To lower patient costs, lawmakers must push for middleman oversight

Updated on April 5, 2019

By Andrea Baer, MS

As the director of patient advocacy and program management at Mended Hearts, one of my chief priorities is assuring the millions of our patients suffering from heart disease have long-term and affordable access to life-saving medications.

All too frequently, however, it is a struggle for these patients to balance daily expenses with increasingly high insurance costs associated with their prescription drugs. 

Many decisions they are left with are cruel. For example: Should I spend my money on groceries or this month’s co-pay? 
People who suffer from any life-threatening disease shouldn’t have to make that choice. 

Rising out-of-pocket costs for prescription drugs are not only a strain on their wallets. They are a threat to their very existence.

That’s why it was a step in the right direction when the Department of Health and Human Services (HHS) earlier this year announced a proposed rule that would reform the drug rebate system. 

The rule would eliminate protections for these rebates negotiated by pharmacy benefit managers (PBMs) and instead offer those protections to discounts passed directly to consumers. 

The current system harms patients whose co-pays can sometimes be higher than the prices paid by their health plans receiving the rebates.
Allowing these rebates to finally reach patients – as they always should have – will make an enormous difference in their lives and those of their families.

Ultimately, these measures would respect the physician-patient relationship, removing the negative impact of PBMs and making the recommended treatments more accessible.

Unfortunately, by law, the HHS rule can only impact Medicare Part D plan sponsor and Medicaid Managed Care Organizations (MCOs), but Azar is pushing for Congress to extend these protections to commercial insurers. 

One federal lawmaker in particular is listening. Earlier this month, Indiana Sen. Mike Braun introduced the Drug Price Transparency Act and two other bills aimed at lowering drug prices. The Transparency Act would expand the HHS rule to the commercial insurance market and prohibit PBMs from receiving any rebates or reductions in price from drug manufacturers.

That legislation and the HHS rule will be front in center in front of our two United States Senators on April 9, when Sen. Bob Casey and Sen. Pat Toomey will hear testimony from five PBM CEOs on their companies’ roles in rising prescription drug prices during a Senate Finance Committee hearing.

This issue is not lost here at home in Pennsylvania, as the proposed HHS rule was announced just a month before a report by Pennsylvania Auditor General Eugene DePasquale revealed how rebates can drive up the cost of prescription drugs as much as 30 percent for those with private health insurance.

DePasquale suggested the General Assembly mandate that PBMs receive a flat fee for acting as the go-between for manufacturers and insurers, rather than being paid a percentage of the drug price back as a rebate. This type of legislation would align with the rule proposed by HHS Secretary Alex Azar and offer another layer of protection for patients who have been sorely lacking any support. 

In announcing the rule, Azar said, “This proposal has the potential to be the most significant change in how Americans’ drugs are priced at the pharmacy counter, ever, and finally ease the burden of the sticker shock that millions of Americans experience every month for the drugs they need.”

Azar is correct. 

Now, Sen. Casey and Sen. Toomey will have the chance to push their colleague Sen. Braun’s federal legislation forward, making the case for patients with chronic conditions to afford the insurance costs associated with medicine that saves lives. 

Already, DePasquale has stated his case for reform in Pennsylvania, and patients need our federal and state lawmakers to take these steps to rein in the middlemen and make insurance costs more affordable.  

Pittsburgh resident Andrea Baer, MS, is director of patient advocacy and program management for Mended Hearts and Mended Little Hearts. She can be reached at [email protected]

+ posts

Throughout the year, our writers feature fresh, in-depth, and relevant information for our audience of 40,000+ healthcare leaders and professionals. As a healthcare business publication, we cover and cherish our relationship with the entire health care industry including administrators, nurses, physicians, physical therapists, pharmacists, and more. We cover a broad spectrum from hospitals to medical offices to outpatient services to eye surgery centers to university settings. We focus on rehabilitation, nursing homes, home care, hospice as well as men’s health, women’s heath, and pediatrics.