Preserve Patient Access to Neighborhood Pharmacies


Studies and Data

Independent study highlights extent of PBMs' predatory practices in Florida's Medicaid program

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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.

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Who do PBM predatory tactics hurt?

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Patients

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.

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Pharmacists

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.

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Providers

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.

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Payors

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.

News

Alex Andrade tackles Rx drug legislation, but does it go far enough?

The Floridian, February 21, 2020 Florida state Rep. Alex Andrade (R) is advocating for a bill that would create more transparency around the prescription drugs that Floridians buy. But some groups are questioning whether it goes far enough. This week, Rep. Andrade presented his bill about prescription drugs to the House Health and Human Services Committee. The bill, HB 7045, addresses a number of different aspects including creating advanced notice requirements for drug price increases and requiring new reporting standards for certain entities in the prescription drug market. However, critics point out that the bill does not fix one issue that many consider is the biggest issue […]

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Local pharmacists complain drug middlemen hurt patient prices and business

Citrus County Chronicle February 12, 2020 In the competitive pharmaceutical industry where drug manufacturers vie for huge market shares, middlemen work billion dollar deals, and pharmacy goliaths dominate the prescription landscape, it’s hard to be small, and, in many cases, unfair. That’s the take by Jesse Brashear, of Brashear’s Pharmacy in Lecanto and Inverness, and who is hoping proposed legislation that requires more transparency about drug prices. Brashear’s focus during a local press conference Wednesday was predominately on pharmacy benefit managers and House Bill 961. Brashear said pharmacy benefit manager middlemen who work out drug prices between pharmacies and insurance payers often favor large chain […]

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Study finds millions in Medicaid unfairly pocketed by Pharmacy Benefit Managers

The Capitolist February 4, 2020 A new Florida study, released last week, found that major health care companies using pharmacy benefit managers (PBM’s) have positioned themselves to pocket millions of dollars from the state’s Medicaid system that were intended to lower costs for millions of low-income Floridians. The study found that despite processing less than half of one percent of all pharmacy claims, specialty pharmacies affiliated with PBM’s managed to collect 28 percent of the available profit margin from dispensing prescription drugs. The study was commissioned by the Florida Pharmacy Association and American Pharmacy Cooperative Inc. using data obtained from Florida’s Agency for Health Care Administration […]

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PBMs favor their own pharmacies in the Florida Medicaid program

STAT News Plus January 31, 2020 As angst rises over the prices paid for medicines, a new analysis finds some pharmacy benefit managers that contract with Medicaid managed care organizations in Florida are pushing prescriptions to drugstore chains they control, raising costs for consumers and taxpayers. The report, which analyzed approximately 350 million state Medicaid pharmacy claims from 2012 through 2019, noted that PBMs sometimes reimbursed their own pharmacies for certain medicines at substantially higher rates than what other drug stores received, and payments to their affiliated pharmacies greatly exceeded the cost to dispense the drugs. Continue Reading on STAT News

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Pharmacists Say They Take Hit In Medicaid

Health News Florida January 31, 2020 Amid a legislative tussle with millions of dollars on the line, people who operate pharmacies in Florida contend they are getting short-changed by the state. A report released Thursday maintains that pharmacists participating in Florida’s Medicaid managed-care program are being woefully underpaid. State Medicaid officials estimate the cost of doing business in the Medicaid program is $10.24 per filled prescription. But on average, Medicaid managed-care plans paid pharmacists $2.72 per claim in 2018. The 202-page analysis was commissioned by the Florida Pharmacy Association and American Pharmacy Cooperative Inc. and was conducted by 3 Axis Advisors. It was based on […]

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New study highlights predatory practices by pharmacy benefit managers that drive up costs for patients, taxpayers

Capitol Soup, January 30, 2020 Study analyzing 359 million prescription AHCA drug claims documents widespread abuse   Legislators and advocates for reducing costs and improving access to prescription drugs today hailed a new independent study documenting that Pharmacy Benefit Managers (PBMs) have pocketed millions of dollars from the Florida Medicaid system – funds that should have been directed toward health care for millions of low-income residents. The study, commissioned by the Florida Pharmacy Association and American Pharmacy Cooperative Inc. with data obtained from the Agency for Health Care Administration (AHCA) by the Small Business Pharmacies Aligned for Reform (SPAR), highlights the predatory nature of a handful […]

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