Doug Hoey is CEO, National Community Pharmacists Association.

B. Douglas Hoey, RPh, MBA

Medicare Part D open enrollment for 2021 is here. Beginning October 15, 2020, beneficiaries get a chance to review options for next year and make changes to their coverage.

For many patients, their neighborhood pharmacist is the definitive Medicare expert – the provider patients turn to with questions about Part D and choosing the right drug plan. What these patients don’t know is that their trusted independent pharmacist is helping them choose between plans that often financially harm the neighborhood pharmacy and lead to higher costs at the pharmacy counter.

In September, the Centers for Medicare & Medicaid Services announced it expects average 2021 premiums for Medicare Advantage plans to decline 34% from 2017, with Part D premiums expected to decline 12%, approximately $4 per month, in the same time frame.

Good news for seniors? Not really, despite what the Trump administration proclaims.

Insurance plans are shifting consumer savings of slightly lower premiums by charging higher prescription copays on many prescriptions. It’s like squeezing a balloon until it pops, but in this case, it is seniors taking prescriptions who are getting hurt. This hocus pocus is made possible by insurance company subsidiaries called pharmacy benefit managers (PBMs). They get billions of dollars in rebates from pharmaceutical manufacturers and billions of dollars of payments from pharmacies, called pharmacy direct and indirect remuneration (DIR) fees. But seniors still don’t see lower prescription costs at the pharmacy counter.

In other words, for “savings” equal to the cost of a couple of cups of coffee a month, seniors throughout the United States, especially the nation’s sickest, are paying billions of dollars more in out-of-pocket costs for their prescription drugs.

An analysis released earlier by this year by XIL Consulting, one of the country’s top pharmacy industry analysts, found that DIR fees overall have skyrocketed by 1600% in the last 5 years, totaling $8.5 billion since 2013. The firm also said that, “a loophole in the program allows health plans and PBMs to pocket an excessive amount of pharmacy DIR fees rather than offset prescription costs for seniors.”

XIL Consulting also noted that under Medicare Part D, fees and discounts are supposed to be passed on to seniors. “But that isn’t happening,” the report said. “While seniors are bypassed for DIR pharmacy discounts, at the same time, they are struggling to afford their prescriptions.”

Bad news for patients. But these fees don’t only hit senior’s pocketbooks. They lessen patients’ access to quality care, too, by pushing pharmacies to the brink and forcing them to lay off staff or even close their doors altogether. In fact, 4% of all pharmacies closed the 2 years before the coronavirus disease 2019 pandemic. As a result, consumers had 2000 fewer pharmacy choices and “pharmacy deserts” are spreading in some regions.

The current prescription payment model – as complex, cumbersome, confusing, and covert as it is – only serves the PBMs well. But patients deserve to be able to understand what’s truly happening with their care and what it’s really costing them.

By failing to take action, the Trump administration and Congress are allowing PBMs to continue manipulating these loopholes, hurting patients, and squeezing billions of dollars in fees from pharmacies. Policymakers have the power to get PBMs under control. They must have the will to use it.

By B. Douglas Hoey, pharmacist, MBA, CEO of the National Community Pharmacists Association. NCPA represents over 21,000 pharmacies that employ approximately 250,000 individuals nationwide. Community pharmacies are rooted in the communities where they are located and are among America’s most accessible health care providers. To learn more, visit

Articles

Policymakers have the power to get pharmacy benefit managers under control. 

Opinion: PBM Hocus Pocus Harming Seniors, Small Business Pharmacies

As the country grapples with the opioid abuse epidemic, communities are working together to have conversations, engage with partners and develop solutions to prevent the improper use of these medicines. Prescription opioid abuse and misuse is a serious and sensitive topic because misuse of these medicines often starts in the home. Patients and their caregivers need to be able to turn to a trusted and accessible healthcare provider. Often, that person is their local pharmacist.

Pharmacists play a crucial role in educating patients about the potential risks and side effects of the medicine every time they pick up or refill a prescription. By having these important conversations, pharmacists can ensure that their patients who are prescribed an opioid understand the serious risks associated with these medicines, which include dependence, addiction, or overdose, especially with prolonged use.

Pharmacists also have the opportunity to remind patients of the steps they can take to ensure opioids do not end up in the wrong hands. These include knowing how to safely use and securely store opioid pain medications when they are prescribed and how to promptly dispose of any unused or expired pills.
	Right now, there is a persistent and growing gap in education and awareness on the proactive steps that can be taken to mitigate the risk of misuse before it occurs. A poll conducted by Morning Consult in 2018 underscored the lack of awareness among consumers about prescription opioid safety and highlighted the need for more focused education around safe use, storage, and disposal of these pain medications.

For instance, 36% of respondents said they did not know they needed to dispose of leftover prescription opioids, and nearly 30% said they did not know how to do so safely. However, nearly 70% said that, with detailed instructions, they would be more likely to securely store and properly dispose of prescription opioids.

Allied Against Opioid Abuse (AAOA), a national initiative to help prevent prescription opioid abuse and misuse through education, has joined efforts to raise awareness about the rights, risks, and responsibilities associated with prescription opioids. AAOA has convened national and local partners from across the pharmaceutical supply chain, public health, and healthcare to work together to educate patients and their families about opioid safety prevention methods, including the safe use, storage, and disposal of these pain medicines.

Our organizations worked with AAOA to engage and mobilize the pharmacy community in patient education efforts around prescription opioid safety. Together with state pharmacy associations in Connecticut, Florida, Minnesota, Ohio, Pennsylvania, and Tennessee, we developed a pharmacy toolkit to equip the pharmacy community with resources to help prevent and reduce instances of prescription opioid abuse and misuse in the communities that they serve.

The AAOA Pharmacy Toolkit provides educational materials to help pharmacists engage in conversations with their patients and healthcare provider colleagues about prescription opioids and how to prevent abuse of these pain medications. Key components of this educational effort encourage pharmacists to talk to their patients about the potential side effects and risks associated with opioid medications; safe use and taking the medication only as prescribed; alternative pain treatments and other ways to manage pain; and proper storage and the prompt disposal of unused pills.

We believe that increasing public education and awareness of prescription opioid safety is an important step to reversing the trend of misuse and abuse in communities nationwide.

By arming pharmacists and pharmacy staff with resources and materials that focus on the rights, risks, and responsibilities associated with prescription medicines, they will be able to provide pain-management guidance to patients with legitimate needs for opioids and help to minimize instances of misuse of these medicines in the home.

What one pharmacist says the AAOA Pharmacy Toolkit can do to help combat the opioid epidemic. 

Opinion: A New Toolkit to Fight Opioid Abuse 

Most complaints I hear invariably lead back to a dreaded three-letter combination: PBM (pharmacy benefit managers). One of the PBMs' most pernicious business practices revolves around another dreaded three-letter combination: MAC (maximum allowable costs). It sounds innocuous. After all, what is problematic about a list of products that includes the maximum amount a plan will pay for generic drugs and brand-name drugs that have generic equivalents?  

Independent community pharmacies are not informed of how products are added or removed from a MAC list or of the methodology for calculating reimbursement - which can change in an instant. In other words, our members sign contracts with the PBMs for inclusion in their pharmacy networks, but are operating blindly under these reimbursement models.   

The time has come for pharmacists to work on reforming the maximum allowable costs put forth by the pharmacy benefit managers