ASCO Addresses PBM Effects on Cancer Care

Certain cost-control practices of pharmacy benefit manager (PBM) companies have the potential to limit patient access to timely, high-quality cancer care, according to a position statement from the American Society of Clinical Oncology (ASCO).

Responding to oncologists’ concerns, the statement identifies PBM practices that “might compromise physicians’ ability to provide the right treatment at the right time for people with cancer; place cancer patients at risk of serious complications due to drug dispensing errors, or drive up out-of-pocket costs for patients.”

Examples of potentially harmful PBM practices included “gag clauses” that prohibit pharmacists from telling patients about lower-cost drug options, requiring patients to use mail-order prescription services in lieu of seeing a physician, and “brown bagging” or “white bagging” policies that require oncologists to administer drugs they have not prepared in their offices.

“There’s no doubt that the high cost of cancer care is a major burden on patients and the healthcare system, but efforts to address the problem shouldn’t come at the expense of quality patient care,” ASCO president Monica M. Bertagnolli, MD, said in a prepared statement.

To address concerns raised by the oncology community, ASCO recommended that:

• PBMs and payers immediately address quality-of-care concerns related to cancer patients, including assurance that changes to prescribed therapy are made only in the context of consultation with and approval of a patient’s physician
• Gag clauses be prohibited, and that the Centers for Medicare and Medicaid Services (CMS) eliminate contractual requirements that prevent pharmacies from sharing information with patients about cost-effective medication options
• CMS require PBMs to provide detailed accounting of direct and indirect remuneration (DIR) fees, to instruct contractors and PBMs to discontinue use of existing Star performance ratings and related DIR claw backs on oncology dispensing physicians and practice-based pharmacies, and to rely on measures and standards appropriate to the specialty
• CMS prevent PBMs from excluding qualified in-office dispensing or provider-led pharmacies from its networks
• CMS consider extending use of the JW modifier to report the amount of a drug that is discarded to aid identification of sources and cost of waste related to chemotherapy drugs
• Pharmacy and therapeutics committees should extend full and meaningful participation to oncology specialists

The complete report, entitled “Pharmacy Benefit Managers and Their Impact on Cancer,” is available on the ASCO website.

https://www.medpagetoday.com/publichealthpolicy/healthpolicy/74891