PhRMA recently joined two major forums in Washington D.C.—the Congressional Hispanic Caucus Institute’s Leadership Conference and the Congressional Black Caucus Foundation’s Annual Legislative Conference. Across both events, panelists emphasized that patients deserve a health care system that ensures timely, reliable access to the medicines their doctors prescribe.
But today, too many patients face unnecessary obstacles caused by two issues that stand in their way:
- Utilization management (UM) tools like inappropriate prior authorization and fail-first requirement barriers, which delay or deny treatment.
- Pharmacy benefit manager (PBM) practices, which drive up costs and limit coverage by excluding more medicines from formularies every year.
Together, these practices create a system where patients are forced to wait, fail first on less effective therapies or never gain access to the treatments they need.
The Growing Burden of Utilization Management
UM tools were originally intended to manage costs, but in practice, they have sometimes become roadblocks to care. Patients and providers alike report that these tools delay treatment, deny coverage and undermine trust in the provider–patient relationship.
The Role of PBMs
At the same time, PBM practices compound these barriers. Often, PBMs do not pass negotiated savings on to patients, they have increasingly excluded lower cost medicines from formularies and mark up medicine prices at their affiliated pharmacies. These decisions leave patients with fewer options, higher out-of-pocket costs and longer waits for the medicines their doctors believe are best.
Where We Go From Here
Patients deserve a health care system that prioritizes timely access, affordability and trust. Reform is needed to:
- Modernize utilization management practices.
- Address harmful PBM practices that keep medicines out of reach.
- Strengthen trust between providers, patients and the system.
It’s time to modernize our system so that medical innovation reaches people when they need it, not after unnecessary delays or denials. PhRMA remains committed to working with policymakers, providers and community partners to make that a reality.