Opinion/Guest column: Reining in PBMs best prescription for patients

By: Mike Ashworth | Worcester Telegram & Gazette | April 13, 2025

"As a foundation dedicated to helping heart failure and transplant patients, we at the HeartBrothers Foundation see firsthand how burdensome health care costs can impact recovery. Pharmacy benefit managers, or PBMs, originally intended to reduce drug costs, have become barriers to access and drive up prices through perverse incentives. Congress must protect patients by passing meaningful PBM reform this year.

I am a transplant survivor myself. Ten years ago, I received the call that would change my life and begin a lengthy recovery. This followed several years of surgeries and treatments for a major heart attack, damage to my left ventricle, congestive heart failure and significant surgical complications.

Over the years, I have relied on several treatment options to manage my symptoms. Like other transplant survivors, the insurance coverage I pay for makes it possible for me to afford these lifesaving medicines. This is why it’s so crucial that Congress rein in the damaging practices of PBMs that can make it more difficult for patients to access and afford the drugs they need. I, monthly, have to argue with my PBM to get my anti-rejection medications. In August, because a prescription was submitted incorrectly, I was forced to pay $1,062 to access my Siromilus.

HeartBrothers CEO, Mike Ashworth

Unfortunately, this is a common occurrence for transplant patients. As a foundation, we receive daily requests for help with the financial burdens of obtaining medications, and we are precluded from helping patients in this manner due to grant restrictions.

PBMs and insurers negotiate significant rebates from manufacturers for drug placement on formularies but often keep these savings instead of sharing them with patients. In response to this practice, the U.S. Senate Finance Committee passed S.3430 last year, which requires PBMs and insurers to share rebates with patients at the pharmacy counter, a crucial change for heart transplant recipients who need costly immunosuppressive drugs.

Once a patient meets their deductible, cost-sharing is based on the medicine’s net price instead of the inflated list price by PBMs. This reform aims to reduce costs for transplant patients facing expensive treatments while encouraging stakeholders to prioritize patient outcomes over profit margins.

Patients also face challenges due to how the current system incentivizes PBMs to promote higher-cost drugs. PBM fees are linked to list prices, leading them to favor expensive medications over more affordable, effective alternatives. This situation can result in higher costs and limited options for heart transplant patients, adding stress during their critical recovery period.

Senate Bill S.2973 aims to delink PBM service fees from coverage or formulary decisions, eliminating harmful incentives that prioritize expensive drugs over affordable alternatives. This reform would ensure patients receive appropriate medications to manage their illnesses rather than those that simply increase PBMs’ profits. Delinking PBM fees from drug prices is essential for making medicine more affordable for Medicare beneficiaries and saving taxpayer dollars.

Congress has demonstrated bipartisan support for efforts to bring savings back to patients by reining in PBMs. Last year, several congressional committees took up these crucial reforms and even questioned PBM executives directly. The Federal Trade Commission has published two reports on how PBM business practices impact independent pharmacies and patient costs. Meaningful PBM reforms were nearly included in a year-end spending package but ultimately did not make it across the finish line.

We fell short last year, but the fight continues. The House Energy and Commerce Health Subcommittee recently heard testimony on how regulating pharmacy benefit managers can lower patient costs and increase competition. Congress must maintain this momentum to bring fairness and transparency to an industry that desperately needs it. These reforms offer hope to millions of Americans living with chronic conditions, including those in the heart transplant community whom we work with every day."

Mike Ashworth is president and CEO of the HeartBrothers Foundation, a Northborough-based nonprofit organization dedicated to helping heart failure patients and their families.

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