The Power of PBMs in Oncology: Unveiling the Middlemen: Oncology Update with John Marshall

In the ever-evolving world of oncology, access to effective treatments and their affordability is a constant concern. In Episode 5 of Oncology Update with Dr. John Marshall, we delve into a topic that affects both cancer patients and healthcare providers: pharmacy benefit managers (PBMs). These middlemen control much of the flow of drugs between manufacturers and patients, but as Dr. Marshall and his guests explain, their role is fraught with complexities that are increasingly impacting the delivery of care in oncology.

PBMs: The Unseen Influencers

Pharmacy Benefit Managers (PBMs) are third-party administrators hired by health plans to manage prescription drug programs. While PBMs were originally introduced to streamline drug access and control costs, they have evolved into powerful entities, with a few key players controlling around 80% of the market. In oncology, where medications are life-saving but often extraordinarily expensive, the role of PBMs has come under increased scrutiny for their influence on drug pricing, availability, and patient care.

As Dr. Marshall points out, the impact of PBMs extends beyond just pricing: “I used to think of PBMs as maybe a good thing, a way to manage prescriptions on a higher level for patients who needed chronic prescriptions. But recently, I’ve had several episodes where I couldn’t prescribe the drug I wanted to for a patient, being told I had to order a different drug first.”

The lack of transparency in how PBMs operate, combined with their increasing control over drug formularies, is creating barriers for oncologists trying to prescribe the best treatments for their patients.

The PBM Money Trail

One of the highlights of this episode is Dr. Marshall’s interview with Antonio Ciaccia, an expert in drug pricing. Ciaccia emphasizes how PBMs have turned drug pricing into a game of hidden profits. “Between the moments of money going in and money squeezing out, there is a lot being lost in translation,” Ciaccia explains. PBMs negotiate huge discounts with drug manufacturers, but those discounts don’t always translate into lower costs for patients. Instead, PBMs pocket the difference, leaving patients and even state Medicaid programs paying inflated prices for drugs.

Ciaccia also underscores how the system incentivizes higher prices: “PBMs incentivize pharmacies to charge higher sticker prices because it allows them to negotiate bigger discounts. But patients end up paying based on those inflated prices.”

The Oncologist’s Dilemma

For oncologists like Dr. Marshall, PBMs present an additional layer of complexity in providing care. Many new oncology drugs are oral therapies, meaning they fall under the pharmacy benefit rather than the medical benefit, putting them squarely in the PBM’s realm of control. Dr. Marshall’s conversation with Stacey McCullough, PharmD, from NCODA (National Community Oncology Dispensing Association), highlights the frustrations that many providers feel when dealing with PBMs. McCullough notes, “Fragmentation of care should be avoided. PBMs often insert themselves between the physician and the patient, which disrupts the continuity of care.”

One of the significant issues raised is the lack of oversight and communication between PBMs and healthcare providers. When PBMs change a patient’s medication based on cost considerations, it can derail treatment plans without the physician’s knowledge.

Reforming the System

Both McCullough and Ciaccia stress the need for greater transparency and accountability in the PBM system. As oncology treatments increasingly move towards oral medications, finding a way to ensure that PBMs serve patients rather than profit from them is critical. According to McCullough, “We support the continuity of care, and the physician should always be the overseer. Any fragmentation in the care process can lead to inferior outcomes for the patient.”

Ciaccia echoes this sentiment, emphasizing the need for a system that incentivizes lower drug prices and improved patient care, rather than allowing PBMs to profit from inflated prices.

Conclusion

As Dr. Marshall eloquently puts it, “We have to fix this.” PBMs play an essential role in the drug supply chain, but their practices are creating unnecessary costs and barriers for both patients and providers. In oncology, where timely access to the right treatments can mean the difference between life and death, reforming how PBMs operate is not just important—it’s urgent. By bringing greater transparency and accountability into the system, we can ensure that cancer patients get the care they need without unnecessary delays or inflated costs.

For oncologists, patients, and policymakers alike, the time has come to reassess the role of PBMs and to push for a system that prioritizes patient outcomes over profits. The insights shared by experts like McCullough and Ciaccia provide a roadmap for how we can begin to make these necessary changes.

Listen to the full episode of Oncology Update: Oncology Update Episode 5