Third-Party Payers Don’t Realize Burdens Placed on Pharmacists

PBMs and HMOs, by imposing a workload that doesn’t allow enough time for needed functions, seem to want pharmacists to fail, this author asserts.

By Jeffry R. Ellis, RPh

At a time when HMOs and pharmacy benefit managers should be helping the pharmacist with third-party frustrations, they seem to be undertaking every means possible to make it worse. From the PBMs’ seemingly impossible task of issuing prescription cards in a timely fashion, to the insulting reimbursement rates forced on pharmacies, HMOs and all third-party payers seem to want everything for nothing.

Prescription cards were offered in the beginning and seemed, to many of us, to be a good way to increase business. The reimbursement rates were bad, but maybe they would increase foot traffic in the pharmacies and the patient would buy an ice cream cone or something. What could it hurt?

Boy, did we find out. Now 80 percent of our patients use third-party payers. The pharmacies’ cash customers, who subsidized all of those prescription-card customers, no longer exist. So who finances the prescription-card customers? Apparently, the pharmacies.

That is why you have long lines at drug stores and little or no drug counseling. I find I am judged as a pharmacist on my ability and expertise in entering the information into the third-party portion of my computer in such a way that the computer on the other end of the phone line understands and adjudicates my entry. Do my years of education and experience in drug information, interactions, and side effects count for anything? Not very much. I have become an insurance man! And boy, do I resent it. As a result, I personally badmouth the entire industry every chance I get — and I get a lot of chances.

I am starting to refuse to answer questions on copayments and why certain medications are not covered. I have decided that this is not in my purview. All questions should be directed to the HMO’s 800 number on the back of its prescription cards. Let the customers deal with the seemingly unending messages and number trees.

No time to counsel

I must fill more prescriptions to survive, and that leaves little or no time for conversations with patients. So the HMOs pay big money for high-priced medicines to keep people out of high-priced hospitals. Then people take them incorrectly, and end up in the hospital — which we are all trying to avoid. The $2 cut in my fee seems to cost the HMO industry a lot.

Then there is the myth that customers can save money with mail-order pharmacy. The patient saves by getting three months for one copayment, but that is a totally artificial number mandated by a PBM.

The HMO could make it the same copayment at the retail level, but the HMO doesn’t want to. Maybe the HMO owns the mail-order houses. Don’t think I don’t tell the patient that every chance I get. People hate mail-order pharmacy. Heck, they don’t call me for refills until they have been totally out for a couple of days. HMOs expect them to plan two weeks ahead, and then expect me to cover when the HMOs are unable to get it to them in two weeks.

I fervently believe most of the ills of the drug distribution system are due directly to third-party payers.

Jeffry R. Ellis, RPh, is a staff pharmacist at the Medicine Shoppe (about 400 prescriptions a day) in Sandwich, Ill., as well as the director of Region 8 of the Illinois Pharmacists Association.

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