If You Don’t Know What a PBM is – READ THIS.

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By Cristina Manos RPh.

I am a licensed pharmacist of 23 years and PBMs have been making my life miserable for over a decade. Unfortunately, we are now at a point where our locally owned pharmacies across the nation are closing down.

Even if you don’t work in a pharmacy, if you get prescriptions filled and have to use insurance at the pharmacy – you are engaging in a business transaction whereby your money does not go to the person providing you with the service, especially in the case of local providers like your local pharmacy or medical supplies store.

In some cases, the locals are not reimbursed full cost on drugs or equipment, which means they are paying to have you as a customer, and they are losing money on the transaction. This includes Medicare and Medicaid, plans because unfortunately the prescription side is contracted with these PBMs – Prescription Benefits Mangers. It’s often referred to as your “prescription insurance.”

To make matters worse, if the pharmacy system shows the insurance company, via its PBM, paid something on the medication, the PBM will come back months later and take the money back in a clawback. This is supposed to be illegal in a few states that have started to catch on to PBM corruption, but there is very little regulation, and almost no enforcement. The clawbacks come by way of a corrupt tactic called a “DIR Fee” and other methods such as laborious audits.

DIR Fees are the method by which PBMs want pharmacies to convince every diabetic patient, and person with high LDL cholesterol, to be on a statin. This is an example of one metric included in the equation. All of the “network” pharmacies must try to convince doctors to get patients on statins, on a certain kind of blood pressure medication and on their preferred diabetic medication. If one pharmacy scores perfectly on these metrics, it won’t matter because the network performance is measured. Most pharmacists cannot (and should not!) convince a doctor to prescribe something for a patient that the doctor has not prescribed in the usual course of their practice. Most pharmacists are not going to waste their time trying to do that because they do not have the extra time to pull away from serving their patients. Most pharmacists don’t understand why they are being forced to perform this service, and they are not being compensated for the extra work.

In many cases, the local pharmacy owners don’t even realize the clawbacks are happening. And in many cases, the actual “metrics” and clawbacks are conducted via programs and online platforms developed by the warehouses, like Cardinal Health, that provide medications and medical equipment. In some cases these companies manufacture their own medical supplies. The warehouses/suppliers, “healthcare companies,” work with the insurance companies to figure out drug pricing and repacking. These healthcare companies have also become conglomerates and present themselves as a company that wants to improve patient compliance. Because these suppliers are in the middle of the money flow from Big Pharma to the pharmacies in the communities, they have a pulse on profit margin opportunities. Now, even the suppliers are working with the PBMs and the drug companies, steering the profits back to the conglomerates. Every algorithm is profit driven. I have not seen that any of this has to do with quality patient care.

I, myself, had crippling pain from taking statins. My mother had brain fog and memory loss, and my sister experienced both of those things. I have had friends, patients, family members, as well as people in the medical profession tell me that they have experienced these same side effects from taking statins. This is complete insanity, in my professional opinion, that there is a thing called a “DIR Fee” that has to do with getting all patients in certain diagnostic categories on very specific drugs or the PBM gets to take back money it has already paid on prescription drugs that have nothing to do with the medications the PBM is tracking. This kind of blind, blanket prescribing is dangerous to the public and should not be happening. Clawbacks of any kind should not be happening.

The PBMs are owned by the big chain pharmacies like CVS/Caremark, in this example. CVS pharmacy would be your preferred pharmacy, so you would be steered over to CVS for a cheaper copay, or to have the medication covered. This takes away your choice. You may save $3.14 on a copay but you still have to drive further and wait longer to get your prescription. Your insurance demands this; your insurance for prescriptions is the PBM CVS/Caremark, who also merged with Aetna insurance company a few years ago. PBMs take away your consumer choice, and they try to dictate what medications you should be taking.

It can seem like you’re maybe saving a little after you figure in the price of gas and your valuable time, but your premiums aren’t that low, there are a bunch of drugs that aren’t covered, and you have to expose yourself to, and deal with, the public when going to pharmacies that are also large stores. Or sit in a drive through line and wait while every other person in line is taking forever because their insurance is not covering their medication, and they think arguing with the pharmacy professional will somehow change that. This is the scene at your “preferred pharmacy.”

As a licensed pharmacist, I’m watching the locals I work for, and prefer to work for, struggling to make a profit. Several pharmacy owners are about to close their doors permanently. I am paid around $35K less a year than my last job as a staff pharmacist for a big chain. Now I have almost no benefits. I’ve had trouble getting full time hours. My own prescriptions can’t be filled in the pharmacy I work in because it is not the preferred pharmacy under my plan. I have no choice on where to buy my medications if I want them to be covered. The locally owned pharmacy is where I prefer to work and shop.

In a fair market I would love to own a pharmacy and proudly serve my community by offering personalized, quality patient care. Working for the huge companies is miserable. I did it for over 20 years and can attest to the profits-over-people company culture running rampant in big chain pharmacies. The employees and the patients are just numbers, who are there for the end point of making money.

Three PBMs own 77% of the market. They are CVS/Caremark, Express Scripts and Optum Rx. This means up to 77% of all pharmacy and medical claims processed in any given pharmacy are subject to billing transactions that will result in the pharmacy losing money.

Pharmacists all over the nation crave to get away from the corporate jobs and work for locals. There are barely any locals left to work for, and thus about 80% of our workforce is trapped in working in the McPharmacy. While your pharmacy workers are probably some of your favorite people, they are struggling with work life balance, as these corporations that rake in billions are not willing to fully staff their pharmacies. Employees struggle to keep up with high volume as a voice comes out of the ceiling to remind them there are 2 phone calls coming in and someone is in the drive thru lane waiting to be served. Stress levels increase as people are lined up for COVID and flu vaccines, as well as COVID tests. The companies haven’t been generous in giving more staff to their pharmacies to help with the issue, except in cases where extra help was hired on for temporary positions at relatively low wages to help vaccinate.

We are struggling as pharmacy professionals. We need the public to help with this problem. We must have the support of our patients to be able to bring awareness to this important topic. I’d hate to think that in the future, my patients could be getting their medications from a talking vending machine run by PBMs.

I’m encouraging every patient, consumer and pharmacy professional to send letter to your representatives in Congress, to your Governor, and to any other entity (the FTC) that can have influence on this important topic. Help save small businesses by demanding our representatives end these corrupt business practices and break up monopolies, so that we have our right to consumer choice regarding where we shop and where we go to receive healthcare. That is our right as Americans.

See my proposed legislation at:

PBM Regulation Proposal


PLEASE DONATE JUST A LITTLE TO HELP US KEEP GOING:

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THANK YOU!! THANK YOU!! THANK YOU!!

 

 

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