State by State: Advocacy Advances PBM Reform, Part 2

Wisconsin Advocacy Ushers in PBM Oversight

In March, the Wisconsin legislature passed the

2021 Wisconsin Act 9

with overwhelming bipartisan support. Enactment of this PBM reform legislation establishes, for the first time, PBM oversight in Wisconsin. Establishing some regulatory oversight of PBMs is a huge win, said

Wisconsin Association of Hematology and Oncology

Board Member-At-Large Dean Gruber, RPh. PBMs will now be required to obtain licensure from the state’s Office of the Commissioner of Insurance (OCI). This step means that starting in 2022, the OCI will have authority to enforce legislation related to PBMs.

“A cancer diagnosis continues to be one of the greatest risks for bankruptcy in the U.S. today, and our patients need financial help,” said Kurt Oettel, MD, a past president of the Wisconsin Association of Hematology and Oncology. “The PBM business model, which was originally intended drive down cost of care, too often adds to the cost of care for patients. Additionally, the barriers placed by PBMs with step therapy or prior authorization add to unnecessary delays in care.”

Previously, due to the OCI’s lack of oversight authority, patients or pharmacies with a complaint about a PBM business practice in Wisconsin had little recourse. Shared frustrations over the inability to effectively arbitrate in these instances helped drive advocacy engagement, said Gruber.

The issue of lack of PBM oversight gained traction over time among diverse advocacy groups as more and more patients were affected, said Gruber, who was able to testify on behalf of the reform legislation in both the Wisconsin State Assembly and Senate. “At the end of the day, I think what’s good for the patient is good for healthcare,” said Gruber. This is patient-based legislation with patient-based protections that start to level-set the playing field.”

Compromise is a part of the legislative process. During the discussion about Act 9, there were a few concessions, and some provisions were removed. Advocacy work remains to be done, Gruber explains: “We need to continue to engage in dialogue with the PBMs, the Office of the Commissioner of Insurance, legislators, healthcare professionals, and most important, patients for continued change.”

The increasing need for oncology financial advocates, social workers, and other professionals to help patients engage their healthcare benefits is an added cost of cancer care delivery, said Gruber. “Because as a healthcare provider I cannot help patients with adherence, I cannot help patients with side effect management, I cannot help patients with knowing how to take their medications if they are unable to navigate their pharmacy benefits at the site of care that is best for them.”

For both the Tennessee Oncology Practice Society and the Wisconsin Oncology Hematology Association, advocacy aimed at PBM reform is an ongoing effort that requires patience, persistence, and perspective. Taking the long view, Dean Gruber describes the process as thinking about “how can we chip away at this day after day, quarter after quarter, because change is not necessarily going to come fast.”

Read more about the power of PBMs and how the Tennessee Oncology Practice Society helped advocate for recent reform measures.