The reimbursement battle between pharmacies and pharmacy benefit managers (PBMs) continues stronger than ever. There seems to be little to no control in place on the PBM power to set predatorial maximum allowable costs (MACs), and they are taking full advantage.
So, how has the industry responded to this, and are the responses of any help to independent pharmacies? I hope to explore some of the programs and opine on their benefits and utility.
A number of options are now presented to patients with regard to getting their medications. As the number of insurers and PBMs have passed more of the cost burden onto patients, these solutions on the surface do present some potential savings to the patient, but how do they work, and does the pharmacy benefit? These programs range from Rx card programs such as GoodRx, to prescription processing websites, to creative insurance benefit provisions programs. In looking closely at these, from a pharmacy’s perspective, they provide reimbursement that, at best, may be marginally better than or very similar to the PBM plan. The only exception is manufacturer-sponsored Rx cards, which provide better benefits to the patient and some to the pharmacy filling the prescription. In most cases these cards are capping reimbursement to the pharmacy by creating margin for the sponsor.
Patients now also have the option, through sponsored websites, to go around their insurer and/or PBM and have their prescriptions filled either by mail order or through a pharmacy. The mail option obviously generates no benefit for independent pharmacy. Some of the site sponsors have negotiated contract rates with pharmacies for provision of services. While this does afford the pharmacy the opportunity to both participate and negotiate rates, in most cases the leverage in these negotiations is with the site sponsor and not the pharmacy. Once again, the site sponsor is building margin for itself, which in most cases is at the expense of the pharmacy.
Finally, pharmacies are now being solicited by organizations that suggest they negotiate directly with local employers setting up their own network and supposedly “cutting out the middleman.” While in theory this may sound good, putting this into place involves time, energy, and staff that a typical independent pharmacy may or may not have available. In a best-case scenario, the independent pharmacy will still be at the mercy of the sponsor and will run a reputational risk and be responsible to local employers and friends they have solicited for services that the pharmacy has no control over.
So what is independent pharmacy to do? As a pharmacist with over 40 years of experience, I see a couple of takeaways. First, the profession of pharmacy has historically done a poor job of both advocating for and elevating the profession. This is evidenced by the either minuscule or nonexistent Rx fill fees. Second, by stressing price and competition through chains and mail order over professionalism, the pharmacist value proposition within the healthcare spectrum now approaches nil.
It is very difficult, once the barn door has been opened, to close it — let alone recover anything that has been lost. However, assuming that nothing can be done is also of no benefit. While it may be a long and hard process, the process must be started nonetheless. As a healthcare professional, the pharmacist’s responsibility is to his or her patient. Pharmacists should not be restricted by a middleman to deliver their component to the healthcare continuum. When presented with a physician’s order, the pharmacist’s only consideration should be how to best meet the patient’s need in filling this order. The economic wants of an insurance company and or PBM should not be part of that equation.
Action Points
There needs to be greater direct involvement by pharmacists in pharmacy organizations, both at the state and the federal level. In some states this has helped pharmacy by disallowing the PBM’s ability to create financial disadvantages through affiliated parties.
Pharmacy organizations need to be more active at the federal level, ensuring that the patient relationship is not controlled by the insurer.
Pharmacy organizations need to continue to work to have reimbursement rates become more transparent. This will give pharmacists the ability on the buy side to ensure that they are not buying and stocking products that they have no hope of recouping the cost of at the time of dispensing.
In conclusion, current options seem to have one thing in common. They provide a workaround, differing in benefit for patient and cost for pharmacy without addressing any of the underlying issues and/or cause of the problem. In no way are they recognizing the pharmacist’s place within the healthcare continuum, let alone compensating for it.
Today pharmacists graduate with more clinical training and expertise than ever before. Their training affords benefits to the patient with regard to drug therapies, potential drug interactions, and disease state monitoring. Today’s pharmacists can administer vaccines and do disease state testing and monitoring for diabetes and other chronic conditions. It is only appropriate that the pharmacist’s contributions are recognized and compensated.
It is time the profession started a more aggressive process, both politically and directly with the insurers, whereby it can elevate pharmacists’ standing and acknowledge their vital contribution to healthcare. CT
Mike Sosnowik, R.Ph., is president of PharmSaver. Learn more about the company at www.pharmsaver.net.