Like an evil chess Grandmaster, PBMs are incredibly adept game players, exercising diabolical patience and foresight as they craft the long-term cons they sell as "saving money" on behalf of consumers and plan payers.
Pharmacists are well aware of the complicated tactics that make up the PBM playbook and result in unnecessary millions charged to end payers every year.
Knowing patients and end payers are being ripped off is one thing. Calling attention to the rip off is an entirely different - and extremely risky - matter. But a PUTT member pharmacist is taking a new approach: documenting the perpetuated spread pricing that occurs between the deductible and benefit phases in a patient's plan, and reminding patients they have the right to request a "receivables statement".
What is "Perpetuated Spread Pricing"?
Imagine this scenario: you're a consumer with normal prescription drug coverage through your employer. It's late January, time for your monthly medication refill. You go to your local drugstore, the pharmacist inputs the script and updates your insurance as per usual. Because you're in the deductible phase, you're charged the full copay and the PBM bills your plan at the contracted rate. You and your health plan repeat this process monthly until your deductible is met and your copay is $0.
Now imagine your coworker, a member of your same insurance plan, who takes the same medication and dosage but has met their deductible a little earlier than you. They have a $0 copay and the health plan pays the same contracted rate as before, right?
When the pharmacist inputs your co-worker's information, it returns pricing based on what should be "contract pricing" but after the deductible is met, the system automatically prices that same medication at "MAC pricing".
This behind-the-scenes switch allows PBMs to continue to charge the health plan the higher contracted rate, but reimburse the pharmacy substantially less, resulting in greater spread - and therefore increased profits - to the PBM.
When the patient is in the deductible phase, they very often pay an average of 235% more for medication that, when the deductible is met, the PBM is now indexing against MAC, and now paying itself more by charging the health plan the contracted rate and reimbursing the pharmacy for the lower-priced MAC rate.
Perpetuated spread pricing is a direct violation of the contract between the PBM and the consumer's insurance plan, especially since the medication price charged to the consumer between the deductible and benefit phases is substantially different. Unless two patients with the exact same prescription under the exact same group insurance plan come into the same pharmacy to fill their identical prescriptions at the same time, no one might ever catch on to the discrepancy.
It's convoluted consumer defrauding at its finest.
Pharmacists legally aren't allowed to disclose this level of information to consumers without risking multiple lawsuits from the PBMs and insurers. The only way for consumers to actually ensure they're not being overcharged is under new state & federal anti-gag clause legislation.
Most states have recently passed anti-gag clause legislation. This same legislation allows patients to request a receivables statement when they fill a prescription. If a consumer were to do this each time they filled their prescriptions, they could see actual prescription charges and could compare prices against what their plan says they should be charged.
The PUTT member pharmacist discovered this new level of consumer fraud because it was his plan - and one of his co-workers on the same medication - who were charged the different amounts for the same prescription. He filed a formal complaint with his state's department of insurance and was told he "wasn't considered a consumer" and therefore the complaint was thrown out.
PUTT encourages members to review your state's anti-gag clause legislation to check for the receivables statement language, and then inform patients of their right to know how much they and their health plan are being charged for their prescriptions.
In the world of healthcare, pharmacy benefit managers are no better than the playground bullies that try to take your lunch money.
Forced mail order is a perfect example. Recently PUTT has begun receiving copies of "choice requirement" emails and mailings from our members that read like a low budget suspense novel. Patient walks into their pharmacy to fill their long-term prescription, days later they receive notice from their insurance carrier's PBM that they will be required to pay the full price of the medication going forward if they don't transfer the prescription to mail order service. (cue the scary music)
Privacy rights notwithstanding, steering tactics like this one create a horrible situation where entire families and communities pay the price. It's a prime example of how PBMs care only about their bottom line, not the patients, and certainly not that patient's community. Never mind that this patient may require special assistance from their local pharmacist who knows their medical history & watches for drug interactions between their medications. Never mind that mail order medication is usually shipped to the patient from a distance and can easily be rendered ineffective in treating that patient's condition due to a lack of temperature control during transit, which could cause them to become far sicker than before. Never mind that the required 90 day supply of medication that mail order plans force to be ordered could potentially result in extra medications ending up in the wrong hands and on the wrong side of the law. Never mind that the patient's local pharmacy is the go to hub for healthcare in that particular community and that by forcing patients to use mail order instead of filling their prescriptions locally, that pharmacy could ultimately be forced to close its doors. The list of detrimental outcomes is long and ominous.
Job losses, destruction of local business, patient safety issues, illegal drug trafficking, and spoiled medication possibilities swirl like a rip tide effect around these PBM forced "choice requirements". Georgia got it right with their recent anti-steering legislation this past session, but how many more community pharmacies will fall to these over-sized healthcare bullies in other states before legislation is passed to stop the fleecing? How many more patients will become sicker - or worse - from improperly stored medication during transit? How many more prescription drugs will hit the streets due to forced ordering excess? It's time to stop the madness and bring these healthcare bullies to justice. Without PBM regulation, America's prescription drug system is doomed to continue into a downward spiral of monopoly, oligarchy, disease, and patient despair. We all deserve better.
PUTT Summit 2019 Recap: Pharmacists, Physicians & Patient Advocates Gather with State Legislators to Engage in Unfiltered Conversation to Rein in PBMs
Last month independent pharmacy owners, physicians, attorneys, activists and patient advocates from across the country gathered with state legislators at the second annual PUTT Summit for a day and a half of candid discussion on the topic of reining in PBM abuse.
Hosted this year in Austin, Texas, at the historic Driskill Hotel, participants organized in think-tank fashion to honestly assess and collaborate on forward-thinking ideas and strategies to implement in their home states.
“This year's presenters really brought the information home in an insightful and engaging manner,” said PUTT President Scott Newman. “Dr. Stephen Schondelmeyer, Dr. Joel Strom, and keynote Greg Reybold challenged us to think about the issues in new, broader ways that I’m certain will empower our collective efforts to stop PBM abuse in our home states.”
This year’s Summit included a review of Georgia’s new anti-patient steering law and a presentation by Dr. Stephen Schondelmeyer on “Key Factors Affecting Pharmacy’s Future.” The highlight of the Summit, the State Legislators Panel, featured Arkansas Rep. Jason Rapert; New York Sen. James Skoufis; Georgia Rep. David Knight; Louisiana Rep. Bernard LeBas; and Arkansas Sen. Kim Hammer.
Following the Legislative Panel, participants engaged in workshops focused on bills from New York, Louisiana, Tennessee, Oregon, Georgia and other states that had passed progressive anti-PBM abuse laws, analyzing bill language for use in their own states’ future legislation. Legislators, including former Florida Lt. Governor Jeff Kottkamp, participated in the process, lending insight on the legislative process.
Following Friday’s work session attendees were treated to a cocktail reception hosted by American Pharmacies at the exclusive Austin Club, once the city’s gala opera house, and then gathered in groups for dinner and a fun night in the heart of Austin’s downtown music district.
From the workshops to the after hours cocktails, this year's Summit was a successful combination of information and expertise sharing, networking, and innovative planning. Watch out, PBMs! We're locked, loaded, and ready for battle!
As states begin to address the heretofore unchecked practices of pharmacy benefit manager (PBMs) middlemen amidst a rash of publicity and legislation, Georgia has quietly introduced and passed legislation that could change the game for Georgia patients and serve as a model for other states looking to protect patient choice and access to care. This legislation - HB 233 by Rep. David Knight - awaits Governor Brian Kemp’s signature before passing into law May 12th.
While most state legislation, including HB 323 in Georgia, looks to rein in problematic PBM practices, Georgia’s HB 233 takes a new tact – regulating pharmacies that are owned/affiliated with PBMs and insurers through the elimination of patient steering practices.
HB 233 specifically prohibits pharmacies owned by PBMs and insurance affiliates from receiving self-dealing referrals and from engaging in data mining for commercial (non-patient care) purposes. The bill also requires pharmacies to disclose affiliates to the Board of Pharmacy and contemplates Georgia Board of Pharmacy oversight.
“Though often overshadowed by issues such as DIR fees and spread pricing, PBM-owned pharmacies have been able to engage in patient steering on the grandest of scales, to the point it has become a core business strategy,” says Georgia state representative David Knight. CVS says as much in a statement from CEO Larry Merlo in their 2017 Annual Report:
“Over time we have developed new plan designs that save our clients money while simultaneously moving share into our channels. For example, the new plan members we enrolled over the past three selling seasons will contribute an additional 40 million prescriptions to the enterprise in 2018.”
Frustratingly, PBMs often take the position that state law requiring regulation is preempted by federal law, thus limiting the scope and impact of many previously-passed state laws Yet pharmacies are subject to significant state regulation. What makes HB 233 unique -- and apparently gives PBMs pause -- is that it targets the very point at which PBMs ARE subject to state regulation - their pharmacies.
“It’s a simple yet brilliant strategy that may change the game and provide patients the broadest possible protections. For patients who have been forced into mail order or other PBM-owned pharmacies, there are few issues more important in healthcare than patient steering,” says Scott Newman, PUTT president. “Steering, whether into mail order or a PBM-owned brick-and-mortars impacts the most vulnerable patients. PUTT applauds the State of Georgia for recognizing the need to stop the practice all together.”
HB 233 had more than 90 co-sponsors and enjoyed near unanimous support. However, despite the grassroots support, the PBM lobby is currently exerting tremendous pressure in the hopes of getting a veto by May 12, which is the state deadline for Governor Kemp to veto 2019 legislation. In the meantime, the pharmacists and their patients wait, hopeful that patient mandates and steering will soon be a thing of the past.
Canadian and Foreign Drug Importation Won't Provide Choice OR Cost Savings for Patients and Plan Sponsors - Here's Why:
At a time when prescription drug prices are so high that several states are considering legislation to make foreign prescription drug importation legal, PUTT again warns legislators and consumers that this proposed “solution” will NOT fix the problem of high drug prices.
As pharmacists, our first concern is for patient safety. But we also know (a little too well) how drug prices force some patients into rationing medicine or not filling a prescription, and that legislators are responding to constituents’ concerns for drug cost. Still, foreign drug importation, while it may provide some superficial cost savings, will not provide the kind of choice or value patients need.
Consider the proposed plan in Florida. PUTT requested public records for Flagler County’s much-touted CanaRx program, and learned a few things:
Lesson #1: Transparency works. Under Florida’s “sunshine laws” we can see the 2018 quarterly cost reports for prescriptions available under CanaRx. On the report, the green highlighted items are prescriptions ALREADY available as generic in the U.S.
In the midst of one of the most actively healthcare-focused legislative seasons in years, several states have begun to address the issue of PBM abuse by introducing legislation that attempts to rein in the unchecked power of the middlemen.
In Maryland, Brian Hose and Steve Wienner - two seriously committed pharmacists - led the fight along with the Maryland Pharmacists Association, Epic Pharmacies, and the Independent Pharmacies of Maryland for PBM reform that culminated in the recent passage of three bills that target unfair PBM practices and now require pricing transparency, and the elimination of DIR fees.
Because every big legislative win has its roots in small past victories, PUTT asked Brian and Steve to share their story and advice for other pharmacists working at the state level to enact change.
"This year was out of the ordinary," said Brian. "A lot of it was due to small changes that have been taking place in the years prior, when the PBMs would give us a small concession and then find a way to skirt the law, which would then set us back two steps. The legislators finally started to see what was going on and made some measurable changes this year."
“It's been years and years in front of the legislature,” said Steve. “I think a lot of people don’t realize that you’re not going to be involved for one year and get everything you want.”
Both Steve and Brian have spent more than five years actively testifying in front of the Maryland state legislature. They have participated in legislative work groups tasked with finding common ground and/or compromises between independent pharmacies and the PBMs; educated legislators on the intricacies and importance of NADAC; and driven home the value of independent audit firms as non-partisan, trustworthy resources for pending legislation.
Since PBM contracts prohibit pharmacies from informing the end payer about pricing and fees, they and their fellow pharmacists worked toward legislation that would allow a work-around. Said Steve, “If I pick up a phone and call them, I can’t say ‘your PBM is screwing me,’ but when the Maryland Insurance Administration drops 50 to 100 appeals on them and says ‘this is a problem and these are the drugs,’ now you have a 3rd party saying ‘you need to investigate that’.”
Insight, “outside the box” thinking and absolute tenacity have fueled their motivation to bring about real change in Maryland, which, like other states, has seen the closure of scores of pharmacies as PBMs cut reimbursements, increase DIR fees and use audit penalties as a means to improve their own bottom line.
Both Steve and Brian advise pharmacists to stay actively involved throughout the entire legislative process to achieve their ultimate goal. “We saw a big shift this year in the way that government agencies were behind us,” says Brian. “Before, they would try to be an impartial mediator through the process, this year they testified on behalf of these bills, they drafted language that strengthened the bills -- they were very involved.”
An added benefit to pharmacists remaining actively involved: Maryland legislators are beginning to understand the added value independent pharmacies provide patients. This is especially important in a state where, on average, there’s a chain drugstore within 10 miles of every citizen.
The proof is in the legislation passed. While HB 754 was not passed in its original form, (a sore point for many) these two feel that the combination of all 3 bills lay a solid groundwork for building upon next session.
Their advice for pharmacists entrenched in legislative battles in other states? Make sure you have someone in every step of the process. From the hearing to the work groups to the sub-hearing. It’s not easy, but someone’s got to be involved.
“We are advocates for our profession. We’ve been doing it for a long time, and we’re glad to see the success,” said Brian.
“Everyone has to give back to their profession in some way,” says Steve. “Some do it in academia, teaching, or study; some do trials in their store; the way we personally give back to our profession is through legislative activism.”
Some superheroes wear capes. This dynamic duo proudly wears lab coats!
When it comes to making a buck, PBM middlemen have no shame. Rebates that should be lining the pockets of Medicare Part D insured American patients are being unscrupulously rerouted to line their own pockets instead. It's time to put a stop to these greedy tactics that have resulted in the skyrocketing of prescription medication costs. It takes less than 5 minutes to make your voice, and the voices of your patients heard. Don't miss this opportunity to play a part in this important healthcare legislation.
Click HERE to tell the HHS that you support their proposed amendment to the safe harbor regulation on discounts!
"The power of one, if fearless and focused, is formidable, but the power of many working together is better" ~ Arroyo
Straight Talk: Local Louisiana Pharmacists, Sec. Alex Azar Discuss Urgent Issues Facing Patients and Their Pharmacies
One day after President Trump declared in his State of the Union address the need for prescription drug pricing reforms, Health and Human Services Secretary Alex Azar paid a visit to patients and pharmacists at Chateau Drug and Gifts in Metarie, LA to continue the conversation. Chateau Drug owners Kerry and Diane Milano, both pharmacists, hosted Sec. Azar and a small contingent of patients and pharmacists for an in-depth discussion of issues facing small business pharmacies and their patients.
Sec. Azar addressed several “hot button” issues: high drug prices, lack of choice, secret mark ups and exorbitant DIR fees charged by PBMs that ultimately undercut pharmacies and are passed on to patients as higher drug costs and insurance premiums. During his visit, Sec. Azar observed Chateau Drug pharmacists in action filling prescriptions and counseling patients, noting the degree to which independent pharmacies are the patient’s most accessible healthcare providers.
The visit, which was coordinated by the Louisiana Independent Pharmacies Association (LIPA) and NCPA, came as a result of Sec. Azar’s interest in some of the state’s proactive laws, which provide a level of patient and pharmacy protections against price gouging and retroactive fees. In 2016 Louisiana passed a law prohibiting PBMs from directly or indirectly charging or holding a pharmacist or pharmacy responsible for any claim-related fees that were not disclosed upfront or after submitted for reimbursement. According to a recent PUTT survey, most independent pharmacies pay an average of $107,302 per store in retroactive DIR fees.
Just last week AP news reported that Sec. Azar had asked Congress to pass the administration’s new prescription drug discount plan and provide it to all patients, not just those covered by government services plans like Medicare. The plan would channel the now hidden rebates on prescription drugs directly to patients, removing that money from the current grasp of the PBMs. In a separate story released on February 5th by CNBC, President Trump was quoted on the issue as saying, “It is unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place. This is wrong, unfair, and together we will stop it.”
Dear Judge Leon,
My name is Teresa Dickinson, and I am an independent pharmacy owner in Phoenix, AZ. I am also the president of Pharmacists United for Truth and Transparency (PUTT), a coalition of more than 1,200 independent and community pharmacies across the U.S. I am writing on behalf of my organization and small business pharmacy owners everywhere to express our full opposition to the CVS-Aetna merger. We are greatly encouraged to know you are carefully considering the merger of these two excessively large corporations that together control a disproportionate share of the healthcare marketplace.
Sir, you mentioned feeling as though you are “in the dark” with regard to the merger. We promise you are, as are most Americans about the true nature of the pharmacy benefit manager (PBM) industry. CVS, along with Express Scripts and OptumRx, control nearly 80% of all prescriptions filled in the U.S. All 3 are either owned, or poised to be owned, by extremely large health insurance companies who also seek to control and serve as the gatekeeper between patients and pharmacy, medical providers and other sectors of the healthcare system.
Here are some things you may not know about CVS:
If you're worried about the impact of the seemingly inevitable CVS/Aetna merger, consider the following:
On February 8, 2018, Arkansas Attorney General Leslie Rutledge opened an investigation into the CVS Caremark reimbursement rates to Arkansas pharmacies, much to the delight of her state's community pharmacies -- and the nation. Ms. Rutledge took a bold and remarkable stand against PBM abuse. Since that day: