A few days ago, Will Maddox wrote a column for D Magazine entitled Amazon Teams Up With Local Pharmacy Benefits Manager. This news article, discussing the partnership between CerPassRx (a PBM) and Amazon’s PillPak, demonstrates the huge discrepancy in how the profession of pharmacy is perceived today.
Maddox’s article describes the hot-button issues of medication adherence and cost in the pharmacy world. The PBM industry has a long history of touting its success in reducing costs to payers, but cost is generally not an issue anymore. Pharmacies routinely receive reimbursement that does not even cover the cost of the medication on a large percent of the prescriptions they dispense. So PBMs are looking for something else to keep themselves relevant.
Adherence has become a big part of the PBM marketing focus. This started several years ago with the emergence of EQuIPP’s metrics for Percentage of Days Covered (PDC) as applied to specific medications being taken by Medicare Patients. The general premise: medications do not help if you don’t take them regularly. Adherence is often touted as a main driver in keeping overall healthcare costs down, but as we will see below, it is not the complete picture.
Near the end of the article, you will find the following statement:
Buscetto sees this move as one more step on the way to eliminating retail pharmacies, which he doesn’t see as part of the future of medication delivery.
Now this is not a direct quote from Mr. Buscetto, so I cannot take him to task. But clearly Will Maddox was left with this impression after interviewing the CerPassRx executive. This is where the descrepancy I alluded to above becomes apparent.
If you read the 409 words penned by Mr. Maddux, you will find the word care just once: when describing his company as a value-based care PBM. The word cost and the word patient appear 3 times each. What is entirely missing in the article, and what is missing in most discussions of medications coming from PBMs, is the combination of the two words to make patient care.
You see, while adherence is important, it is not the end-game. Patient outcomes are what matter. Is the patient achieving their blood pressure goal? Are they experiencing any adverse effects? Adherence means nothing if the medication is not achieving the desired goal, or the patient is not reaching the appropriate outcome. The wrong medication taken 100% of the time is still the wrong medication. Adherence alone does not ensure that the patient won’t end up in the ER or the hospital.
Outcomes are what matter in drug therapy management. And these are the things that are not strengths of mail order pharmacy. It is the personal relationship with the patient and the repetitive nature of monthly refills that allow the pharmacist to do far more than just dispense medication.
The PBM industry has focused entirely on drug spend for decades, but they completely ignore the bigger picture: patient care by the pharmacist has a large impact on the effective utilization and optimization of medications. Other subtleties, like the fact that sometimes a more expensive medication will actually save the payer significantly more in overall health spend than the differential drug cost, or that making formulary choices based on rebates does not improve patient care, are largely ignored by PBMs.
So ignoring the inherent limitations of mail-order packaged medications* and the challenges that mail order would face should we end up living in a world without “retail” pharmacies**, we still have to come to grips with the fact that drug product by itself is not a panacea. Pharmacists are essential health care workers, and the personal relationship between the pharmacist and the patient is an important part of patient care.
There will always be someone pushing an agenda that runs counter to patient care. The PBM industry has been doing this for years under the guise of saving money. But there is something more important: pharmacists pushing the patient care agenda. And it is imperative that every community pharmacist works their hardest to ensure that they are actually taking care of their patients. If you don’t make THIS encounter count, perhaps Amazon truly is going to replace the community pharmacy.
Footnotes
* PillPack, like many of the similar options used for commingled drug packaging, works well until a medication change is made. Adding a medication is fairly easy: one just sends a second strip pack with the new medication This is not ideal, but it is a generally accepted work-around. Discontinued medications, however, create real problems. The patient has to manually remove the medication from the pack each time they take medications until the pack ends, and that completely erases the advantage of the med packaging. The problem is aggravated by the use of extended day-supply (90 day) orders. If PillPack were to send a new pack out the the patient, they would necessarily have to waste the medications, and no insurance will pay the pharmacy, even if they are Amazon, for dispensing the same medication twice.
** There are many cases where patients require same-day fills of medications. While these are mostly acute medications, mail order really cannot do this. If Amazon were to create the capacity to do same-day delivery of medications around the country, they would essentially have “retail” pharmacies in or near every community and their supposed “competitive advantage” would be completely eliminated.