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Why is it so difficult to get the medicines your doctor prescribes? Why do patients and families spend countless hours on standard care treatments? Why are potentially life-saving drugs delayed for weeks or months?
The question being asked too often can be blamed for one of the least understood issues in healthcare today: the role of pharmacy benefits managers (PBMs). Not doctors, these powerful intermediaries are increasingly deciding which medicines to get, how much to pay, and where to get them.
My role as CEO of PontChartrain Cancer Center has made the front row seating of systemic dysfunction PBMS permanent.
PBM was originally created to reduce drug costs and streamline access to drugs. (istock)
My 19-year-old daughter recently faced a medical condition requiring standard care prescribed by her doctor. Even with my specialist expertise, her doctor and I spent countless hours fighting PBM to approve her medication. It was finally approved in February, but it took her 10 weeks for her to have access to it.
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At every stage we encountered a system that no one wanted to take responsibility for. One after the other, I handed over the questions like a hot potato game. The psychological sacrifice of this ordeal on her, our family, and her medical team is beyond words. What hopes do other Americans have if I can't get through this deficit when I have all my resources and knowledge at my disposal?
Unfortunately, this is not an isolated incident. Millions of patients across the country face similar barriers. The ongoing number of PBM strangulation in medicine has forced them to withstand denial, delays and disruptions in care.
These are not merely inconvenient management. They are life-threatening obstacles. Patients suffering from cancer, chronic or rare diseases are caught up in a system that appears to value the benefits of PBM companies more than human life.
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PBM was originally created to reduce drug costs and streamline access to drugs. But over time they transformed into entities that manipulate the system to maximize profits at the expense of patients.
What's even worse is the vertical integration that allowed PBMs to control all aspects of the prescription drug supply chain. Today's biggest PBMS – Caremark RX, LLC (CVS), Express Scripts, Inc. (ESI), and Optumrx, Inc. (Optumrx) – It's not just about managing drug benefits. They also own pharmacies that fulfill their prescriptions and insurance companies that pay them.
This means they have financial incentives to prioritize their own interests at every step. It guides patients to their pharmacies, limits access to competing medications, and reduces out-of-pocket costs. With nearly 80% of prescription drugs controlled by these three PBMs alone, their decisions shape the healthcare experience for virtually every American. This vertical integration integrates power in a way that simply harms the patient.
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The Federal Trade Commission (FTC) recently revealed how three large PBMs equipped their drug supply chains to inflate costs and fill profits. The latest FTC report released in January 2025 highlights how PBMS has added important markups on the rise in costs for specialized generics, cancer, HIV and other life-saving drugs.
Even during federal investigations, the FTC report shows how these intermediaries can guide their income from 2017 to 2022 to their pharmacies, reimburse at a higher rate than their independent competitors, and engage in predatory practices such as spread pricing.
However, despite growing evidence and bipartisan demanding reform, Congress failed to act at the end of 2024. This missed opportunity is more than disappointing. Patients cannot wait while lawmakers are in politics.
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Congress must take immediate action to pass meaningful PBM reforms. House Energy and Commerce's Health subcommittee recently held a hearing to discuss PBM-driven price inflation, barriers to care and market integration. This testimony reinforced what patients and healthcare professionals already know. PBMs should raise costs, limit access, and don't lower them.
These reforms have broad, bipartisan support and represent real solutions. Patients deserve more than an ambiguous commitment. They deserve action.
President Donald Trump eliminated government waste, fraud and abuse and became the cornerstone of the administration's agenda. PBM reform is a clear extension of its mission. These intermediaries have long exploited inefficiency. Now it's time to restore transparency, fairness and patient-first policy to the system.
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Congress must pass meaningful PBM reforms – today, not tomorrow. For the countless patients my daughter and I have fought over the years, this is not an abstract policy argument. It's real, it's urgent, it's deeply personal.
It's time to put patients in front of profit and politics. Congress missed an important opportunity in 2024. In 2025, stop these life-threatening PBMs and restore humanity to healthcare. For my daughter and our loved ones, we can't afford to wait anymore.
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