Cancer treatment has never been cheap. But in the pricey world of pharmaceuticals, the cost of oncology drugs has become jaw-dropping. And where there are big dollars, there is a battle between business interests, which is why cancer doctors are declaring war against pharmacy benefit managers.
There’s nothing immediately impressive about the shelves of medication at Tennessee Oncology’s specialty pharmacy, except that they’re worth millions of dollars.
Senior vice president Stacy McCullough holds up one example. It costs $19,000 a bottle.
“Nothing in your sight is going to be less than $10,000 for the bottle,” she says.
These pill bottles are what McCullough calls “the battle ground.”
They are not found in the typical pharmacy — only in specialty pharmacies like this one. But because of the price tag, the medication is closely monitored by the entity often paying the bill, known as pharmacy benefits managers.
PBMs essentially oversee the drug side of a health insurance policy. CVS Caremark, OptumRx and ExpressScripts are the big three. And these days, PBMs aren’t just deciding what cancer drugs an employer’s health plan will cover. They’re also
competing with these independent specialty pharmacies and selling the chemo medication themselves.
The dispute over who gets to sell these high-dollar pills is what’s changed in recent years. Cancer clinics and PBMs weren’t so much at odds back when chemotherapy required IV infusions.
But these days, chemo can often be delivered through oral medication. So the pills – worth hundreds of dollars a piece — are packed up and shipped to a patient’s house. (Talk about a package you don’t want stolen off the porch…)
While this can be done from anywhere, McCullough argues that Tennessee Oncology’s pharmacy is still best suited to serve its own patients.
“These medications need management,” she says. “Patients need to be closely monitored. Patients need a relationship with their healthcare provider.”
Big oncology practices around the country have joined forces. The Community Oncology Alliance based in Washington, D.C., has been
gathering anecdotes of grievances to build their case so lawmakers rein in the PBM industry.
Nicole Pankey of Rutherford County has become one of those cautionary tales. She didn’t even know who her PBM was until they started second-guessing her prescriptions, like one called Granix that’s $500-a-dose to prepare her body for chemo.
“It causes my bone marrow to produce white blood cells,” she says.
Pankey is a former Army crew chief turned financial analyst. She was diagnosed with stage 4 pancreatic cancer last year. She wanted to start chemo right away to give her the most time to see her kids grow up.
Her PBM required her to use their pharmacy, which is customary. But they were out of stock.
“They called me and said, ‘Oh, we can’t fill your prescription. I’m sorry.’ And I was like, ‘Excuse me?’ I was not happy with that answer,” she says.
Pankey spent hours on the phone, pleading with anyone who’d listen. And eventually, the PBM agreed to pay for the medication at the doctor’s pharmacy. So her chemo regimen stayed on track.
“The thing is, I pushed. I’m strong enough to push,” she says. “It could literally be the difference of life or death if I don’t get my chemo or my white blood cells drop too low. You know, I don’t know if my mother would do that. My mother probably would have stopped at the first no.”
The Case For PBMs
PBMs are easy to demonize. Their job often involves questioning what a patient’s doctor has prescribed or suggesting a lower-cost alternative. And lawmakers have
scrutinized how cozy they’ve become with pharmaceutical companies.
But the Pharmaceutical Care Management Association, a PBM lobbying group, says in a statement to WPLN that their role helps encourage competition among drug manufacturers. They also say running their own specialty pharmacies helps provide a “seamless experience” for patients.
And giving all the power back to cancer doctors and their pharmacies isn’t a perfect solution either, says Vanderbilt health policy professor Stacie Dusetzina.
“PBM’s are really trying to help manage spending growth,” she says.
Dusetzina studies rising drug prices. Cancer medication is a chief offender. And she says physicians and pharmacists need someone making sure they go with the cheapest alternative that’s still effective.
“Which basically translates to trying to keep your premiums on your health insurance lower so your employer can do things like pay you more rather than just paying for your health benefits,” she says.
It’s just that cancer patients aren’t thinking about their monthly insurance premiums when they run into a cost-control measure that stands between them and potentially life-saving medication.
And cancer drug prices are
“If PBMs were doing such a great job, you would see spending go down,” Ted Okon says, the Community Oncology Alliance’s chief executive.
He contends the struggle with PBMs could even turn back advances in cancer care if patients start deciding the cost and the headache isn’t worth the effort.