“You cannot get through a single day without having an impact on the world around you. What you do makes a difference, and you have to decide what difference you want to make.” Jane Goodall
After returning from my family vacation, where I decided to stay in pharmacy practice and ownership, I started planning my actions to fight back against the unfair and deceptive practices of PBMs. I didn’t have a masterplan and I also understood I didn’t have a full understanding of PBMs or PSAOs - the entities that contracted with them. I also didn’t have systems in place to proactively track my reimbursement to determine which claims were insufficiently reimbursed or even underwater (reimbursement less than my own cost). So, I began to research and study the PBM industry, and to my surprise, I found a plethora of information about their unscrupulous practices including underwater MACs, gag rules, DIR fees, and claw backs (just to name a few!).
I contacted my PSAO and persistently worked my way up to a key individual who had the power to make decisions and provide me with important information to better understand PBM contracts. She also provided me with a process to proactively follow my reimbursement and communicate my findings of underwater claims to the PSAO’s help desk.
Next, I started writing letters to my legislators describing what was happening to my practice, the concerns I had about my practice’s financial viability, and the impact it was already having on the closure of rural pharmacies. I provided them with HIPAA-appropriate patient cases that described the care I was providing to patients and the insufficient reimbursement to cover my product cost, let alone the cost to provide appropriate services. I had frequent discussions with the executive director of our state pharmacy association, Kate Gainer, to inform her of my work and receive further guidance on how to effectively advocate for my cause. I discussed with her about filing a class action lawsuit against the PBM and she connected me with our association’s lobbyist. After speaking with the lobbyist, he connected me with a colleague who had success in filing class-action suits.
I spoke with the Executive Directors of the American Pharmacists Association and the National Community Pharmacists Association to coordinate my activities with theirs. Lastly, I sent an e-mail to the CEO of a large health plan in Iowa to let him know what was happening - that the unfair PBM reimbursement was having a negative impact not only on my practice, but more importantly my ability to effectively provide care to my patients. I provided a patient example in which we we lost over $700 every time we filled one prescription because the PBM refused to investigate and adjust their pricing to reflect the 8,000% increase the drug had in just one month. I challenged the CEO to look at community pharmacy differently—not just as a product cost but the value community pharmacists bring to improve patient care and reduce overall health care costs through medication optimization services.
To my surprise, each one my actions turned out to be productive. Working closely with my state and national associations, we accomplished the following “wins” within the next 9 months:
1. We were successful in working with state legislators to pass a bill, unanimously with bipartisan support, regulating PBM MAC pricing and creating transparency and oversight requirement for PBMs by the Iowa Insurance Division.1
2. Developed and implemented a pilot project with a large Iowa health plan that paid us a true professional fee for patient care services in addition to product reimbursement. That pilot project resulted in saving the payer approximately $300 per member per month for approximately 600 beneficiaries.2
3. Partnered with three other pharmacy owners who met with a lawyer to educate him about PBMs. On a contingency basis, he agreed to take our case and filed a class-action arbitration against the PBM.
4. I was invited to present to the Iowa Government Oversight Committee about the unfair practices of PBMs—going head-to-head with one of the big three PBMs.
5. Presented to other state pharmacy organizations about the work we were doing in Iowa regarding PBM reform.
Lessons Learned
Once I made the decision to fight back, I fully understood I may not have any impact—but what was more important was taking back control of my life, and no longer reacting, but proactively doing whatever I could to try to improve the situation. That decision, in and of itself, started the healing process. Win or lose, I felt better about just taking action. My psyche, attitude, and overall health was improving with every action I took. The more I learned, the more confidence I gained, and the more committed I became. I realized that taking action helped me to overcome my fears—my fears which were of the unknown, potential retaliation of the PBM, losing my practice, not being able to provide for my family, and losing my profession.
I was frequently asked during that time about my fears. My answer is that I am scared every day, but I don’t let the fear stop me from taking action. I realized I couldn’t control the actions and practices of PBMs, but I could control my actions to fight back. In that sense, I stopped being defensive and reacting to PBMs—rather I took the offensive, fought back, and regained my own control. That is what made all the difference!
References
1. https://www.iarx.org/blog_home.asp?display=49
2. Am Pharm Assoc (2003). 2017 Nov-Dec;57(6):692-697. doi:10.1016/j.japh.2017.07.006.Epub 2017 Aug 24.