I was disturbed recently after reading a news report in which the head of a large pharmacy benefit manager (PBM) stated the company’s intentions to eventually start influencing the price of oncology drugs as well as extend its management, oversight, and influence to cancer drugs administered in doctors’ offices and hospitals. Meetings have already begun with top oncologists, according to the company leader who was interviewed, and the company is looking to find ways to eventually guide doctors toward preferred drugs in the PBM’s approved formulary in ways that do not cause patients to be upset.
These steps—indicative of a growing trend for entities outside of the oncology space to take control of oncology spend—portend a sea change in control and influence over the oncology space. So why should practices, physicians, patients, and cancer centers be concerned about what appears to be an approaching battle between drug manufacturers and PBMs?
There is no denying that we currently enjoy significant improvements in the battle against cancer, and that pharmaceutical advances have played a major role. There is also no denying that there is only so much money available to pay for healthcare, and that choices are and will continue to be made for all diseases. There is already great pressure on the pricing of cancer drugs, and that pressure will continue.
When developing a formulary, however, the focus of third-party administrators of pharmaceuticals is ordinarily on the price of drug A versus drug B, not on the total cost of cancer treatment. When facing the complexities of cancer care, it is imperative to stay focused on the larger picture. Accessing appropriate treatments for complex patients with cancer when formularies are built with such a narrow focus will be difficult at best, potentially leading to adverse consequences for the patient, as well as greater overall costs.
Physicians see the patient, know the patient, and know the parameters of health status, family and work concerns, and psychosocial aspects of the patient and the patient’s caregivers. Medical benefits address the total costs of care and the fit of specific drugs within the whole continuum of care. Pharmacy benefit management focuses on the drug. Management of medical benefits and pharmacy benefits are simply not interchangeable.
What can practices do? Engage local employers and health plans in discussions about oncology management. Review your own processes for cancer management and drug selection: are there opportunities for improvement that do not adversely affect the patient and can be managed better by your practice? Inform your state societies about this as an issue to watch and address. Engage the pharmaceutical companies with whom you work. The total cost of care is indeed a societal problem, and one that is hitting all of us right now.
Contracting and pricing negotiations will continue to happen. However, if and when such negotiations by third parties affect patient access and safety, and can lead to unintended financial, health, and medical consequences, the medical community should, and will, be heard.
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