Melissa J. Hinton: Pharmacy red tape gets in the way of health care

(Susan Walsh | AP file photo) Sen. Bill Cassidy, R-La., shows a chart during a Senate Finance Committee hearing with pharmacy benefit managers on Capitol Hill in Washington, Tuesday, April 9, 2019, exploring the high cost of prescription drugs.

I help people. That’s what I do. I’ve been a practicing nurse since 1986 and a nurse practitioner for the past 11 years. I’ve watched the health care profession entirely change when the coronavirus emerged.

Suddenly, nurse practitioners like me are in the spotlight, on the front line, rather than quietly doing our jobs in the background. Many of the nurse practitioners I know would rather be doing our work one patient or family at a time, rather than in public. But, now that NPs are more visible, I have a few recommendations that I think could make a positive change for all of us.

As a global positive change, know that every health care worker feels the stress of this moment with you. We see the statistics every day, the evidence of our patients' panic with every cough, and the arm’s-length distance that people keep between themselves and anybody wearing scrubs. Even in the difficulties of this year, we’re using our experience, education and personal approach to help people make it through their medical problems and their fears. We feel the weight of this. Each patient is an individual. Your nurse practitioner cares.

We’ve all seen the landscape of health care change significantly. The bureaucracy. The paperwork. The insurance red tape. All the ever-changing mandates and regulations and loopholes that lead patients to view health care as a burden. We all feel the frustration rather than feeling, well, healthy.

Which brings me to the local change. In my practice, I have come to dread the words “pharmacy benefit manager.”

Pharmacy benefit managers work for health insurers. They insert themselves as intermediaries between patients and their care providers. The PBMs' job is to secure “rebates” on prescription drugs to get preferential treatment on the insurers' drug plans. But this also limits which medications will be paid for on your plan.

For me, the decision on whether patients can use a particular prescription medication should be based on their personal health history and need. This can prevent more side effects and having to “try” multiple medications before we can use the right one.

Unfortunately, the reality is that these PBMs keep a chunk of the rebate for themselves and the health care plans, rather than the full discount going to the patient who needs the medication. That “rebate” the drug companies offer would otherwise go straight to the patient, not the PBM. In 2015, as much as $106 billion in rebates went straight to those PBMs, not the patients. This means that you may be paying out of pocket for the medication you need, but many cannot afford those high costs.

Earlier this year, the Utah Legislature considered changing this practice to pass those rebates to the customers at the pharmacy counter instead. At the last minute, the bill did not pass.

I’m a nurse practitioner, which means that I wear many hats. But I was not trained as a financial counselor. When I’m talking to patients about the medications that could help them live healthier, happier lives, I should be able to prescribe the medication that I need to without having to worry about which insurance company bureaucrats are taking how much of a percentage. And my patients shouldn’t have to worry about that either.

PBMs restrict medical practice and your access to medications. Ask your legislator to put some action behind those “clap for our heroes” gestures of gratitude so that you can get the care that you need. Because what I’d like to do most is focus on helping people like you. That’s what I do.

Melissa J Hinton is President of Utah Nurse Practitioners

Melissa J. Hinton, Salt Lake City, is president of Utah Nurse Practitioners and has a doctor of nursing practice degree from the University of Utah.

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