Preserve Patient Access to Neighborhood Pharmacies
Studies and Data
Independent study highlights extent of PBMs' predatory practices in Florida's Medicaid program
This independent study from 3 Axis Advisors was developed using data straight from the state Agency for Health Care Administration. The analysis covers more than 350+ million prescription claims in Florida between 2012 and 2019, coupling that data with information from 100+ pharmacies. Some of the most shocking tactics the report uncovers involve the routine practice of PBMs and managed care organizations "steering" patients to affiliated pharmacies and then paying those pharmacies more than other ones for the same drug.
Legislative Leaders are Calling for Action
“Markets fail when markets get corrupted and that is what has happened here. When the middleman is allowed to own the end-retailer then the middlemen’s incentive to manage cost appropriately for the benefit of the chain is broken. And that is what has happened here.”
-- Rep. Randy Fine
“The power and control of PBMs has grown significantly over the last five to ten years. What we’re seeing is insurance companies owning PBMs and PBMs owning insurance companies. What is happening in the long run is that the price of prescriptions are going up.”
-- Sen. Gayle Harrell
“The practices PBMs use to drive up profits are complex, but the solution is simple: We need to increase access to care for all Floridians while ensuring that prescription drug savings make it to the patient and not the pockets of predatory PBMs.”
-- Rep. Jackie Toledo
When it comes to PBMs,
we all pay the price.
Pharmacy Benefit Managers (PBMs) are middlemen who have strayed from their original purpose of negotiating savings for patients and now keep the profits for themselves, leaving the rest of Florida’s consumers to pay higher drug prices. PBMs use anti-competitive practices to short-circuit the free market and create health care monopolies.
These predatory tactics decrease access for patients, force neighborhood pharmacies to close down, and raise costs for everyone. We need legislation that will increase transparency and accountability on PBMs and ensure that patients are prioritized over profits.
Who do PBM predatory tactics hurt?
Forcing neighborhood pharmacies out of PBM health networks causes many patients to drive extra miles from their home to receive medications simply because their local pharmacy is not in their plan. This not only steers business away from neighborhood pharmacies, it severely restricts patients’ access to medications and drives up their costs.
Many neighborhood pharmacies diligently refill prescriptions only to be hit with reimbursements that are pennies on the dollar – with some even facing negative reimbursements or clawbacks – while PBMs continue to make record-breaking profits. No business can sustain operations under this model, and it is a clear manipulation of the system that promotes anti-competitive practices.
PBMs are overstepping their scope and making medical decisions best left to physicians and pharmacists – and their years of training. PBMs are motivated by profit, not by what is best for the patient, and many times PBMs require the use of drugs or specialty medications that are not the most beneficial for the patient.
The anti-competitive policies that PBMs push increase health care costs for everyone. PBMs don’t make or provide the drug – they don’t even touch the drug – yet they add costs to the overall health care system that must be absorbed by pharmacists, patients, and all Floridians.
How Can We Fix This?
This year, the Florida Legislature is considering legislation to address these challenges. SB 1444 and HB 961 implement transparency, accountability, and free-market policies that will help preserve patient access and keep drug prices affordable.
Here are some highlights of the legislation:
- Protect the free market by prohibiting anti-competitive policies that reduce patient choice and create health care monopolies
- Eliminate the practice of steering patients to PBM-owned pharmacies, especially when it involves taxpayer dollars
- Prohibit the predatory practices that PBMs use to squeeze independent pharmacies, including post-adjudication fees, spread pricing, and cumbersome audit practices
By supporting this legislation, we can bring about concrete change in the industry and put a stop to the abuses that leave Floridians suffering.
Why Are Neighborhood Pharmacies Disappearing?
..Customers don't just rely on these pharmacists, they LOVE them! Why, then, are they in danger of closing?
The answer lies in a complicated web of managed healthcare and the pharmacy benefits managers (PBMs) hired to administer prescription drug programs. PBMs negotiate the prices on drugs, create "networks" of pharmacies and, in some cases, have a financial stake in the pharmacy chains they affiliate with. Independently owned pharmacies in Florida, like Bill's Prescription Center, say PBMs are shifting dollars to their affiliated companies (pharmacy networks), beyond the oversight of the U.S. Center for Medicare and Medicaid Services and the industry boards designed to protect taxpayer dollars. Is it a conflict of interest when Medicaid can give management of prescription drugs to an insurance company that also owns the PBM and its affiliated pharmacies, without oversight of their interactions? Owners of local pharmacies say it is and are asking for transparency and oversight.
CBS Tampa Bay
Neighborhood Pharmacies Struggle to Stay Open Due to PBM Restrictions
Whether you realize it or not, your pharmacy options are becoming more limited but not because of COVID, but from something called Pharmacy Benefit Managers, or PBMs. It's a big enough problem that one Tampa lawmaker is working to pass a bill to protect independent pharmacies and demand transparency.
To break it down simply: the PBM operates as a middleman between pharmacies and insurers. Initially, they were supposed to reduce health care costs and pass on savings to customers. But as time went on, the PBM model started to change. For background, PBMs make money from fees from supply chains, rebates from manufacturers, and from pharmacy spreads. But in recent years there's been growing criticism that PBMs are starting to play the system to make the most money for themselves, not saving customers money and ultimately forcing independent pharmacies to struggle because of bad pricing models. It's also important to note that PBMs work with commercial insurers, with Medicare for its Part D benefit and with the Medicaid program.
"Another issue we are noticing is PBMs are hiding behind private contracts avoiding transparency about how they are creating revenue...
Pharmacy Benefit Managers are the Real Reason Behind Skyrocketing Drug Prices
Within the healthcare industry, there are pharmaceutical manufacturers, pharmacists, insurance companies, and Managed Care Organizations (MCO) for Medicaid, but there is one more player that few outside of the industry discuss—the pharmacy benefit manager, or PBM. A PBM’s original role was to negotiate lower drug costs between drug manufacturers and insurance companies, with the goal of passing those savings on to the consumer. Instead, the rise of PBMs, who have amassed great power with little oversight, has led to higher drug prices with a lack of price transparency. Small, neighborhood pharmacies are going out of business, and many of them attribute it to being underpaid through reimbursements managed by these pharmacy benefit managers.