PBM Delays Put Patients At Risk, Oncologists Warn

By Consumers For Quality Care, on March 13, 2019

Cancer patients are facing delays in receiving care and access to critical oncology drugs as a result of pharmaceutical benefit managers (PBMs) practices. These delays, oncologists warn, are putting their lives at risk, Medscape reports.

“[A] patient had metastatic kidney cancer, and his oncologist was seeking to treat him with sunitinib malate (Sutent, Pfizer), a preferred first-line oral therapy. But the patient’s pharmacy benefit manager (PBM) refused to cover the cost of the medication. The PBM told the oncologist that the patient’s kidney must first be removed.”

The patient’s oncologist concluded that due to the extent of the disease and the patient’s coexisting conditions, he was not a candidate for surgery. The patient waited three months as his doctor and his PBM fought over the course of treatment. During that time, he did not receive treatment. Finally, the PBM relented.

Dr. Michael Diaz, a medical oncologist and president of the Community Oncology Alliance (COA), says that the delay in delivering treatment is concerning. The patient could have and should have received treatment, but instead waited as parties quarreled. Moreover, the PBM attempted to direct the care for a patient it had never met.

The PBM does not have the same liability as the physician on record. “They have no repercussions on their end — and yet they’re making medical decisions,” he noted.

The COA has been collecting patient stories for years and it has become increasingly clear to oncologists that PBM delays have major impacts on cancer patients. Delays are usually due to prior authorization issues or an increasingly complex health care system that confuses consumers. When dealing with diseases as advanced as cancer “delays can mean the difference between life or death.” As more oral cancer drugs are prescribed, the issue becomes a greater concern for consumers.

Lisa Day, a pharmacy technician in Ventura, CA, says that when pharmacies have to jump through hoops for consumers, wait times for medications can jump from a day to over a week, a month, or longer.

“During that time, we’ve had patients say, ‘Forget it, I’m going on hospice,’ ” Day told Medscape Medical News.