Winners and losers in the prescription drug market

The experience of shopping for our medications is awful. We spin a roulette wheel every time we fill a prescription, with no transparency into the cost of the drug or whether there are appropriate alternatives that could make medications more accessible or provide cost savings. We are unwitting participants in a disempowering system that limits choice, adds billions to the cost of drugs, adds hundreds of billions to the cost of healthcare, and too often forces those with the greatest need to make costly trade-off decisions.

It’s something I call the prescription drug debacle.

The dysfunction of our prescription marketplace is made worse by the absence of an advocate who looks out for our best interests. We used to rely on our trusted neighborhood pharmacist to advise and guide us, but in the current structure they are victims themselves — struggling to financially survive while being captive to a system that creates obstacles in the way of providing quality care. Insurers are financially motivated to either pay as little as they can for our medications or, in some cases, profit from them. Pharmaceutical companies are incentivized by the system to treat every condition with another prescription, instead of being compensated for the positive results of their product . Where does this leave the consumer?

The costs borne by the prescription drug debacle are real.

We waste our time trying to understand our healthcare benefits and the convoluted rules and pricing logic that determines which drugs are covered, under what conditions, and at what cost. We go back and forth with our doctors and pharmacists (while they go back and forth between each other or their respective call centers) trying to get answers. Doctors rarely have visibility into affordability, and pharmacists are left interpreting and enforcing the rules, or risk going unpaid.

We spend more money (a LOT more) for the prescriptions we take because our options are either restricted or unknown — whether a different pharmacy could offer the drug at a lower price, or if an alternative, less expensive drug could deliver the same or better results. There are countless examples of how the current system, in pursuit of profits on drugs, purposely blocks access to more affordable options. Worse yet, drug prices are artificially inflated as middlemen arbitrage the market and extract “rent” in exchange for allowing others (pharmacies, employers and manufacturers) to participate.

We sacrifice our health when we succumb to the system’s disempowerment. Americans abandon prescriptions at the pharmacy counter approximately 450 million times each year because their medication is not covered, or they can’t afford it even if it is. These abandoned prescriptions drive another $300 billion annually in avoidable medical costs in the form of additional visits to the doctor, trips to the emergency room, or hospital expenses. Employers bear the additional expense of their employees’ lost productivity and increases in absenteeism.

While there are many disturbing stories that demonstrate the personal impacts of this situation, one very real example that exemplifies the problem is the 2018 report of a 38 year old San Antonio teacher who made a difficult decision many are faced with every day. A second-grade teacher and mother of two, she was diagnosed with the flu and prescribed an anti-viral medication, and when confronted at the pharmacy counter with a co-payment in excess of $100 she walked away because of the cost. Her husband eventually insisted that she take the medication, but it was too late. She passed away a few days later due to complications from the flu.

No one in this country should be faced with the choice she had to make. These are the unacceptable costs — and the people who have the most to lose — that result from the prescription drug debacle.

So who wins?

The costs are clear and the impacts on consumers and employers are stark. But not everyone gets the short end of the stick in the prescription drug debacle.

The U.S. prescription drug market is organized around a group of companies called pharmacy benefit mangers (PBMs) that serve as middlemen coordinating our access to drugs, the price we pay and our options as consumers. It’s the PBMs that prop up a structure that is out of sync with modern consumer expectations, and that disempowers patients, drives up costs and ultimately makes us less healthy. When we’re sicker, we work less and cost the medical system even more. Existing incentives are perfectly designed to keep it that way.

This market is ripe for disruption. It’s time for a new model that places the consumer at the center, armed with the information and choice to take control of their prescription drug purchasing and their health.

It’s time to end the debacle.  See how we’re rewriting the script.