Healthcare’s secret middlemen


Until recently, filling a prescription was an easy process for you and your pharmacist. You may have noticed lately increased references to specialty tier medicines. These special medicines are often accompanied by a rather special price under the friendly sounding guise of cost-sharing or co-insurance.

Just to be clear, cost-sharing often means the patient gets to pay more. But that’s not all. Certain health plans and their partners are now trying to further limit patients’ access to these life-saving medicines by requiring mail-order delivery.

Secretive Middlemen

So who is behind all these changes? The answer is secretive, unregulated middlemen known as pharmacy benefit managers, or PBMs.

PBMs are the middlemen between the drug makers and insurance companies. PBMs play a major role in determining which medicines are available to you and at what cost. Sadly, many PBMs profit via practices that are detrimental to both patients and the pharmacists who care for them.

When most people think of a pharmacy, they envision large chain store. But the more than 500 independent pharmacies in Kentucky play a much larger role in providing care, particularly for those in rural areas.

Mom and Pops at Risk

In these settings, pharmacists are more than just someone behind a counter. In many ways, these mom-and-pop style businesses are the most immediate and accessible medical professionals in their area and are often cornerstones in their communities.

Yet these small pharmacies have been threatened for years by unfair PBM practices. It began with shadowy reimbursement methods that mean pharmacies often receive less than the actual cost of the medicine they dispensed. And now they’ve graduated to overt efforts to circumvent local pharmacies with required mail orders that could put trusted caregivers out of business.

This troubling new practice requires patients to forgo their face-to-face consultation with local pharmacists and refill prescriptions for specialty medicines via mail. This removes access and consumer choice from the system and prevents another critical interaction between the patient and a well-trained healthcare provider.

This often impacts patient communities who least can afford a change in their treatment regimen, including those with cancer, mental and behavioral health issues and chronic pain.

Fortunately, Kentucky lawmakers can address these problems with common sense legislation. For starters, lawmakers should finally make PBMs play by the rules and treat independent pharmacies fairly and correctly according to the law.

But perhaps the most important step Kentucky lawmakers can take is giving the Kentucky Department of Insurance authority to regulate PBMs in the same manner as insurance companies.

Under the current setup, pharmacists have no recourse to resolve unfair, inappropriate or even arbitrary actions of PBMs. By regulating PBMs, the state will have the ability to both sanction and fine those companies that engage in activities prohibited by state law.

-Rosemary Smith is the Director of the Kentucky Independent Pharmacist Alliance (KIPA).