I am inherently clumsy. My family says it’s endearing, but I doubt they found it as lovable when I fell down the stairs earlier this year. I was heading out to catch an early morning flight to Los Angeles, I missed a step, and my ankle was the casualty. And so began a saga of navigating a complex healthcare system that far too many Californians, particularly Latino communities, are finding harder and harder to afford. It is nearly ten months later and despite resting and trying my best, I am still caught in a vicious cycle of trying to heal.
My unexpected accident both hindered my mobility and added a medication that I needed to help manage my pain. To compound my worries about how the injury would affect our budget, the whole state then shutdown to curtail the spread of COVID-19. Trips to the pharmacy to pick-up medications had the potential to be both dangerous and expensive. It was at this point, that I realized that the process, the insurance programs and assistance that I have spent decades paying into—were now my lifeline.
The first time I went to the pharmacy to pick up my new prescription, I braced myself for the worst. And at first it was the worst. I had forgotten send over my insurance card with my prescription and the bill out-of-pocket for a few generic pain pills—was astronomical. However, after inputting my insurance, I was pleasantly surprised to find that my medication was incredibly affordable. I found that my insurance works with what is known as a pharmacy benefit manager (PBM) who advocates on my behalf to keep my medications (even the unexpected ones) affordable and gives me the option to have me prescriptions delivered. Thanks to the work of my PBM, this medication wouldn’t break our budget—and I didn’t have to leave our home to receive my prescription.
PBMs are often conflated with insurance companies and characterized as middlemen who work in the shadows of the health care industry to raise the cost of drugs so that they can pocket and profit from the rebates. According to both big PHRMA and some lawmakers, the ever-rising cost of drugs is the fault of PBMs. But the companies, which partner with health plans to negotiate savings on drug costs for millions of Americans, are wrongly blamed for rising costs at the pharmacy counter. After my personal experience, I realize it is really the pharmaceutical manufacturers, not pharmacy’s or the PBMs, who set and raise the list price of prescription drugs.
I have now seen firsthand what these benefit managers do for patients and communities like ours, and we as a advocates for better healthcare, need to encourage their efforts to work to lower drug prices and ensure patients receive timely, appropriate, safe and effective medicines at lower cost. Without the involvement of benefit managers, we are likely to see insurance premiums and co-pays would rise. What I now know is that without my PBM, my whole ankle debacle could have been a more expensive journey. What this means for the growing Latino community in our state, is that we need to look beyond the rhetorical bias of the drug companies and the politicians, and educate ourselves on the processes that help us navigate the healthcare delivery systems. As the nation faced an unprecedented public health crisis and millions of Californians were ordered to shelter-in-place, PBMs provided critical access to medicines, giving patients predictability and peace of mind when they needed it most. The industry recognized that other illnesses did not stop in the wake of COVID-19 and worked tirelessly to ensure that folks received their medications when they needed them.
Because pharmacy benefit managers loosened restrictions to allow more patients to receive 90-day supplies of some prescriptions, instead of the more typical 30-day supply, and offered home deliveries of prescriptions at no added cost, Californians have been able to safely receive the treatments they need from home. As an example, in California, one organization, CVS Caremark, has partnered with UCLA Health and other hospitals through its Coram infusion care business to transition eligible patients to home-based care, freeing up more hospital beds for COVID-related care.
In turn, as political and business leaders face a series of difficult decisions ahead — about when and how to get back to work and school, and how to balance budgets that have taken an unprecedented hit — our healthcare organizations will continue to play a critical role in the months to come as we face some of the darkest weeks of the pandemic yet. When the legislature returns in 2021, I urge lawmakers in Sacramento to consider the negative financial impact on consumers and employers before moving forward with policies that would restrict healthcare options like PBMs’ ability to negotiate cost savings that lower health care costs for California patients.
Although I’m still waiting for my ankle to heal completely, knowing that my prescription drugs remain affordable and that I’m able to obtain them safely, provides me with a sense of security and awareness about what solutions are available to me for healthcare. In the face of the uncertainty due to the COVID-19 pandemic, it is more important than ever for political, business, and civic leaders to prioritize health care access and affordability. We need to appreciate the work that the pharmacists and benefit managers and others in the industry are doing as they are clearly our allies in the critical mission to provide care to the important and growing communities or our state.