Pharmacy Benefit Management and Community Pharmacy | Adam Kaye, PharmD | RxEconsult

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How PBMs Affect the Future of Community Pharmacy Category: Pharmacy by - June 3, 2012 | Views: 14818 | Likes: 1 | Comment: 0  

Let me begin by stating the obvious: Community Pharmacy is at a crossroad.

Reimbursement is at an all-time low. Salary’s and drug costs are as high as ever. Consolidation in the drug manufacturing industry, long-term care, and chain drug stores has reduced the availability of pharmacist jobs at almost every level. Out-sourcing in hospitals has also reduced both job security and compensation. When I was in pharmacy school it was mentioned time and time again that just filling a prescription is not enough. The pharmacists of today or at least since the mandate of OBRA-90 required pharmacists to do more. Review patient allergies and health conditions, monitor patient labs when available and inspect profiles for potential interactions. Who knew that increased work-loads and staff reductions would make this next to impossible without complete reliance on computerized pharmacy database software?

Some of you are able to do a good job despite all these obstacles. WITHOUT A DOUBT WE CAN ALL DO BETTER!

I am reminded of one of my favorite episodes of TwilightZone. In typical TwilightZone fashion, the thrilling episode begins with aliens landing on earth, soon followed by the entirety of the planet tuning in for a thoughtful broadcast of a state of world news conference. The aliens have nothing but noble intentions. They will share scientific agricultural techniques that will allow for the growing of crops that will allow farmers with even the most destitute desert lands to produce enough food to supply the worlds hungry with sufficient nourishment! How great! What a deal for the world! And so many will benefit because of their generosity and support! Well, if you have not seen the episode that I am talking about…you may be surprised to learn that the aliens did not really have such humanitarian intentions after all! It turns out that soon after the aliens solved many of earth’s issues including famine and war, the creation of a civilization exchange allowed many of our inhabitants to travel in the aliens space ships to “see” for themselves how wonderful their world is. It was finally determined that a bible-like book that was presented to the people of earth titled “TO SERVE MAN” was not actually as noble as it appeared. The CIA-like translation expert finally determined, a little late for some, that the alien literature was nothing more than a cookbook! Imagine the shock to those that allowed their families to leave with the aliens only to later become their meal.

Drug Reimbursement

Why am I telling you this story? Because I feel that community pharmacy and healthcare in general is also being deceived in a similar fashion-as the story line I just recited. People are always looking for an easy way of doing things. Let someone else do any job that is complicated or time consuming. Let someone else pick up the scraps. 10 cents a transaction-NO PROBLEM! A small percent of my profits say AWP-17%, [generating an undisclosed 5% spread for the pharmacy benefit manager (PBM)], sounds fair to me This is how I believe the PBM situation is at this moment in history. In the old days of healthcare, patients paid the full price for medications and submitted reimbursement forms, often with the assistance of a pharmacist. Patients were very excited to get a check in the mail to cover their medication costs. Pharmacists were happy to get paid quickly and fairly for their services. Fast forward to a few decades ago when computerized billing in pharmacies and instantaneous billing and determination of patient co-pays or deductibles became available. The insurance companies were growing and soon they found ways to save money by giving away the majority of control of their medication payment systems. The PBMs allowed the insurance companies to provide drug coverage and allow community pharmacies to quickly bill for their patient’s medications. But at what cost? The consequence of this convenience is actually driving community pharmacy out of existence. Ridiculous reimbursements do not allow for any sustainable profit margin. Examples of HIV or atypical anti-psychotics actually costing pharmacies with reimbursement of 10% BELOW the cost of the drug.

We need pharmacy players to agree with what is fair or not and stop signing contracts that do not provide fair compensation. We need to stop allowing the Tail to Wag the Dog! We need to demand fair reimbursement by PBMs to provide necessary services to healthcare. What we need today is to enact laws that require fair reimbursement for healthcare costs. Instead of shifting prices for the insured or cash-paying, for the rich or the poor, or for government or private entities. We need standards for healthcare payments. With financial fixes we can once again attempt to focus on how we can serve our patients to the utmost of our capabilities!

Adam M. Kaye Pharm.D., FASCP, FCPhA


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