Pharmacy Benefit Managers Expose Patients to Negative Health Outcomes, GHLF Updated Studies Shows

Webinar Scheduled for November 9 at Noon (ET)

ESI and CVS Health continue to expose hundreds of thousands of patients to the risks of taking medicines their doctor did not prescribe, according to an existing peer-reviewed and updated study, and new research by the Global Healthy Living Foundation (GHLF).

The updated research found that more than half the exclusions (57%) had questionable medical or economic benefits for patients. The original peer-reviewed research and its update, which is not yet published, focuses on ESI, the second largest pharmacy benefit manager in the United States.

The new study includes CVS as well as ESI and looks at three drug classes — cardiovascular, neurologic, and dermatologic — to try to further quantify the number of potential patients harmed when drug availability is restricted, a practice known as formulary exclusion.

Profits Over Patients

“All studies exposed concerning trends in pharmacy benefit manager (PBM) formulary exclusions that prioritize more profitable drugs rather than those originally prescribed — putting profits over patients' well-being and underscoring the need to enhance transparency and accountability in health care,” said lead author Robert Popovian, PharmD, MS, Chief Science Policy Officer at GHLF, Senior Health Policy Fellow at the Progressive Policy Institute, and Visiting Health Policy Fellow at the Pioneer Institute.

"Formularies were originally meant to help patients get cost-effective treatments and generic equivalents, but now they prioritize PBMs' profits through rebate contracting schemes, often mandating substitution with a non-equivalent medication," Mr. Popovian added.

"This means patients may not get the best treatment options, leading to mortality, morbidity, or worsening in quality of life.”

Co-author Anne M. Sydor, PhD, Director of Research Development and Communications at GHLF, said “We know that when certain medicines are excluded, it affects hundreds of thousands of patients, making them sicker and sometimes even putting their lives at risk. This forced switch to different medications also adds to the challenges patients and their caregivers face, and it ends up costing more for everyone involved in health care — patients, caregivers, employers, and the government. Ensuring that the well-being of patients takes precedence over corporate profits in health care decision-making is a paramount concern.”

For Catherine Hicks, who lives with JIA and epilepsy, formulary exclusions have stopped progression of care and needlessly worsened her condition. “Formulary exclusions almost killed me,” she said.

“Being without my medication that we knew worked, and going through the process of appeal and starting stop-gap measures such as steroids and trying other medications, made me extremely ill and landed me in the hospital for 10 days with acute pneumonia that teetered briefly into sepsis.”

For more information about these studies, please contact the lead author, Dr. Robert Popovian (rpopovian@ghlf.org).

GHLF will host a webinar concerning formulary exclusions and their impact on patients on November 9 at 12 pm EST. Click here to register.

About Global Healthy Living Foundation

The Global Healthy Living Foundation is a U.S. based, 501(c)(3) nonprofit, international organization whose mission is to improve the quality of life for people with chronic illnesses by advocating for improved access to health care through education, patient-centered clinical research, support, advocacy and economic and policy research. GHLF is also a staunch advocate for vaccines. The Global Healthy Living Foundation is the parent organization of CreakyJoints®, the international, digital community for millions of people living with arthritis and their supporters worldwide who seek education, support, activism, and patient-centered research in English, Spanish, and French. In addition to arthritis and autoimmune disorders, GHLF supports dermatology, gastroenterology, neurology, cardiology, infectious diseases, and pulmonary patients through a host of different programs and activities which draw nearly 1 million patients a month to GHLF websites. In addition, a library of podcasts via the GHLF Podcast Network, has more than 500,000 listeners to date. GHLF never asks the public for donations. Visit ghlf.org for more information.

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