never, ever were in network, in other words).

    Then they called me last week, told me they’d investigated my complaint & found that it had no basis(!). Then they told me that they had decided not to punish me for registering the complaint (I swear I’m not making this up). I rephrased their message about 4 times, sure that I was seriously misunderstanding something. Nope: they’d called to let me know that they were so generous that they weren’t going to kick me off their insurance for complaining that they were utterly incapable of providing accurate information.

    I’ve never wished more in my life that I’d recorded a phone call. It was, without a doubt, the most insane, surreal conversation I’ve ever had in my life.

    *I quite counting at 48

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