The other day I sat contemplating the pricing of a large pizza. Yes, I am a bit of a math geek, and I was having trouble wrapping my head around why the price of a 16 inch pizza was only a couple of dollars more than a 12 inch pizza despite the exponential nature of the area as pizzas get larger (113 sq inches for a 12 inch pizza vs 153 sq inches for a 16 inch pizza, almost a 40% increase in size). I am sure someone has looked at all of the variables( ingredients needed, time required to assemble the pie, pizza oven space requirements, baking time etc.) and justified the discrepancy, but it still bothered me.
As I thought about this some more, it occurred to me that pharmacy (and more specifically the pharmacy benefit managers or PBMs) are doing the same thing. The emphasis on the 90 day refill is high in the industry, even to the point of incentivizing the patient with a lower copay (just like pizza) to “upsize” their prescription. Like the pizza industry, I am sure someone has measured all of the variables and come to the conclusion that, like the large pizza, 90 day fills are better.
But is this wisdom actually accurate? Whom does this benefit? Remember that the PBM industry has, by and in large, made this judgment using their variables. Is it good for the payor, the patient, or the pharmacy? What is the goal or outcome that is being sought? To a pharmacist, the goal should be improved outcomes and a decrease in total health care spend. For some reason, I doubt that these are the outcomes cherished by the PBMs.
Benefits of a 90 day “Super Size” Rx
The Patient:
A super size Rx may result in fewer trips to the pharmacy. This assumes that the patient doesn’t visit the pharmacy for other reasons, of course. Patients also pick up necessities at their local pharmacy (think OTC items), receive vaccinations, have their blood pressure checked or cholesterol tested, or to ask questions or advice from their pharmacist. Even after implementing a medication synchronization program, many of our “sync” patients still come the the pharmacy just as often as before. Indeed, fewer trips to the pharmacy may actually be a bad outcome for patients.
Compliance is often touted as a benefit of a 90 day refill. This, however, turns out to be somewhat difficult to prove. Claims data may show better compliance, but it is impossible to know if the patient is actually taking the medication properly and achieving the optimal outcomes with claims data alone. When a pharmacist takes time to talk with a patient, they can actually assess both compliance AND outcomes. Super size refills creates fewer interactions with the pharmacist to assess the patient and can actually delay the pharmacist’s ability to address compliance and intervene to improve outcomes.
Cost is used an incentive for Super Size refills. The patient will often pay less for a 90 day supply than they would for three 30 day supplies. For many patients, this savings, over multiple prescriptions and over the course of the year can be significant.
The Payor:
Insurance companies are the ultimate payor. In the case of Medicare Part D, the payor is Medicare. To the entity holding the purse strings, 90 day fills offer little real advantages. While it is possible that a supe rsize refill costs the payor less than a 30 day refill, drug costs are only a fraction of the costs that the insurance has to consider. Any savings, in the form of improved outcomes from medications can far exceed any savings for 90 day prescription fills. A recent program between a pharmacy in Iowa and a major insurance payor demonstrated that pharmacists can impact total health spend for their patients, and the degree of this impact can be very substantial. Overall, the payor may benefit more from an increase in patient-pharmacist interactions rather than a decrease.
The PBM:
Extended day supplies benefit the PBM in several ways. Many extended day contracts feature both decreased pharmacy reimbursement and decreased dispensing fees (the two places pharmacies are actually paid for their effort). This directly benefits the PBM by decreasing their cost. Another potential benefit is for the PBM to emphasize their own mail-order pharmacy. Extended day fills are really the only way this type of pharmacy can exist. Any emphasis on extended days supply creates opportunity for the PBM owned mail order pharmacies to extend their business.
The Pharmacy:
The pharmacy stands to loose the most from extended day supplies. While the PBM argues that extended day supplies are easier for the pharmacy (only having to fill a prescription 4 times a year versus 12 times a year), this benefit is negated by a myriad of negative economic impacts on the pharmacy, including decreased front end sales and diminished reimbursement of the prescription itself. A prescription, to a pharmacist caring for the patient, is a lot more than just a bottle, label, and drug product. It is a chance to make that encounter with the patient count. Pharmacy is a profession, not a product.
The Real Pharmacy Benefit: Pharmacists
In the end, the PBM industry has pushed its own agenda by forcing down reimbursement for drug product and emphasizing its own metrics. It is time for the patient and the payor / plan to start recognizing the importance what the pharmacist does and how it impacts patient care. It is also imperative that pharmacist step up, if they are not already working as a clinical interventionist. Every pharmacist should be working to make every encounter with their patients count!
