NCPA's highest priority goal to change the pharmacy payment model has meant, for the most part, fighting the one-sided business practices of the health insurer-owned PBMs. If there's one thing that sports teaches you, to paraphrase the Olympic champion and WWII veteran, Louis Zamperini, it's that we must fight to the finish if we're going to succeed. There is no giving up.
The arena for NCPA's fight has been, for the most part, legislative — and decades of effort has seen some of its biggest returns in recent months. Federal lawmakers have advanced several bipartisan bills targeting PBMs since May, spurred by NCPA's advocacy and echoed by actions taken in several state legislatures to halt the anticompetitive practices that put patients at risk and squeeze independent pharmacists.
We've put points on the board and NCPA has contributed to fundamental changes in how pharmacy payments happen by shining a light on the confusing, convoluted, and covert model and advocating for a model that aligns the interests of pharmacists, their patients, and payers.
As activity on Capitol Hill heats up, independent journalists are starting to pay greater attention to the anticompetitive practices of PBMs thanks to awareness that NCPA and others have raised.
In March, ProPublica published "How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them," alleging that patients are frequently forced to pay out-of-pocket expenses for services that should be covered. Also in March, House Oversight and Accountability Committee Chair James Comer (R-KY) launched an investigation on the role of PBMs in rising healthcare costs by requesting input from the Office of Personnel Management, Centers for Medicare and Medicaid Services, and the Defense Health Agency, as well as documentation about practices from CVS/Caremark, Express Scripts, and OptumRx. After NCPA's Congressional Pharmacy Fly-In, for which he was a keynote speaker, Comer opened the committee's first hearing on PBMs and their business practices on May 22, which included testimony from NCPA member Kevin Duane, owner of Panama Pharmacy in Jacksonville, Florida. That came on the heels of a House Ways and Means Committee hearing in which NCPA member, pharmacy owner, and CPESN luminary, Joe Moose testified.
Then, on May 24, the House Energy and Commerce Committee passed the Promoting Access to Treatments and Increasing Extremely Needed Transparency (PATIENT) Act (H.R. 3561), which includes several provisions vital to lowering prescription drug costs and bringing transparency to anticompetitive practices employed by PBMs. But, it didn't just pass. It passed with a unanimous vote of 49-0 on the strength of bipartisan support and the tireless advocacy efforts of NCPA and other organizations to secure several key provisions, which you can read about. One provision that should be highlighted is a requirement that all state Medicaid managed care programs reimburse pharmacies at the Medicaid fee for service rate, which more accurately reflects the costs to acquire and dispense a prescription medication.
None of this should constitute a victory lap for NCPA and our members — and we can't let up. That is what the PBMs and their health insurer owners want to happen. After decades of oppression, NCPA is pushing ahead like never before to work with state and federal legislators, to talk with patients, and to engage leaders in communities across the country.
We are now able to see the potential for a tipping point on PBM business practices — a point where the tilted, one-sided, business relationship between PBMs and pharmacies and practically everyone else in the healthcare ecosystem, have the chance to recalibrate.
None of this progress is possible without the value and the relationships independent pharmacies provide to society. The hits to PBM business practices have been coming fast and furious. NCPA is not letting up. We ask you to do the same.
B. Douglas Hoey, Pharmacist, MBA