Concerns about high drug prices can take a significant toll on Americans every day. A new West Health-Gallup study recently found that a mere 55% of Americans believe they can afford their healthcare and prescription drugs, down six points in just one year. Thankfully, Congress has a rare bi-partisan opportunity in this upcoming lame duck session to address one of the primary drivers of this crisis: pharmacy benefit managers, or PBMs.

These powerful middlemen control prescription drug access for millions of Americans, and their business model is nefarious -- but currently legal. PBMs, which represent for-profit insurance companies, extract (or dictate) substantial rebates and discounts off the nominal "list" price of medicines and also decide which medicines should be covered on different insurance plans.
These for-profit PBMs pocket the lion’s share of these discounts for themselves and send the rest to insurers -- while patients are stuck paying copays and coinsurance based on the much higher list prices.

The consequences are heartbreaking. The West Health-Gallup study reports that "72.2 million Americans avoided necessary medical care in the past three months due to cost." This only exacerbates other barriers to care for vulnerable populations. Many patients who have walked away from the pharmacy counter empty-handed did so because of unaffordable copay or coinsurance payments.

One of the most important remedies to this dangerous situation is to reform how PBMs work and require them to be accountable and to return discounts and rebate savings to patients. Two bipartisan bills currently before Congress offer real solutions. The first, the Modernizing and Ensuring PBM Accountability Act, would "delink" PBM compensation from drug prices. Currently, PBMs earn fees calculated as a percentage of a drug's list price. PBMs would have to charge flat fees based on actual services provided, eliminating their incentive to favor higher-priced medications.

The second bill would require patient cost-sharing to be based on a drug's actual net price -- what insurers pay after rebates and discounts -- rather than its list price. This seemingly simple change could dramatically reduce out-of-pocket costs for patients with conditions like asthma, heart disease, and those requiring blood thinners.

These PBM practices also have an impact on overall health and wellness. When patients can't afford medications, manageable chronic conditions can escalate into medical emergencies. This creates a cascade of costly hospitalizations and complications that strain our entire healthcare system. They also adversely impact access to care. Pharmacies, particularly independent community pharmacies that proudly serve vulnerable populations are being squeezed to the breaking point by PBM practices. This is particularly appalling when you consider that one of the largest chain pharmacy corporations also owns one of the largest PBM operations.

Congress needs to seize the moment and act now to address PBM overreach and abuses. Strong majorities across party lines are demanding change. These reforms wouldn't solve every problem, but they would represent a significant step toward a more transparent, patient-centered system.

Salvatore J. Giorgianni, PharmD, CMHE is the Vice-President and Cofounder of Healthy Men Inc. and Chair-Emeritus and Cofounder of the American Public Health Association Men's Health Caucus. This piece originally ran in Medical Economics.