Through the years Val and I have been with many friends sharing their stories about “getting my prescription.”
The topics range from “insurance won’t cover the med that works for me anymore” to the more involved missives of “I need more than a 30 supply but I need to use mail order. So then I try to use my local pharmacy instead, but my co-pay is twice as much.” In each case, the parameters placed by the insurance carrier limit the flexibility of access for the individual consumer.
I’ve developed the viewpoint that the consumer, or patient in this case, means little to the provider of their prescription medication coverage. But do I, the patient, have a choice? One could choose another insurance carrier but in recent years reduced options and economic necessity result in nearly identical choices for medication coverage.
Several states either have legislated, or are moving to legislate, Patient Choice; NCPA offered talking points and various websites review impacts to patients. Below I’ve included a quote from the Minnesota Pharmacists Association nicely summarizing a 2015 viewpoint. The points are clear and describe benefits to both consumers, patients, and local pharmacists. In a cursory review, Patient Choice sounds reasonable with potential to be adopted nationally.
Yet it leads me to wonder, if I had a choice, how would my choice impact YOU as a pharmacist?
Please share your thoughts! Thanks – Daina
Patient Choice and community pharmacy network access:
Pharmacies are the primary place Minnesota patients go for prescription medications and for health information and services from their pharmacist to help them manage those medications and seek care for illness. In most households, the pharmacy is the first place people go when they are sick and the health care provider they visit most frequently. In fact, many pharmacies now offer “minute clinics” and other front-line services to their patients.
Pharmacists provide patients with a broad range of information and services ranging from answering simple questions to drug management services that assure that the medications a patient is taking are appropriate or them, that the patient understands their medication purpose and effects and the patient is taking their medications regularly and appropriately. Medication adherence dramatically increases when a pharmacist is involved in the care of a patient.
There is grave concern among patients and pharmacists about a patient’s right to use the pharmacy of their choice. More and more pharmacy health plans are moving to a benefit design that excludes local pharmacies. Patients are prohibited by their Pharmacy Benefit Manager (PBM) from choosing their local pharmacist for their medication care needs. Many PBMs require patients to have their medications dispensed through mailorder and/or specialty pharmacies simply because a medication is higher priced. The majority of these mail-order and specialty pharmacies are owned by the PBM.
The patient-pharmacist relationship is more than just a friendship that has developed over the years or a business transaction between the drug dispenser and the PBM. The relationship between a community pharmacists and the patient can have significant impact on the long-term health of the patient and better health outcomes with their medications. Patients should not be forced to choose between their medications and the care they receive from a local pharmacist. Patients should have the right, as they do in many states across the country – including all states bordering Minnesota, to choose where they have their prescriptions filled.
Mail-order mandates: At minimum, no pharmacy benefit design should mandate the use of mail-order pharmacy. The patient should have the right to use the pharmacy of their choice to fill their prescriptions. Community pharmacies should have the right to participate in mail-order or 90-day fill contracts, with patients paying the same co-pays as they would with mail-order, as long as the pharmacy is willing to accept the same reimbursement and other contract terms and conditions as PBM mail order.
“Specialty drugs:” As medication treatments have become more complex and have increased cost, a class of drugs called “specialty drugs” has emerged. Often, these drugs have required special monitoring, patient education or other complex services that many community pharmacies are not prepared to provide. As a result, specialty pharmacies have emerged to meet the need.
However, today, many PBMs own their own specialty pharmacy and decide via their contracts and closed networks what drugs must be dispensed through that specialty pharmacy. This conflict of interest has resulted in many new expensive drugs being labeled as “specialty drugs” even though they require no specialty services. Patients should be able to choose to have these specialty drug prescriptions filled locally with their community pharmacist as long as the pharmacy is willing to accept the same reimbursement and other contract terms and conditions as the PBM specialty pharmacy.
Patient Choice – makes it your right to see the pharmacist of your choice and at a local location near you. Patient choice allows your local Minnesota pharmacist into closed networks if he or she agrees to the contract terms and conditions at no additional cost to the payer or to patients. So if a pharmacy benefit manager changes or mandates mail-order or a specialty pharmacy for their insured patients, you don’t need to worry about the quality of your patient care services.
I’ve heard this proposal will raise healthcare costs? There is absolutely no evidence to support such claims. Many states, including all of the states bordering Minnesota, have passed similar pharmacy/patient choice legislation and there is no evidence of medication care costs increasing because a patient chooses to have their prescription filled with their local pharmacist. MN, ND, SD, IA and WI all passed similar legislation over the past 20+ years for healthcare insurance providers and have seen no healthcare cost increases due to providing patients with pharmacy care or physician choice.