Why is it such a challenge to obtain the medications recommended by your doctor? Why do patients and their families spend extensive time advocating for standard treatments? Why are potentially life-saving medications often delayed for weeks or even months? The prevalence of these questions can be attributed to one of the most misunderstood issues in healthcare today: the influence of pharmacy benefit managers (PBMs). These influential intermediaries, rather than your healthcare provider, increasingly dictate which medications you receive, how much you pay for them, and where you obtain them. As the CEO of the Pontchartrain Cancer Center, I have witnessed firsthand the systemic challenges perpetuated by PBMs.
Originally established to reduce drug expenses and facilitate medication access, PBMs have evolved into entities that wield significant control over treatment decisions. A personal experience involving my 19-year-old daughter, who required a doctor-prescribed standard treatment for a medical condition, exemplifies the complexities faced when dealing with PBMs. Despite my professional background, her physician and I encountered numerous obstacles in securing approval for her medication. While it was eventually authorized in February, accessing the treatment took a painstaking 10 weeks.
Throughout this ordeal, we navigated a system where accountability seemed evasive, with responsibility being shifted from one party to another. The emotional toll of this experience on my daughter, our family, and her medical team is indescribable. If I, armed with resources and knowledge, struggled to navigate bureaucracy, what hope remains for other Americans?
Regrettably, such challenges are not isolated incidents. Countless patients nationwide confront similar hurdles, enduring denials, delays, and disruptions to their care due to the escalating dominance of PBMs in medicine. These impediments are not mere administrative inconveniences but life-threatening barriers. Those battling cancer, chronic conditions, or rare diseases find themselves ensnared in a system that appears to prioritize PBM profits over patient welfare.
Originally intended to lower drug expenses and enhance medication accessibility, PBMs have morphed into entities that exploit the system to maximize financial gain at the expense of patients. Furthermore, the vertical integration that enables PBMs to control every aspect of the prescription drug supply chain exacerbates the situation. Today, major PBMs like Caremark Rx, LLC (CVS), Express Scripts, Inc. (ESI), and OptumRx, Inc. (OptumRx) not only oversee drug benefits but also have ownership stakes in pharmacies and insurers. This alignment incentivizes actions that boost profits, such as directing patients to in-house pharmacies, restricting access to competing treatments, and inflating out-of-pocket expenses.
Given that nearly 80% of prescription drugs are managed by these three dominant PBMs, their decisions profoundly influence the healthcare journeys of most Americans, consolidating power in ways that harm patients. Recently, the Federal Trade Commission (FTC) shed light on how these major PBMs manipulate the drug supply chain to escalate costs and bolster their financial interests. The FTC’s latest report, unveiled in January 2025,
The soaring costs of essential medications like those for cancer, HIV, and other life-saving drugs have been on the rise due to the practices of pharmacy benefit managers (PBMs). Recent investigations have revealed that these middlemen have raked in $7.3 billion in revenue from 2017 to 2022 by directing patients to their own pharmacies, overcharging compared to independent competitors, and engaging in harmful practices like spread pricing. Despite calls for reform and mounting evidence, Congress failed to take action by the end of 2024, jeopardizing patient care. Prescription drug prices have surged nearly 40% over the past decade, underscoring the urgent need for PBM reform.
Congress must act swiftly to enact meaningful reforms to address PBM-driven price inflation, access barriers, and market consolidation. Efforts to bring transparency and fairness to the system have garnered bipartisan support and offer tangible solutions. It is imperative to move beyond rhetoric and deliver concrete actions to benefit patients.
President Donald Trump’s commitment to eliminating waste and abuse in government aligns with the necessity of reforming PBMs, which have exploited inefficiencies for far too long. Restoring patient-centered policies is crucial to ensuring a healthcare system that prioritizes people over profits. The time to act is now, not tomorrow but today.
The missed opportunity in 2024 must not be repeated in 2025. Let this be the year we put an end to the harmful practices of PBMs and bring compassion back to healthcare. We cannot delay any longer in prioritizing patients over financial gains and political interests.
