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What happens when insurers take the doctor out of the equation?

An April 16 story in Modern Healthcare underscores the challenges hospitals face as their pharmaceutical care is being taken over by insurers’ PBMs.

In a recent article, Modern Healthcare shared some of the repercussions of a growing trend: health insurance companies taking patients’ pharmaceutical care from doctors. It’s clear that insurers can reap massive financial benefits by operating their own pharmacy benefit managers (PBMs), which oversee patients’ prescription drug benefits. But as the article shows, this trend can negatively impact patient care.

The article points out this practice’s effect on the administration of specialty drugs, which are prescribed to patients dealing with conditions like cancer or multiple sclerosis. When insurers require patients’ pharmaceutical care to be managed by their own in-house PBM, the patient’s doctors are shut out of the loop once the prescription is given, with no way of knowing if it has been filled, or when to follow up.

Matthew Rim, associate director of the University of Illinois Health Sciences System (UI Health), told Modern Healthcare that his health system is only allowed to manage about half of its patients’ specialty drug treatments because UI Health doesn’t have contracts with these insurer-owned PBMs. Rim adds that UI Health is compelled to transfer patients to PBMs when they’d rather stay within the UI Health system for their medication management.

It looks to us like transferring patients’ pharma management to PBMs—against their and their doctors’ will—creates a precarious situation. The debate even prompted the American Hospital Association (AHA) to call upon policymakers to examine insurers’ drug policies that shut out physicians from crucial parts of the medication management process. And when the AHA raises a red flag, we’re listening.

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