Guest Author
In 2023, an estimated 162,410 people in Florida received a life-altering cancer diagnosis.
Early detection is key to ensuring the best chance for successful treatment. But, even with an early cancer diagnosis, when the most appropriate form of cancer care is delayed, inaccessible or unaffordable there is a lower chance of survival, greater problems associated with treatment and higher costs of long-term care.
During the 2023 Legislative Session, Gov. Ron DeSantis and the Florida Legislature made strides to add necessary accountability and transparency to pharmacy benefit managers (PBMs).
And this year, we applaud Gov. DeSantis for his commitment to improving cancer care — recommending $3M for the Mary Brogan Breast and Cervical Cancer Early Detection Program and tripling state funding to $60 million for the Florida Cancer Innovation, as well as continuing to fund other important cancer research programs, including the Casey DeSantis Cancer Research Program.
These efforts are crucial to research and early detection efforts, but we also must ensure timely access to innovative and affordable treatments.
PBMs are at the center of this discussion at the state and federal levels.
Today, only three PBMs control more than 80% of the U.S. market and are vertically integrated with insurance companies and pharmacies. Essentially, they decide what medicine you can access, how much you pay for it, and where you can pick it up. It also results in significant negotiating power, securing substantial rebates and discounts when purchasing medications from drug manufacturers. However, these savings rarely reach patients at the pharmacy counter, leaving Floridians with chronic conditions, including cancer, paying nearly double what their insurer pays for their medication.
It’s time to require insurers and PBMs to share these savings directly with patients at the point of sale.
PBMs and insurers are also responsible for many access and affordability barriers like copay accumulator programs and utilization management tools.
As PBMs drive up the cost of medications, a significant number of Floridians heavily rely on copay assistance. Unfortunately, most insurance plans have instituted “copayment accumulator programs,” which prevent copay assistance from counting toward patients’ cost-sharing requirements. This results in staggering surprise bills.
Florida can join 19 states that have passed legislation to ensure all copays count, regardless of their form, by passing Senate Bill 228 and House Bill 363 by Sen. Tom Wright and Rep. Lindsay Cross.
Time is not merely a factor in cancer care; it is a critical determinant of outcomes.
Utilization management tools like step therapy, prior authorization and non-medical switching, though designed to control costs, often impede timely access to prescribed medications. Transparent processes and timelines are essential to ensure patients receive the right medicine at the right time, as determined by their physician.
These patient-first policies are proven, simple and necessary solutions that Gov. DeSantis and the Florida Legislature should incorporate into their health care agenda.
As we explore potential solutions, it is crucial also to discuss models that pose serious challenges, like International Drug Reference Pricing or government price-setting policies. While well-intentioned, these models often create greater access barriers without lowering costs. Cancer patients in countries with government price-setting policies, on average, have access to only 40% of new cancer medicines available through their government health plans and endure an alarming 28-month longer wait for coverage compared to patients in the U.S. Cancer patients, especially those with a metastatic diagnosis, require a full range of timely, innovative options to ensure positive outcomes.
Gov. DeSantis and the Florida Legislature have championed major advancements in the cancer community, but we cannot forget the importance of timely access to innovative, affordable medication and treatment options.
Let’s work together to pass simple solutions that will make all the difference for patients.
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Michelle Flowers is the founder of the Oncology Managers of Florida.
