State should tackle abuse of consumers by PBMs

Months of work by Dispatch reporters have shown readers that pharmacy benefit managers operate as the worst sort of middlemen, siphoning billions in profit from prescription-drug transactions without adding much, if anything, of value.

But last Sunday’s article by Dispatch reporters Marty Schladen and Catherine Candisky showed something worse: The PBMs’ disregard for consumers and drive to maximize profits are so great that they’re willing to make cancer patients wait days, even weeks, for lifesaving drugs.

It’s long past time for state and national lawmakers to intervene on behalf of consumers against this parasitic business model.

Delaying drugs for some patients is the result of an increasingly common PBM practice of insisting that, in order to get insurance coverage, patients must get prescriptions filled via the mail-order pharmacies the PBMs own.

Never mind that your oncology practice or hospital has a specialty pharmacy on site and could give you the medication to take home with you; if you want your insurance to help cover the $10,000 cost, you have to go home and wait and hope that no misunderstandings or postal mishaps delay your cancer treatment any more than a few days.

It seems absurd, but then so are the other abuses that are baked in to the PBM model, and so is the fact that the health-care industry has tolerated them for so long.

PBMs have been around since the late 1960s and have grown in size and impact, espsecially since the advent in 2003 of Medicare Part D coverage of drugs. The idea was for PBMs to act as beneficial middlemen — helping insurers decide which drugs to cover, handling patient paperwork and using their buying power to negotiate rebates from drug manufacturers.

But PBMs have developed with a confounding absence of checks against conflicts of interest.

In Ohio, they’ve been given free rein to decide not only how much to bill insurers for a given drug, but also how much to pay the pharmacy that dispenses it. The PBM may have, as advertised, negotiated a big discount from the drug manufacturer, but nothing keeps it from charging the insurer (or the patient, through copays) a high price anyway — in effect, keeping much of that rebate for itself.

And because Ohio’s Medicaid program has ceded much authority to PBMs, those being ripped off include taxpayers.

Amazingly, Ohio also has allowed PBMs to hide these practices by keeping their price information secret.

Critics allege that the abuse doesn’t end with raking in money that should be going back to patients’ and taxpayers’ pockets.

The Ohio Pharmacists Association claims that CVS Caremark, the PBM that handles most of Ohio’s Medicaid prescriptions, is driving small independent