by Dorothy Leone-Glasser, Georgia Recorder, [This article first appeared in the Georgia Recorder, republished with permission]
December 30, 2024

Georgia patients, particularly those living with chronic health conditions, are struggling to balance high costs at the pharmacy counter with other daily necessities. Yet, a growing industry of insurance middlemen known as pharmacy benefit managers (PBMs) are compounding these struggles by meddling in our local health system, increasing health care costs, and blocking access to critical medications. Georgia lawmakers must prioritize reforming PBM practices that are putting life-saving treatments out of reach and to help improve access to care for patients.

PBMs are hired by health insurance companies to negotiate drug prices with manufacturers for the health plans they represent. Today, these middlemen have evolved into one of the most influential stakeholders in the health care industry. Making enormous profits, they exert significant control over what treatments patients can access and how much they will be required to pay. PBMs are able to operate with little transparency or oversight, and their decisions are often based on what is most profitable for a health plan, not what is best for a patient.

This “profit over patients” business model is putting critical care out of reach for many Georgia patients. PBMs receive significant rebates and discounts from pharmaceutical manufacturers for the cost of medications and treatments, but they don’t pass those savings on to patients receiving the care, increasing what patients are required to pay out of pocket when they pick up their medication at the pharmacy.

As someone who has lived with multiple chronic conditions, including cancer, arthritis, and lupus, and spent my career as a nurse, I know firsthand how dangerous not being able to access a prescribed treatment can be. PBM reform is long overdue in Georgia – last year, Arkansas state lawmakers passed legislation requiring PBMs to pass 100% of manufacturer rebates directly to patients at the point of sale. Several other states across the country, including West Virginia and Florida, have either passed legislation to increase PBM transparency or require passing savings directly to patients.

Access to consistent treatments is critical for Georgia patients, particularly those living with chronic health conditions such as hypertension, arthritis, and cardiovascular disease, to manage symptoms and lead healthy lives. In 2021, almost 70% of Georgians reported experiencing a health care affordability burden in the previous year, and nearly 40% of Georgians reported cutting their pills in half, skipping doses, or not filling their prescription to accommodate for high costs. When patients are unable to access or afford treatments they need, they are more likely to experience worsened health outcomes and even higher medical costs due to unnecessary hospitalizations or additional doctor’s appointments. Access to doctor-prescribed treatments can help patients avoid these adverse outcomes, but PBMs continue to stand in the way of necessary care.

Scrutiny of these middlemen and their predatory practices has rightfully grown over the past year, with federal and state bipartisan policymakers and regulators calling attention to the outsized role PBMs play in driving up health care costs. After a two-year investigation, the Federal Trade Commission (FTC) found that PBM integration with chain pharmacies and insurers has allowed them to dominate the broader health system. The FTC even moved forward to file suit against the three of the nation’s largest PBMs in September, citing their anticompetitive tactics as a barrier to health care access. In addition, a recent New York Times report found that PBMs often act in their own financial interest, including pushing patients towards drugs with higher out-of-pocket costs because it’s more profitable for the PBM.

It’s clear that PBMs have a significant role to play in rising health care costs here in Georgia. Unfortunately, last session Georgia legislators failed to help vulnerable Georgia patients by not passing a bill that would give the designated discounts directly to patients. During next year’s legislative session, state lawmakers must take action to implement meaningful reform. Policies that would increase transparency and accountability of PBM practices, such as requiring them to share any negotiated medication savings directly with patients, would bring immediate relief to patients struggling to manage high costs for care.

At the federal level, Congressman Buddy Carter has been a longtime champion of PBM reform and Congressman Jake Auchincloss is cracking down on inflated drug costs – it’s time our state lawmakers do the same. Policies that improve PBM transparency and accountability and ensure PBMs aren’t profiting at the expense of Georgia patients are commonsense solutions that should be a top priority when our state lawmakers reconvene next year.

Georgia Recorder is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Georgia Recorder maintains editorial independence. Contact Editor John McCosh for questions: info@georgiarecorder.com.