Value of Medicines: PBM waste makes valuable drugs valueless
On Oct. 28, 2016, my mother, Joan Biamonte, died of complications from metastatic carcinoma of the lung. Despite having her original tumor characterized and going through a regimen of chemotherapy allegedly tailored to her tumor type, her cancer proliferated and spread into her liver and brain.
After she passed away, well into 2017 there was still a shelf of one of the kitchen cabinets filled with the medications she used to take. Crestor. Diuretics. Painkillers. And her cancer medications. My father has since bundled her unused drugs into a plastic bag in the basement, awaiting legal disposal.
While looking for something else, I found her Afinitor (see the photo above) – an unopened box of 28 pills and several packets. Considering that the “listed” pharmacy price online for Afinitor is $14,524.24 for 28 pills, that is some serious money sitting there.
My mother had to stop taking Afinitor because she experienced just about all the debilitating side effects and it had no effect on the spread of her cancer. But that’s not the reason for all those extra pills.
Back in July 2016, my mother was explaining to me how much time she had spent on the phone with her PBM. “They don’t know basic math,” she complained.
Her regimen was one pill a day for two weeks, then a week off. A “month’s” worth of medication under that regimen was literally 14 pills. So one box covered two months.
However, her PBM sent her three months of her prescription, as most PBMs do – so something like three boxes (84 tablets) arrived at a time. This was a logical assumption for a regular, generic, small-molecule drug, but this protocol worked less than well with a high cost, complex antineoplastic agent.
It took my mother a lot of hours on hold and then finally talking with at least two or three people to get them to stop sending her the Afinitor in job-lot quantities. And they didn’t want the extra back, for fear of contamination and tampering.
Who paid for that Afinitor? For the most part, Medicare. My mother had her share of costs to pay, but less than $72,000 comparatively speaking (I think she still had to pay about $10,000 and some of that was covered by supplementary insurance, but it was still a hit for someone on a fixed income). And because of the general non-transparency of PBMs, there is little chance of knowing just exactly how much that Afinitor cost Medicare.
This incident is probably just one of many, not just at this PBM but at others as well. There are probably millions of dollars in excess, expensive medications sitting on shelves all across the country, as someone at a PBM shrugs their shoulders and thinks, “Well, so long as their insurance is paying for it…”
According to Dan Renick, president, Precision for Value, “there’s been some movement in the market to allow specialty drugs to be delivered by local pharmacies.”
This is “because as we get into these very high-cost drugs, even marginal mismanagement ends up being a very large expense to the system,” he says, “We all pay for that. In that case, depending on the out of pocket payment, you personally pay, and we have a lot of waste in the system.”
Precision for Value has seen that if a healthcare system bears more risk, “they become more sensitive to things like that and tend to handle it better. For example, in our work with clients we sometimes do something called ‘private care optimization,’ where it’s just not treating a patient, it’s treating them in the more efficient and effective side of care. It allows them to access, and better afford care, and eliminates waste.
“It’s got a lot of benefits if it’s done correctly but again it’s another one of these changes that can be difficult to put in place because there are so many deeply embedded ways of going about doing the business.”