By Fox News (Opinion) | Created at 2025-03-08 17:24:44 | Updated at 2025-03-09 15:14:35
23 hours ago
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Why is it so hard to get the medications your doctor prescribes? Why do patients and families spend countless hours fighting for standard-of-care treatments? Why do potentially life-saving drugs get delayed for weeks or months?
That these questions are too often asked can be blamed on one of the least understood problems in healthcare today: the role of pharmacy benefit managers (PBMs). These powerful middlemen – not your doctor – increasingly decide which medicines you get, how much you pay for them, and where you get them.
My role as CEO of the Pontchartrain Cancer Center has given me a front-row seat to the systemic dysfunction PBMs perpetuate.
PBMs were originally created to lower drug costs and streamline access to medications. (iStock)
My 19-year-old daughter recently faced a medical condition that required a standard-of-care treatment prescribed by her doctor. Even with my professional expertise, her doctor and I spent countless hours fighting with a PBM to get her medication approved. It was finally approved in February, but it still took 10 long weeks before she was able to access it.
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Every step of the way, we encountered a system where no one wanted to take responsibility; one person after another passed the problem along like a game of hot potato. The psychological toll of this ordeal – on her, on our family and on her medical team – is beyond words. If I, with all the resources and knowledge at my disposal, cannot cut through this red tape, what hope does any other American have?
Unfortunately, this is not an isolated incident. Millions of patients across the country face similar barriers: forced to endure denials, delays, and disruptions to care because of the increasing PBM stranglehold on medicine.
These are not just administrative inconveniences; they are life-threatening obstacles. Patients suffering from cancer, chronic conditions or rare diseases are caught in a system that seems to value PBM corporate profits over human lives.
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PBMs were originally created to lower drug costs and streamline access to medications. Over time, however, they have transformed into entities that manipulate the system to maximize profits at the expense of patients.
Making matters worse is the vertical integration that has allowed PBMs to dominate every aspect of the prescription drug supply chain. Today, the largest PBMs – Caremark Rx, LLC (CVS), Express Scripts, Inc. (ESI), and OptumRx, Inc. (OptumRx) – don’t just manage drug benefits. They also own the pharmacies that fill prescriptions and the insurers that pay for them.
This means they have a financial incentive to prioritize their own profits at every step: steering patients to their own pharmacies, limiting access to competing medications and driving up out-of-pocket costs. With nearly 80 percent of prescription drugs controlled by just these three PBMs, their decisions shape the healthcare experiences of virtually every American. This vertical integration consolidates power in ways that simply harm patients.
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The Federal Trade Commission (FTC) recently exposed how the big three PBMs have rigged the drug supply chain to inflate costs and pad their profits. The FTC’s latest report, released in January 2025, highlighted how PBMs added significant markups on specialty generics, inflating costs for cancer, HIV and other life-saving drugs.
Even while under federal investigation, the FTC report shows how these middlemen generated $7.3 billion in revenue from 2017 to 2022 by steering patients toward their own pharmacies, reimbursing themselves at higher rates than independent competitors, and engaging in predatory practices like spread pricing.
Yet despite growing evidence and bipartisan calls for reform, Congress failed to act at the end of 2024. This missed opportunity is more than disappointing – it’s dangerous. Patients cannot wait while lawmakers play politics.
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Congress must take immediate action to pass meaningful PBM reform. The House Energy and Commerce's Subcommittee on Health recently held a hearing to discuss PBM-driven price inflation, barriers to care, and market consolidation. The testimony reinforced what patients and healthcare professionals already know: PBMs are driving up costs and limiting access, not lowering them.
These reforms have broad bipartisan support and represent real solutions. Patients deserve more than vague commitments; they deserve action.
President Donald Trump has made eliminating waste, fraud, and abuse in government a cornerstone of his administration’s agenda. PBM reform is a clear extension of that mission – these middlemen have exploited inefficiencies for too long, and it’s time to restore transparency, fairness, and patient-first policies to the system.
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Congress must pass meaningful PBM reform – not tomorrow but today. For my daughter and for the countless patients I’ve fought for over the years, this isn’t an abstract policy debate. It’s real, it’s urgent and it’s deeply personal.
It is time to put patients before profits and politics. Congress missed a crucial opportunity in 2024. Let’s make 2025 the year we finally stop these life-threatening PBMs and restore humanity to healthcare. For my daughter and for our loved ones, we cannot afford to wait any longer.
