State of the Profession......PBMs

A couple month ago I had a little post on pharmacy benefits managers and some of the tactics they use in the course of their business. The post focused on how PBMs use any and all means at their disposal to pay the absolute minimum for medications. From a business standpoint, I would expect nothing less from them.

But they do engage in some practices that, even though the practices are not part of the practice of pharmacy, end up shaping the opinion people have about pharmacists. We've all been put in the situation where we have to basically explain to the patient why their copay for a particular angiotensin receptor blocker is 85 bucks this month when it was only 15 dollars last month.

Patients don't want to hear that their insurance company has shifted the cost to them. Their perception is that the pharmacist is trying to price gouge them. Never mind that the actual reimbursement to the pharmacy is $2.40 over our actual acquisition price.

Then we have the nice little practice where the PBM requires that the patient utilize the mail-order service (or a particular retail chain) for their maintenance medications. This forces the patient to choose between staying with their preferred pharmacist (and paying a substantial penalty) or utilizing the PBMs choice of pharmacy (and realizing the full benefits of the insurance). Given the economic situation that most of our patients are in, they choose to use the PBMs preferred pharmacy.

Combine these little tricks with all of the hoops that insurers require us to go through just to get Mr. Jones a two-week supply of his carvedilol until his mail-order arrives and it's pretty easy to see why pharmacists don't really like PBMs. What should be a partnership to keep our mutual patients healthy has turned into an adversarial situation on each claim that we submit.

In my opinion, pharmacy benefits managers have too much say in the practice of medicine/pharmacy today. Rather than letting the health care practitioners select the best medication to treat a condition, a group of accountants are making the decisions.

Part of this is due to the manner in which pharmacy benefits managers are set up. PBMs exist solely to adjudicate claims. That's it. They have no vested interest in the overall health-care outcomes of the patients that they cover.

In order to truly treat the patient and not the corporate P & L, PBMs should be required to be part of a larger health care insurer. It has been my experience that insurers who manage both medical claims and prescription claims tend to manage the patient better than insurers who handle just the drug portion of the insurance. Insurers who handle both medical and prescription claims know that sometimes the more expensive medication is what actually is best for the patient and will help decrease health care expenses over the long haul.

If insurers had to cover both medical and prescription claims, we might be able to really advance the concept of medication therapy management. But as it stands now, only pharmacies can contract with the PBMs (with a few exceptions) and pharmacists are blocked from being providers for major medical plans.

If pharmacy benefits managers were truly interested in the benefits that pharmacy can provide, we would see them reach out to us in an attempt to help them control their costs by utilizing the specific skill sets that pharmacists possess. As it stands now, the only benefits the PBMs are interested in are their bonuses at the end of each fiscal year.

Addiction and abuse

I decided to take a break from my state of the profession series for today's post. In our profession we (unfortunately) see people who are addicted to drugs on a daily, if not hourly basis.

Some of the people are hooked on substances that are illegal, but even more are addicted to substances that are legal. What once was a means of treating an organic illness or injury has transformed itself into an addiction.

It's easy to look down our noses at these people. We may think that they lack self-control and have allowed themselves to become addicts. For others, they may not be addicted. They just like the buzz they catch from abusing the medications.

Whatever the reason, the sad truth is that there are many people trying to escape issues in their lives and do so through the use of drugs.





There's a billboard along the interstate near the town that I live in. I've seen it hundreds of times and pretty much ignored it. Then one day after driving home, I pulled up the website that was on the bottom of the billboard.

I read the story. It's about a kid that was one of my patients right after I became a pharmacist. I know the family. Grandma, grandpa, and mom all came to my pharmacy. They are good people. Unfortunately, Zach is just another young life lost due to the misuse of drugs.

State of the profession.....Reimbursements Part II

A couple years ago I was working for a regional grocery chain. That was back when NPIs were just starting to be issued. Our director of pharmacy operations encouraged each pharmacist to get their own NPI.

At that time, it was explained to us that all billing for medical services were switching to the NPI as the only recognized identifier. NCPDP numbers would no longer be used in pharmacy transmissions. Physicians would not be identified by their UPIN or DEA, but by their NPI.

So it makes no sense to this pharmacist that individual pharmacists are not able to contract with insurers because, get this, they only issue contracts to providers who have NCPDP numbers.

And what is even better is that the NCPDP will not issue numbers to non-dispensing locations or individual pharmacists. In simpler terms, the NCPDP will enter into a contract with a building (the pharmaCY) but not the health care providers inside the building (the pharmaCISTS).

If pharmacists want to get reimbursed by insurers for other-than-dispensing services, we need our organizations to get us recognized as providers based on our NPIs (the supposed standard for medical billing).

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We pharmacists provide many services for our patients at no charge. On any given weekend I consult with at least four patients every hour. Either to recommend an OTC item or triage an injury that they have sustained. With the way that the current system is set up, I can't bill for these services because pharmacists are not recognized as medical providers. The recommendations that I make on the weekends may save the insurer the costs of an unnecessary ER visit, but there is no system to document these interventions for the insurers.

I would love to be able to bill for these interventions. Then the patients would be able to see how much our professional services are worth. The insurers could see how many visits to the ER were avoided due to pharmacist intervention. We will see some reimbursements for our services.

If we can show our value in this scenario, maybe it will open the doors to being able to bill for MTM services. If insurers see how much money we can save them in acute situations, they may be more open to our services for patients with chronic conditions.

There are a couple issues that could complicate this, which I may discuss if I do a post in the future on insurers. But for now we need to open our minds to the thought that we should be billing for and getting reimbursed for every consult we provide. All we would need to do is make a copy of the medical insurance card, fill out a short SOAP note on the encounter, and bill.

Pharmacy organizations, consider this to be your assignment for the next three months and show us some progress.