Health care costs are complicated, but solutions are straightforward

Being diagnosed with a significant illness can be a frightening experience for anyone. But finding out that your illness requires medication you can’t afford makes the entire ordeal so much more distressing.

As a primary care provider, I see patients here in Miami experience this unfortunate reality far too often — and it often disproportionately affects Hispanic communities.

With prescription drug prices charged to patients continuing to soar, it’s clear we need to fix this broken system and provide relief to struggling families. One way to tackle that is by shining a light on a lesser known but incredibly influential player in the prescription drug marketplace: pharmacy benefit managers.

Pharmacy benefit managers, or PBMs, are non-medical middlemen in the health care system who insert themselves into the treatment process and often pocket savings or discounts that were intended to help patients. Not to mention, three of the largest PBMs control over 75% of the market, and have far-reaching power to control the pricing, distribution and brands of drugs covered by health plans. In the end, these predatory practices rob patients of medical benefits they desperately need and reduce available options.

Earlier this year, Gov. Ron DeSantis took action to curb these practices by signing an executive order that helped lower prescription drug costs while requiring greater transparency and accountability for PBMs. It’s an important step in the right direction, but more needs to be done to provide relief to struggling patients.

The health care system is complex. As a nurse practitioner with over 20 years of experience, I still struggle to understand the intricacies of the prescription drug process — and I know my patients do, too. PBMs have capitalized on that complexity, hiding behind it while benefiting from soaring stock prices and record-breaking profits.

But here’s a glimpse into what that broken system means for real patients.

My patients often come from low- to moderate-income backgrounds, many of them relying on Medicaid. They need the most effective and affordable medications possible. If they can’t get it, they often feel forced to take matters into their own hands.

I once had a patient end up in the emergency room after she took the drug I prescribed her, but used her husband’s dosage. She wasn’t able to afford her own prescription, so she saw her husband’s medication as a more cost-effective alternative. In the end, she spent far more on an ER visit than she would have filling her own prescription — all while putting her life at risk.

In another case, one of my patients felt forced to choose which illness to medicate herself for, purchasing three prescriptions and abandoning the fourth. When she eventually came back with no improvement in her condition, I discovered she could not afford all of the medications prescribed.

Despite recent reforms, PBMs continue to use a complicated shell game that involves inflating drug costs, steering patients to affiliated pharmacies, and even swapping out drugs that a provider has prescribed. The end result is that patients often find themselves in impossible positions, clueless to who the culprit behind the curtain is.

While these persistent health care challenges are complex, the solution is straightforward. We need to create a health care system that puts Florida patients first — rather than one that forces families to make impossible choices between medications and groceries.

That starts by increasing accountability and transparency over PBMs while taking steps to lower drug costs.

It’s going to take time, but lowering drug costs for Florida families is a necessary pursuit, one I hope you’ll join me in supporting.

By Armando Riera