Recently, I was reviewing a new prescription for a patient. It was not the clinical ramifications of the newly prescribed Humolog and Lantus that caught my eye. What caught my attention was the fact that on one of the prescriptions I was making money and on the other I was losing money. At issue is the arbitrary nature of pharmacy-PBM contracts. A pharmacy is often reimbursement at a different rate for medication based only on the day supply it represents for the patient.
The PBM industry is operated by businessmen, and not pharmacists. Their contracts are written by lawyers, not pharmacists. It is not surprising, therefore that most of its focus is on regulatory issues and product cost, and not patient care. To wit, PBMs regularly reimburse pharmacies less for dispensing an extended-day versus 30 day supply. This is a business assumption that a practicing pharmacists would not make. Outside of the drug cost, the overhead, time, and materials vary little with the day-supply. And, if the pharmacist is doing their job, the pharmacist will have fewer opportunities to work the patient between long-term fills. This means that they may actually need to spend more time with the patient receiving long-term fills in order to monitor and evaluate the safety and effectiveness of the therapy. It is not surprise, therefore, that a pharmacist views pharmacy in a very different light than a manager at a PBM.
The problem does not stop at the PBM level, either. Most large pharmacy chains have few practicing pharmacists in their management teams. These pharmacists representing the profession at the corporate level, and look at the business of pharmacy in a very different way. They often have very different and conflicting priorities when compared to pharmacists working in the pharmacy department. The fact that so many chain pharmacies willingly sign contracts that devalue the contributions of their pharmacist clearly demonstrate this. This problem is not seen only in the corporate office, either. In a chain, the pharmacy is usually a department within a larger store, and while the pharmacy manager is hopefully, but not always, a pharmacist, the department managers typically report to non-pharmacist store managers who have their own, non-pharmacy priorities.
Finally, big business does not stop at the corporate level. Often, those successful in business gravitate to politics, and work to influence our politicians and government officials. Our elected officials often understand business much better than they understand healthcare and specifically pharmacy practice. When asked how they would characterize Medicare Part D, my senators and representatives have always been very positive, considering it a smashing success. This is because they are looking only at the costs associated with the drug spend, and not the bigger picture of care and how it impacts the bottom line in Medicare spending.
Do not mistake my description above as doom and gloom. While the Big Business is working hard to corrupt pharmacy practice, the pharmacy profession has long been lead by independent pharmacies and pharmacists in this country. And independent pharmacies are constantly innovating and demonstrating the power of patient care delivered by pharmacists practicing at the top of their licenses. This is slowly gaining the attention, both regional and national levels, with commercial insurers being the first to take notice. Even Medicare is slowly beginning to recognize that quality pharmacy care can help save money outside of the traditional drug spend.
Like a boulder perched on a hill, eventually it will make the journey down. Every pharmacist practicing at the top of their license helps drive the momentum of the boulder. Make your encounters with your patients count. Help us push pharmacy away from big business and back to patient care.