Americans face abusive insurer and PBM practices that limit access to medicines

It’s no secret that millions of Americans face significant barriers to getting the care they need. Patients’ ongoing struggle to navigate the ever-more unaffordable health care system has laid bare just how many barriers there are to care – from inadequate insurance coverage and high out-of-pocket expenses, to a lack of innovative and personalized solutions to their medical needs.

Last month, PhRMA released its annual Patient Experience Survey, asking Americans across the country to share their health care journeys, along with how they believe the system should be improved. In evaluating the nearly 2,600 responses, the message was clear: Patients are having real trouble accessing affordable health care, and they want solutions that hold insurers and pharmacy benefit managers (PBMs) accountable.

Even with insurance, patients face barriers to care.

Insurers work with PBMs to determine which medicines patients can access and what they pay for them. According to the findings, 41 percent of insured Americans have endured delays in and, in many cases, outright denials of care because of their insurance company or PBM. The challenge is even more common for patients in need of reliable access to care, including:

• Insured Americans managing a chronic condition (51%);
• Patients with diabetes (54%);
• Patients with mental health conditions (59%); and
• Patients with respiratory conditions (62%).

Limiting access to care has real-world consequences, especially to patients who must wait on their insurer to approve lifesaving prescriptions, who find that treatment isn’t covered by their high-cost plans or who hit plan prescription maximums.

The Patient Experience Survey also found nearly half of insured Americans have trouble understanding what’s actually covered by their insurance. Meanwhile, over half of respondents stated they were unable to predict how much they would have to pay for medicine, even if their insurance plan covers it.

What is easy to understand is the fact that out-of-pocket costs are going up: 33 percent of patients say their out-of-pocket costs have increased over the past year, 43 percent of patients have experienced deductibles that are too high, and 20 percent have faced copays they simply cannot afford. Nearly half of insured Americans view out-of-pocket costs as expensive or unaffordable. As a result, roughly 1 in 5 insured Americans have accrued medical debt due to the expensive, but necessary, treatment they must pay for out of pocket.

It’s no surprise patients are demanding change. In the survey, an overwhelming 94 percent of Americans found it important that policymakers understand the access barriers and challenges patients face each day. And more than 90 percent agree that those same policymakers should be acting in the best interest of the patient when creating health care policy. Of those policies, out-of-pocket expenses and rising health insurance premiums top these patients’ concerns.

Here’s how policymakers could address these challenges and lower out-of-pocket expenses for patients:

• Crack down on abusive practices by insurers and PBMs;
• Ensure copay assistance provided by prescription drug manufacturers goes to patients as intended and not to health insurers and PBMs;
• Require hospitals and clinics to be more transparent about how much they mark-up the costs for prescription medicines;
• Ensure health insurers and PBMs pass on any rebates or discounts from prescription drug companies to patients at the pharmacy counter; and
• Make hospitals use their prescription medicine discounts to provide much-needed access to low-income and uninsured patients. 

Patients know that they deserve better. Policymakers should advance solutions and programs that put patients first, by making medicine more affordable and accessible, and creating healthier and happier Americans.

Read more about the Patient Experience Survey.