Retail pharmacies are stepping in to help speed up Covid-19 vaccinations much earlier than anticipated after calls for states to take more advantage of their networks and experience.
Independent and chain drug stores weren't supposed to take a large role in distributing the vaccines until later stages, when doses will be much more widely available. But the halting rollout so far has sent governors scrambling for alternatives to hospital systems and local health departments, which have been handling most vaccinations so far.
New York this week is expanding distribution to hundreds of pharmacies throughout the state so health care workers or people ages 75 and older have more options to get vaccinated.
"They know how to do this," Gov. Andrew Cuomo, a Democrat, said at a briefing Friday. He said 1,200 pharmacies had committed to help speed distribution, in addition to other health care providers.
Louisiana made a similar announcement Monday, and some of the biggest chains in the country are widening their distribution to help with states' Phase 1 plans.
Rite Aid said Monday that it had agreements to immunize Phase 1 groups in Delaware, New Jersey, New York City and Philadelphia. In Florida, pharmacies inside some Publix Super Markets began administering vaccinations Friday.
The states generally aren't widening who's eligible to be vaccinated — just adding to their lists of distribution points.
Experts said it's an important step in ramping up distribution, one that makes sense given the millions of flu shots pharmacists administer every year. Continue Reading
The Washington Examiner
By the end of December, West Virginia had given all roughly 28,000 staff and residents of nursing homes and other long-term care facilities in the state the first dose of the coronavirus vaccine.
It was a remarkable achievement, especially given that only about 429,000 doses have been administered to long-term care facilities nationwide, according to the Centers for Disease Control and Prevention.
The key was Gov. Jim Justice’s decision not to use the federal Pharmacy Partnership for Long-Term Care Program. Rather, he let state and local agencies work with private healthcare providers to administer the vaccine.
“As we looked at the federal program and the makeup of our pharmacies in West Virginia, it became that the federal program might not be the best avenue for our state to tackle long-term care facilities,” said Krista Capehart, director of professional regulatory affairs for the West Virginia Board of Pharmacy, one of the agencies responsible for coordinating the effort.
Under the federal program, vaccines are distributed via two large chain pharmacies, CVS and Walgreens. According to Matt Walker, director of the West Virginia Independent Pharmacy Association, it made more sense for West Virginia to rely more on independent pharmacies.
“West Virginia is a small, rural state, and we don’t have a city with more than 50,000 people,” Walker said. “But what we do have is many small communities with small pharmacies that are trusted in those communities.”
About 45% of the pharmacies in West Virginia are independently owned, according to Capehart.
The West Virginia Board of Pharmacy opened the state distribution plan to all pharmacies, including CVS and Walgreens, although only Walgreens participated. Continue Reading
How small pharmacies are playing a big role in COVID vaccine distribution in rural towns: "It's like the Super Bowl"
"Taking care of patients is the ultimate goal of a community pharmacist," said Steven Hoffart. His career as a pharmacist brought him back home, to Magnolia, Texas, outside Houston, where the population is just over 2,000 people.
He is the owner of the independent Magnolia Pharmacy.
Correspondent Mireya Villarreal asked, "Does it make it extra special knowing that this is where you grew up and you're giving back to your own town?"
"Yes," he replied. "It's real heartfelt."
At the beginning of the pandemic, Hoffart stepped up to make hand sanitizer for those on the frontlines. Now, he's stepping up again, by distributing 500 doses of the Moderna vaccine.
There are about 23,000 independent pharmacies in the U.S., and many are the backbone of their community. Now, they are helping fight COVID misinformation, and administering the vaccine in areas where medical resources and access are often limited.
"We have great relationships with our community," Hoffart said. "So, being able to make sure that we're able to get those patients in on a timely manner, it's a challenge, but it's something we're working through every day."
Texas is currently vaccinating Group 1B, which in this state is residents 65 and older, and people 16 and older with medical conditions that could put them at risk for severe illness with COVID-19.
Jane Bough, who got the vaccine, will be 85 years old next month. "I survived 2020," she said.
Her son is an anesthesiologist. "He said, 'Mom, if you could have been in the emergency room with me or the ICU and seen all the people I have put to sleep paralyzed, intubated, you would run to get this vaccine,'" Baugh said.
Big pharmacy chains like CVS and Walgreens contracted with the federal government to help distribute vaccines, but those chains aren't always in rural communities, leaving independent pharmacies to fill in the gaps, with both access to quality care and factual education on vaccinations.
Independent pharmacies across the country, from small towns to big cities, are struggling to stay afloat, and it’s not just due to the coronavirus pandemic. Perkins Drugs & Gift Shop in Gallatin, Tenn., abruptly shuttered both of its locations this summer after serving the area for 125 years. Rolet Pharmacy in Chicago was forced to close its doors for good this past August. The reason? Skyrocketing fees retroactively taken from pharmacies by corporations known as pharmacy benefit managers, or PBMs.
PBMs are the middlemen hired by health plan sponsors to administer prescription drug benefits. They often assess fees on pharmacy transactions after a patient has picked up and paid for a prescription — sometimes as many as six months after — without giving pharmacies even a ballpark estimate of how much they could expect to owe when the bill comes. These unpredictable fees are known as “direct and indirect remuneration” or “DIR” fees, and when applied to thousands of individual transactions, can add up to substantial sums and deny independent pharmacies the financial certainty needed to operate a small business.
To understand how DIR fees work, let’s say it’s Friday afternoon and your boss comes by your work station with your paycheck. You go ahead and deposit the paycheck, you make a mortgage payment, buy groceries, and other necessities. Several months go by, then your boss drops by your station again to tell you that you owe back a big chunk of that paycheck, even though the money has already been spent. Since you didn’t budget for this clawback, you either do not have the money to fund it, or you pay it and can no longer afford your other bills that are coming due.
This is essentially what PBMs are doing to independent pharmacies, over and over again, and it’s forcing them to close. Continue Reading
ABC KAIT8 News
The United States Supreme Court on Thursday, Dec. 10, sided with pharmacists regarding the Pharmacy Benefit Manager (PBM) regulation.
Rutledge v. Pharmaceutical Care Management Association (PCMA) centered around Act 900. Arkansas passed the law in 2015 prohibiting PBMs from reimbursing local pharmacies at a lower rate than they pay to fill prescriptions.
PBM’s are the middleman between pharmacies and insurance companies.
The large organizations negotiate prices pharmacists pay, and in recent years, the amounts reimbursed to pharmacies have dropped.
Attorney General Leslie Rutledge said she believes this has left independently owned and rural pharmacies struggling, with more than 16 percent of rural pharmacies closing in recent years.
In its unanimous decision, the nation’s highest court ruled that Act 900 “amounts to cost regulation” and overturned the Eighth Circuit decision.
Following Thursday’s decision, Rutledge issued the following statement:
“This is an important unanimous win for not only locally owned pharmacies that have experienced financial hardships at the hands of pharmacy benefit managers, but more importantly, this is a win for all Arkansans and Americans to have access to affordable health care. I will always protect Arkansans and small businesses from unfair practices and fight to lower the costs of prescription drugs." - Leslie Rutledge, Arkansas Attorney General
To read the SCOTUS decision, click here.
NBC Nightly News with Lester Holt
One evening in mid-June, Megan Becker stepped outside of her Las Vegas home and scooped up a package containing her medication, a monthly injection to prevent debilitating migraines.
It was a sweltering night – the temperature hovered just below 95 degrees. When Becker opened up the package, which arrived a day late, she found that the ice packs were melted and the medicine, which is supposed to be refrigerated, was warm to the touch.
“They literally just dump the box on my front stoop, regardless of the weather,” Becker, an English professor at the University of Nevada, Las Vegas, said. “It’s just such expensive medication and it seems like such a careless way to deliver it.”
Shortly after the drug, Aimovig, hit the market, Becker began picking it up from a nearby pharmacy. But last year, her health insurance confronted her with a choice: switch to the Express Scripts mail-order pharmacy and get it for roughly $50 per month, or pay out of pocket for the more than $600-per-dose medication.
Becker fought to keep picking it up locally, but said she gave up after two months of what she described as maddening calls with Express Scripts.
“I really, really, really did not want to get it this way and I was not given an option,” she said.
Millions of Americans receive their medications by mail but many, like Becker, find themselves forced to do so by their insurance plans or face the prospect of paying exorbitant amounts for the same drugs.
An NBC News investigation found the growth of mail-order pharmacies has caused many people to feel trapped in a system that has left them with crushed pills, damaged vials and lifesaving drugs exposed to extreme weather.
Interviews with more than 65 mail-order pharmacy customers across the nation revealed deep worries over how their medication is delivered — and no affordable alternatives. Many reported receiving drugs in flimsy packaging without temperature indicators, which can cost as little as a dollar per package. Others have had to plead with pharmacies to send them replacement drugs after receiving medication they thought arrived too warm or cold.
The industry is massive, generating billions in annual sales, but it occupies a gray area with little regulation and even less enforcement, NBC News found.
“It’s a quagmire,” said Georgia state Rep. Ron Stephens, a pharmacist, who has sponsored multiple bills to increase patient choice when it comes to pharmacies. “If they’re sending it without a temperature strip, and you’re the recipient of insulin or a lifesaving drug, you’re taking your life into your hands,” the Republican said.
One vial of insulin costs between $3 to $6 to manufacture. There are more than 200,000 diabetics in Virginia alone who rely on the medication to stay alive. But around a quarter of those people skip doses they can’t afford. Although the nearly century-old drug is relatively simple and inexpensive to produce, patients are charged more than $300 a vial.
Gary Dougherty, the director of state government affairs at the American Diabetes Association, said a lack of transparency around prescription drug pricing is the root problem.
On Monday morning, members of the Virginia House of Delegates Drug Pricing Workgroup assembled via Zoom to discuss potential solutions.
The Problem is PBMs
Several experts on the prescription drug supply chain joined the workgroup meeting, and all drew essentially the same conclusion. The main contributor to out-of-control costs is an utter lack of transparency, particularly with regard to pharmacy benefit managers. Pharmacy benefit managers, or PBMs, are companies that manage prescription drug programs for health plans and insurers. PBMs negotiate with drug manufacturers on costs, as well as determine which drugs will be included on a health plan’s “formulary.” The formulary is a list of specific drugs that will be covered by an insurance plan.
Dr. Madelaine Feldman, a New Orleans-based rheumatologist and advocate for transparency who joined the workgroup meeting Monday, said this relationship creates a set of “perverse incentives” that lead to higher costs.
Basically, PBMs make money for each prescription filled at a pharmacy. To convince PBMs to include their drugs on a given formulary, manufacturers will offer rebates on the drug as well. Feldman explained a hypothetical formula that determines PBM profit: the manufacturer’s listed price for a drug x the percentage rebate offered to the PBM x the number of prescriptions filled. The manufacturer has little control over the third variable, but is incentivized to increase both the list price and the rebate percentage to convince PBMs to put drugs on the formulary.
Rather than drugs that are the most efficacious, for instance, being offered to patients, often the ones on the formulary are simply the most expensive. To further complicate matters, these contracts between drug-makers and PBMs are considered proprietary, which means no one knows exactly how much money is exchanging hands or what is reflected in drug prices.. Oftentimes, the only way to get the data, Feldman said, is to sue.
The language PBMs use to market their services further obfuscates the issue, Feldman said.
The Trump administration finalized a rule Friday that gets rid of the safe harbor shielding Medicare Part D rebates from the anti-kickback statute and a rule that will tie certain Medicare Part B drug prices to those paid by countries overseas.
Trump called for both rules to be published during a flurry of executive orders back in September. The rebate rule is expected to generate significant pushback from providers, payers and pharmacy benefit managers (PBM) that say it will harmfully impact seniors' access to cheaper drugs. The so-called most-favored-nation rule will also change how providers get paid for administering and storing Part B drugs.
The rebate rule will replace the safe harbor for Part D rebates, meaning they could be targeted under the federal anti-kickback law, with a new safe harbor that applies only to discounts offered at the point of sale.
The goal is to curb the use of rebates in Medicare Part D, which Health and Human Services Secretary Alex Azar has described as a "kickback" that drug companies must give to pharmacy benefit managers and insurers in order to get on their plan formularies.
HHS put out a proposed rebate rule in 2018 and it generated intense pushback from the insurer and PBM industry. The industries complained the rule will raise premiums for Part D seniors, pointing to a report from the Centers for Medicare & Medicaid Services' actuaries that the rule would lead to a 19% hike in premiums.
A report commissioned by the PBM industry group Pharmaceutical Care Management Association said that the rule would also hike federal spending and is unlikely to lower prices.
Payers and PBMs are worried that the rule would remove a key negotiating tool that they have with drug companies to ensure lower prices. In turn, the pharmaceutical industry has been a major proponent of the rule.
Rebates have generated PBMs and insurers a lot of money. A 2018 analysis from the consulting firm Altarum found that insurers got $89 billion in rebates from drug companies in 2016.
The threat of premium hikes to seniors was a major reason the White House scuttled the rule last year and its revival is a boost for Azar, who has complained that PBMs don't pass on the savings from rebates to beneficiaries.
Deborah Keaveny owns and operates pharmacies in Winsted and Cokato, and was featured in a Nov. 1 article in the Star Tribune.
She is also responsible for starting a Google group called MNlndys - Minnesota Independent Pharmacies, which currently has more than 100 independent pharmacy members.
"We needed a way to be able to talk about what is working in stores and what is not," she said. "Independent pharmacy has hit a point where we really are fighting to survive, and fighting together is much better than fighting alone."
Going Up Against Giants
Independent pharmacies have been wrestling with Pharmacy Benefit Managers, or PBMs, to keep their customers for several years. Continue Reading
ABC7 Talk Business & Politics
An audit performed for the Arkansas Insurance Department of the state’s three dominant pharmacy benefit managers found different-sized pharmacies were paid different amounts for the same drugs last year, though in most arrangements it wasn’t considered significant, and that at least two of the PBMs charged pharmacies “clawback” fees.
But one PBM, CVS Caremark, says differential payments are normal, and it objects to the audit’s reliance on only one contract to make a determination about those clawback fees, which were legal at the time.
The limited scope examination was conducted of the PBMs serving the state’s Arkansas Works and Provider-led Arkansas Shared Savings Entity (PASSE) health plans. PBMs serve as middlemen between insurers and pharmacies.
The PBMs audited were CVS Caremark, Optum RX and Express Scripts. CVS Caremark provided PBM services for Arkansas Blue Cross and Blue Shield, Centene and the Empower PASSE. CVS Caremark accounted for 85.16% of the Arkansas Works claims examined.
OptumRX was the PBM for Qualchoice. Express Scripts was the PBM for the Summit Community Care PASSE.
The audit covered Jan. 20 to June 30, 2019. The firm, Lewis & Ellis of Allen, Texas, used data only from March 2019 and extrapolated the findings for the rest of the period. The examination was completed on July 27, 2020, and posted Oct. 28.
The audit focused on spread pricing, which occurs when a PBM pays pharmacies less than it was paid by the insurer and pockets the difference. The practice was made illegal by a 2019 law. It also covered two other practices: differential payments where pharmacies are paid different amounts for the same drugs, and direct and indirect renumeration fees, or clawback fees, which are retroactive fees assessed on pharmacists after drugs are dispensed.
The examiner found CVS Caremark and OptumRX had no significant spread pricing. However, it found that more than 83% of claims administered by Express Scripts through the Summit Community Care PASSE showed spread pricing practices. That amounted to more than an 18% difference between what Express Scripts charged the health plan and what it paid the pharmacy.
In its rebuttal, Express Scripts objected to the examiner’s definition of “spread pricing.” It said the auditors calculated spread incorrectly, and it objected to the audit report extrapolating from only one month’s data.