the PUTTblog

A fascinating, if somewhat imperfect, move this month by Blue Shield of California is sparking interesting questions about the future of the “Big PBM” business model and where it might go from here.

Late last week Wisconsin’s Circuit Court, Branch II, joined the California Court of Appeals in finding OptumRx’s forced arbitration contract clause “unconscionable.” The judgment is a victory worthy of its own fireworks, but it surely also came as a huge relief to Wisconsin pharmacies, whose fellow pharmacies in the neighboring state of Illinois received a very different ruling from their 5th District Appellate Court.

OPINION: Do you know who else your lobbyist is working for?

Davis City Pharmacy was originally founded in 1892. Located about half an hour’s drive west of Ft. Worth in Weatherford, the founders of this Texas treasure surely never imagined a world in which 21st century robber barons would have it in for their little community pharmacy - and could possibly permanently close the doors of the 131-year-old small business...

.. How the other pharmacy came to use her NPI is still a mystery (not exactly NPI theft or spoofing, no money paid to that submitting pharmacy, no actual evidence of a crime), but even more mysterious is why CVS Caremark hasn’t reinstated Leah’s pharmacy’s access to billing after she fulfilled every request they made as a condition of reinstatement?...

Florida Governor Ron DeSantis’ January 12th announcement calling for tough new anti-PBM abuse laws was a surprise to many - but not the dozens of small business pharmacy owners who’ve spent years petitioning lawmakers and advocating for change.

PUTT member Ben Levene, who is also a board member of Florida Small Business Pharmacies Aligned for Reform (SPAR), shared some of his thoughts behind Gov. DeSantis seemingly “sudden” decision to pursue legislation that would curtail PBM profiteering...

Happy Holidays! Is it 2023 yet?

Kidding! 2022 was such a good year for PBM reform, we’ll be a bit sad to say goodbye.

We spent much of this year focused on PBM reform education, with PUTT Executive Director Monique Whitney participating on panels at the annual Community Oncology Alliance conference in March and the Partnership to Advance Cardiovascular Health (PACH) in November, in addition to talking to members of the media whenever possible.

Like many of you, we participated in the spring and summer FTC hearings, urging the commissioners to investigate PBMs over practices that disrupt patient care and drive so many pharmacy owners to the brink of - and sometimes beyond - permanently closing. And when the FTC voted unanimously to proceed with the investigative study, that sound we collectively heard in June was the implosion of PCMA’s “shift the blame” strategy (and possibly a rolling head or two).

PBM reform is a united effort, and PUTT was proud to strengthen relationships with other organizations leading the way...

Now that midterm elections are mostly complete, we’re grateful for the reprieve from political ads, debates, texts and robocalls. While midterms are generally not as flashy as their presidential counterparts, they can still have a big impact on proposed legislation.

What Happened This Year:

Redistricting created thousands of new legislative districts that produced new names on many ballots, leaving pharmacy owners across the country hoping Congress continues the push for transparency (and karma) on drug pricing and PBM reform.

Local pharmacies proved to be important touchpoints of healthcare access for patients...

A local pharmacist recently alerted us to a dramatic increase in seemingly predatory east coast area DEA inspections. These inspections appear laser-focused on administrative processes, levying hefty penalties for reasonably minor clerical missteps.

The pharmacist* noted, “Our pharmacy has never had a red flag or been cited by a regulatory agency, yet the agent seemed intent on finding any possible means to assess an exorbitant fine, no matter how irrelevant...

“You should expect a choice of health care providers that is sufficient to ensure access to appropriate high-quality health care.”  – TRICARE Beneficiary Brochure

An apt description of how most of us already feel, “Lost Care and Broken Promises” is actually how Military.com first labeled the travesty of TRICARE decisions that left thousands of active military and retired veterans without access to local medical care at nearby military bases in 2020. 

Just 2 years later, TRICARE - or should we say Express Scripts, because we all know whose job it is to ensure network adequacy - is at it again, this time cutting 15,000 pharmacies from the TRICARE network effective October 24, 2022. Predictably, Express Scripts has the Department of Defense doing its dirty work, making the announcement through official channels and citing “cost savings” as its rationale, even as Express Scripts is wasting no time steering active and retired military to ESI-owned pharmacies and charging a tidy administration fee in the process.

Dear PCMA,

We need to talk. It’s not good news.

First, we feel we should thank you. Remarkably, your clients have somehow united the U.S. in a way usually reserved for terrorist attacks and tragic natural disasters.

Also, we’re impressed at your latest PR offensive. How fascinating to watch the public’s overwhelmingly negative reaction to your recently published opinion pieces defending PBM business practices and claims of value generation.

But it’s time for some tough love. Even your recently-released white paper assessing the (economic) value of pharmacy benefits management is stretching to salvage what may soon become an unsalvageable public image. At this rate you’ll soon join the ranks of the tobacco industry and other notorious industry charlatans who profiteered at the expense of people’s health and safety. You don’t really want that to be your legacy, do you?

In our battle against PBM dirty practices, it’s important to remember our friends across the country who were able to accomplish the goal of passing independent pharmacy-friendly PBM regulation at the state level this year.

As pharmacy owners, it’s easy to focus on the losses we see in our stores, whether it’s a long-time customer who is now in a plan we can’t take, or seeing a dreaded negative reimbursement (or DIR fee report.) That makes the victories that much sweeter, so don’t miss a chance to uplift our friends. All of these victories are in part because all of YOU continue to get loud, and demand action for your patients and your pharmacies.
We all know it’s going to take every one of our regulatory agencies to try to beat the PBM Whack-a-mole game.

Many PUTT members use the summer legislative break to invite lawmakers into their stores. This is an excellent opportunity to show your elected officials how many potential voters from their district you interact with daily, so be sure to take advantage if you can.

One highly important thing to remember when discussing proposed legislation with legislators is the matter of “agreed upon bills”. This does not refer to bills "agreed upon" between Independent Pharmacies and PCMA and/or the Health Insurance Plan lobbyists. “Agreed upon bills” means bills agreed upon between business & labor groups like chambers of commerce and unions. Try to make sure you have support from entities of both sides to drive home any reform points. No one assumes we will agree upon a PCMA-supported bill.

Two states that seem to be continuously on the cutting edge of regulation and reform at the state level are Louisiana and Texas. Here are three different trends we believe should be on everyone’s radar:

Last month, Janssen Pharmaceuticals released its 5th annual U.S. Transparency Report with a notable new addition: a detailed synopsis of how rebates, now hard-wired into insurance benefit design, essentially derail patients from accessing affordable medication.

As March is storming "in like a lion", recent developments at both the state and federal levels may have PBMs feeling buffaloed. And while February's FTC hearing was deadlocked thanks to the “no” votes of 2 FTC commissioners. PUTT, along with multiple other advocacy organizations responded immediately with statements condemning the move.

January marks the start of legislative sessions for most states in the U.S. and is one of the busiest times at PUTT. During the legislative season we monitor hearings and weigh in where invited (or not); seek out and provide evidence where invited (or not); and publish information and documents to help educate legislators and the public understand how PBM abuse harms patients, their employers, and the healthcare system.

Prescription drug cost is one of the few issues everyone can agree needs addressing, yet very few politicians seem able to abandon party-line rhetoric to confront the issue.

If you thought 2021, aka the follow-up to When Satan met 2020, seemed like a mixed bag of forward momentum and frustrating setbacks in the move to reform PBMs, you’re in good company.

It’s feeling a lot like PBM reform is getting really real as the largest pharmacy benefit managers, especially those that might own or exert enormous influence over large retail pharmacies, come under fire for issues related to real-world concerns for patient safety, drug pricing and limiting access to medications.

Like many community pharmacies, Newman Family Pharmacy is the kind of pharmacy patients choose for its incomparable commitment to service and care.