Guest Author
As we close out 2024, Congress must prioritize patient-centered health care.
At the heart of this issue are Pharmacy Benefit Managers (PBMs), whose unchecked practices are creating dangerous barriers to essential medications for millions of Americans.
For people facing serious conditions like multiple sclerosis, these barriers are not just inconvenient — they are life-altering.
Congress must act now to reform the PBM system so that patients, not profits, are the priority.
Patients are often left to bear excessive costs for life-sustaining medications as PBMs prioritize higher-cost drugs that increase their own profits. This practice places an immense burden on those who rely on essential treatments to manage serious health conditions.
For those of us dedicated to supporting individuals affected by multiple sclerosis, it is heartbreaking to witness people struggling to afford the medications they need to control symptoms and preserve their dignity. Currently, just six major PBMs control an overwhelming 94% of all prescription drug claims, creating a near-monopoly that allows them to decide which medications are accessible and affordable.
PBMs often set patient costs based on inflated list prices rather than the real discounts they negotiate. This means that out-of-pocket expenses for patients are not reflective of actual costs but are instead inflated to boost profits for PBMs and insurance companies.
People with chronic conditions — like multiple sclerosis, cancer and many others — are particularly vulnerable, as they need consistent access to expensive therapies. Many are forced to make unthinkable choices between their medication and basic necessities like rent or groceries.
Local pharmacies, which are a lifeline for many patients, especially those in rural or underserved areas, are also suffering under PBM practices. Low reimbursement rates are forcing these pharmacies to close, and PBMs frequently steer patients toward their own mail-order services, disregarding patients’ need for face-to-face guidance and personalized care.
For individuals with multiple sclerosis, who may rely on a trusted pharmacist’s advice to manage complex treatment regimens, this loss of local support can have meaningful consequences.
Congress is paying attention. With broad bipartisan support, several bills have been introduced that aim to curb PBM abuses and protect patients from exorbitant costs. Recently, the Senate Finance Committee unanimously advanced a reform package that tackles these issues head-on, signaling a real chance to shift the power back to patients, where it belongs.
To truly transform this broken system, Congress must ensure that PBM revenues are no longer linked to the cost of drugs. PBMs should earn fair, flat fees for their services — fees that are disconnected from drug prices — so that their incentives align with patient needs, not profits. Furthermore, all discounts and rebates negotiated by PBMs must be passed through directly to consumers at the pharmacy counter, giving patients immediate financial relief. Streamlining burdensome utilization management protocols will also be crucial to reducing the delays and denials patients face in getting their medications.
The evidence is clear and overwhelming: patients will continue to suffer if we fail to reform PBMs. Bipartisan legislation, including the Senate Finance Committee’s Mental Health Lower-Cost Drugs and Extenders Package (S. 3430), is ready for action.
Congress has a rare opportunity to make a meaningful difference in the lives of Americans struggling to afford their medications — particularly those with chronic and complex health conditions like multiple sclerosis.
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Natalie Blake is the executive director of the Multiple Sclerosis Foundation.
