Doug Flora: The influence of pharmacy benefit managers in cancer care harms the patient / physician relationship



Quality, innovative and individualized care is essential to overcome a cancer diagnosis. As an oncologist for almost 20 years, my goal has always been exactly that: to support my patients throughout their cancer journey while offering them a personalized treatment plan to give them the best chance of survival.

Over the past two decades, I have seen oncology care change dramatically. While we still can’t cure or prevent all cancers, technology has advanced in terms of early detection tests and late-stage treatment options. Unfortunately, it is becoming increasingly difficult to prescribe life-saving drugs and therapies that will help our most vulnerable patients in their fight against cancer. The root of the problem lies in the price intermediaries of drugs in our health system. Their unfair practices threaten access to high-quality care for cancer patients and increase financial and administrative burdens for patients and physicians.

Dr Douglas Flora

These pharmacy benefit managers, or PBMs, drive up drug costs and threaten the patient / physician relationship. While PBMs will tell you that they improve access to care by negotiating lower prescription drug costs, the truth is, PBMs overcharge patients for much-needed drugs, underpay pharmacists who issue those prescriptions and then keep the difference to increase their profit margins. – a practice called “differential pricing”.

A 2020 study by the American Society of Clinical Oncology shows that the cost of oncology drugs is increasing at a faster rate than any other class of prescription drugs. In fact, the cost of new drugs regularly exceeds $ 100,000, usually for a single drug. Patients often need a combination of several drugs to manage their condition, so as you can imagine things can get very expensive very quickly.

In addition to the disproportionate role PBMs play in determining the cost of prescription drugs, PBMs also implement “use management” strategies to create more barriers to care and insurance issues. Things like pre-clearances, step therapy (when the patient has to try, and fail, a preferred PBM drug before gaining access to drugs prescribed by their doctor), and switching to non-medical drugs too often dictate what drugs can be prescribed and create unnecessary delays in patient care.

The American Cancer Society Cancer Action Network reported in 2019 that 34% of patients had to wait for cancer treatment insurance approval and that usage management policies resulted in treatment delays and increased stress. for patients. Since delays in cancer care can lead to poorer health outcomes, these issues need to be addressed.

Worse yet, I have seen first-hand how some patients are forced to choose their medications or skip a refill simply because they cannot afford their regular prescription drugs under the current system. The COVID-19 pandemic has only exacerbated the problem due to the loss of jobs and health insurance and delays in routine care. All of this is bad for public health.

PBMs claim to bring value to patients, but instead they simply fit in between the patient / physician relationship to protect their bottom line rather than the well-being of patients.

It’s time to take action to curb the middleman. It’s one way to ensure the quality, innovation and individualized care needed to save more lives against cancer. Because ultimately, a patient shouldn’t have to worry about whether supply chain and price manipulations will affect their ability to survive. Their only concern should be their health and stay strong to win their fight against cancer.

Dr. Douglas Flora is the Executive Medical Director of Oncology Services at St. Elizabeth Healthcare and serves on the Board of Directors of the Kentucky Society of Clinical Oncology.


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