Dear Colleague,
Washington, D.C. overtook Los Angelas this year as the city with the worst traffic in the country. Another dubious honor for the nation's capital. According to Consumer Affairs, congestion on the average weekday lasts 6.5 hours. That means commuters spend roughly 71 days per year sitting in traffic. That's easy for my NCPA colleagues and me to believe. Ugh.
The region has been struggling to reduce congestion for a long time. One solution was the creation of carpool lanes, open only to vehicles with two or more occupants. The urban planners said it would incentivize people to share a ride and cut down on traffic. Well, people started carpooling alright, just not with each other. They started riding with blow-up dolls, department store mannequins, Halloween skeletons, and anything else that might pass for a passenger. A classic unintended consequence.
There are a lot of unintended consequences in pharmacy. The unholy consolidation of insurance companies, PBMs and pharmacies was supposed to create efficiencies and lower prices. Instead, we have higher drug prices and fewer choices.
Direct to consumer—or "pharm to table"—is a trend that could have more unintended consequences. The president's executive order on drug prices issued in May seeks to facilitate direct-to-consumer purchasing for manufacturers who agree to sell at the Most Favored Nation prices. While it's not specified in the EO, the intent is to get to net pricing, versus the murky rebate (and "feebates" to offshore GPOs) pricing that makes U.S. drug prices the highest in the world. As I said then, we strongly support the president's focus on cutting out the PBMs, but "no part of this effort should bypass patient safety and effectiveness by going around the pharmacist."
One unintended consequence is that some pharmaceutical manufacturers have unveiled DTC programs that bypass local pharmacists, the medication experts with the patient relationship. And that will lead to a cascade of other unintended health consequences. Care coordination is one of the biggest concerns. If patients need multiple medications made by different manufacturers—which most do—they'll have to navigate multiple programs and deal with multiple pharmacies, a recipe for unintended consequences.
Manufacturers that I talk to don't want to be pharmacies. They want to develop and sell novel medications that help the patients in our care. They understand the important role community pharmacy owners and their teams play that patients cannot possibly get from a chatbot or a keypad.
Of course, DTC could also be used to defang PBMs and be a huge opportunity for community pharmacies, taxpayers, and patients. It could turn back the clock to the days before rebates/feebates corrupted formularies. It could return us to the days when the price of the drug was the actual price of the drug. Rebates (and now GPO "feebates") are the root of many evils in our costly health care system. They have fueled the monstrous transformation of PBMs from benign claims processors to anticompetitive monopolies costing taxpayer money and overruling doctors', pharmacists', and patients' health care decisions.
A DTC model that takes rebates/feebates out of the system while continuing to allow patients their choice of pharmacy is the right way to go. It will take some time for a new model to detox from the rebate/feebate addictions. In the meantime, Congress can begin the recovery process from previous unintended consequences by passing PBM reform.
Best,
B. Douglas Hoey, Pharmacist, MBA
NCPA CEO
