PBM practices hurt patients and community pharmacists, NCPA says

September 19, 2012

Most community pharmacists - about 87% - believe that PBM reimbursement and auditing practices are affecting their ability to provide patient care and stay in business, according to a National Community Pharmacists Association survey.

Most community pharmacists – about 87% – believe that PBM reimbursement and auditing practices are affecting their ability to provide patient care and stay in business, according to a National Community Pharmacists Association (NCPA) survey.

More than 350 community pharmacists answered survey questions about reimbursement practices and audits conducted by PBMs and other Medicare Part D plan intermediaries, according to a press statement.

"Patients over paperwork; and fair reimbursement practices-that's all these pharmacists are asking for," said NCPA CEO B. Douglas Hoey, RPh, MBA, in the release. "An estimated $290 billion in costs each year are attributed to the improper use of medication."

Nearly all pharmacists surveyed (96%) said, "a typical PBM contract has minimal or no transparency on how generic pricing is determined or what the reimbursement rate will be," according to the release. Seventy-six percent of pharmacists who answered the survey also said that audit requirements across Medicare Part D plans are "not consistent at all," and they increase their compliance burden. PBMs set maximum allowable cost reimbursement for generics below the pharmacy's cost of acquiring the drugs, according to about half of the pharmacists surveyed. Ninety-two percent of respondents also said, "payments are not promptly increased to reflect a drug’s rising market costs."

The NCPA reported that several of the issues the pharmacists brought up in the survey would be alleviated by the enactment of the Medicare Pharmacy Transparency and Fair Audit Act, H.R. 4215.

"This legislation would help reduce healthcare costs by ensuring that local pharmacists can spend more time providing expert medication counseling and other pharmacy services to help seniors get the most out of their medication therapy," Hoey said. "H.R. 4215 cuts the red tape, while allowing legitimate anti-fraud efforts to continue."

More than 600 drugs, such as Budesonide, Atorvastatin, Clarithromycin, Hydrocodone, and more, were listed as having MAC limits set below the pharmacy’s cost of acquiring the product, the release said.

"When a Medicare plan's reimbursement can't even cover the pharmacy's cost of doing business, that plan risks failing at its most basic task: To facilitate the beneficiary's ability to obtain critical prescription medication and counseling on proper use," Hoey said.

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