When COVID-19 first hit America, it brought feelings of fear, uncertainty, and–perhaps strangely–of unity. Briefly in mid-March, the individualistic American mindset seemed suspended as we began to fight this global pandemic together.
But the moment was fleeting. In the following days, items like toilet paper and hand sanitizer were rapidly hoarded. One Amazon seller offered 15 N95 face masks for $3,799. When hydroxychloroquine was floated as a treatment for COVID-19, it was purchased so quickly that immunocompromised patients who needed the medication were forced to microdose or skip treatment altogether.
This behavior isn’t surprising. Our healthcare system has taught us to only protect our individual health–the health of our neighbor is not a concern. The problems we see during COVID-19 aren’t new but emblematic of a long-entrenched mentality about healthcare that pits people against each other to turn a profit.
Nearly a decade ago I decided to become a pharmacist. My naivety back then allowed me to see the order of operations the way I think it should be: a doctor prescribes a patient medication, a pharmacist fills the order, and the patient picks it up.
I did not anticipate the degree of involvement from middlemen. Although everyone knows about health insurance companies, less commonly discussed–and perhaps more nefarious–are the pharmacy benefit managers (PBMs).
PBMs are private companies that administer prescription drug plans for Americans who have insurance through health plans, unions, and more. PBMs play a complicated role of: negotiating formula placement with the drug manufacturer for a rebate; sharing the rebate and managing drug benefits for the health plans; and working with pharmacies to set the payment for medications and dispensing fees. Nearly 270 million Americans have their medicine benefits managed through a PBM.
PBMs arguably yield the greatest amount of power when determining price and access to medications. And they make sure they’re paid for it. In 2017, the PBM company Express Scripts reported revenue of $100 billion while Pfizer had a revenue of $52 billion.
Initially, PBMs had the honorable intention of using purchasing power to reduce drug costs, pass the savings on to consumers, and improve the quality of drugs. But between the consolidation of PBMs and the fact drug pricing is shrouded in secrecy, PBMs started to take more than their fair share. Additionally, PBMs receive a rebate that’s calculated as a percentage of the manufacturer’s list price, incentivizing them to push more expensive drugs. Insurance companies have to pay PBMs’ rebates and patients end up paying high copays to make up for the cost.
Before starting an online pharmacy, I worked at an independent retail pharmacy. One day, a patient came in for a standard cholesterol medication. I told him his copay for a 90-day supply was $90 and, unable to pay the price, he was forced to walk away. Unlike chain store pharmacists, independent pharmacists can see the acquisition price of each medication. I knew we had purchased that same amount of cholesterol medication for $2.
Because I had processed his claim through an insurance company, I had a contractual obligation to collect his copay–even though I could give him a better cash price on the medication. Patients like him repeatedly walked away from the counter because their copay was too high. So long as I worked within the system, I couldn’t help them.
To be fair, everyone knows our healthcare system is flawed; revising it is in every presidential candidate’s “Day One” agenda. But many Americans feel change is slow-moving and the system is too bloated for politicians to make meaningful strides. As the government struggles to rein in PBMs, among countless other issues, private companies have been stepping in to play an urgent role.
Time has shown us that innovation often starts outside the system. For instance, Netflix realized that if it created its own content instead of licensing from others, Americans might “cut the cable cord.” This concept challenged everything we thought we knew about the American consumer and has shown us what is possible when we don’t limit our creativity.
We see a similar shift in healthcare. Many professionals who worked within the system as doctors, pharmacists, and more are breaking away from the entrenched way of thinking and creating disintermediation. Consider Push Health, a software platform created by medical professionals and entrepreneurs who wanted to address inefficiencies in the system. Or Sesame Care, which connects providers and patients in order to provide up-front prices. Or Warby Parker, which saves customers money by creating its own affordable eyewear instead of purchasing through middlemen designers. Honeybee Health, the start-up I founded in 2017, is an online pharmacy with a similar mission. We cut out the PBMs and insurance companies in order to provide more affordable generic medications to the un- or underinsured.
During COVID-19, Americans have been turning to these start-ups with a renewed sense of interest. Telemedicine companies are experiencing a massive increase in users. Honeybee Health has seen a 50% increase in orders, and other companies in this space are likely no different. Unlike the government, these private companies were disentangled from the broken system before the global pandemic and, as a result, have been in a better position to protect Americans. COVID-19 isn’t creating us, but rather providing a chance for us to show our worth.
Unlike America’s fleeting moments of unity, I can assure you we’re here to stay.