Dear Colleague,
Picture the scene. It's January. Formularies have changed. A patient comes in for a refill on his Advair prescription he's been taking for year. The price comes back from the PBM significantly higher than what he paid the previous month (and it's not a deductible issue). You investigate what's going on, though you can already guess. Sure enough, the patient's insurance has made brand name drugs preferred, including Advair HFA, and the drug the patient has been taking is no longer on formulary.
You see this all the time. Less expensive generic drugs being available but not covered because the iInsurer/PBM/pharmacy giant prefers brand drugs to get bigger rebates. It's a cruel logic—make the patient pay more so the insurer/PBM gets a bigger rebate. But it is part of the convoluted, covert, and clandestine broken pharmacy payment model.
You play insurance agent for the patient, figuring out how to help him afford a similar medication to the one he had been successfully taking, contacting the prescriber to authorize the switch, and helping the patient eventually get on his way, medication in hand.
That scene is how it played out for Bil Schmidtknecht, a patient from Wisconsin who went to his independent pharmacy earlier this year. Tragically, Bil and Shanon Schmidtknecht's son, Cole, was in almost the same scenario, except he went to a large chain that wasn't able to take the time to play uncompensated insurance agent. Cole, as a 22 year-old recently living on his own, wasn't familiar with navigating the byzantine pharmacy payment system. When he went to get his Advair refilled—a medicine he had been taking for a decade—he was told it was now over $500. Faced with a choice between paying his rent or getting his medication, he paid his rent. A few days later, Cole had an asthma attack, and on the way to the ER he went into cardiac arrest. He died a few days later.
Bil and Shanon Schmidtknecht are two everyday people. Like most Americans, they had never heard of a PBM or had much reason to think about them. That radically changed when Cole died because he couldn't afford his generic medication because of an insurer/PBM's formulary decision, which was driven by making more money and not better health care.
NCPA and the PBM Accountability Project hosted the Schmidtknechts on a visit to D.C. this week. They had a packed schedule of meetings with numerous members of Congress and officials from the White House. I joined the Schmidtknechts and NCPA's SVP government affairs, Anne Cassity, for the White House meeting. Their story is moving and tragic. It didn't have to happen. The PBM probably would have made a few extra hundred dollars in rebates extracted from the manufacturer on Cole's prescription. The Schmidtknects now bear a cost that can't be measured. There are many more people out there just like Cole, having to make the same terrible choice.
Eerily, Bil Schmidtknecht had almost the exact same experience as Cole. In his case, the difference was that there was an independent pharmacist willing to take extra time to navigate the payment maze. That pharmacist's "reward" was being paid by the PBM less than her cost to buy the drug.
Net closures of independent pharmacies have averaged almost one a day over the last year because of business practices like this one. Independent pharmacies help save lives. Each one closed by PBM business practices threatens the health of people in that pharmacy's community. Congress needs to finish the job it started this year and pass PBM payment reform to help stop the closures and make sure Cole's story never, ever is repeated. #FinishtheFight
Best,
B. Douglas Hoey, Pharmacist, MBA
NCPA CEO
