Preserve Patient Access to Neighborhood Pharmacies
Studies and Data
AHCA Commissioned Analysis of FL Medicaid Confirms Over $90Million in PBM Spread Pricing
This recent independent analysis of Florida Medicare commissioned by the Agency for Health Care Administration (ACHA) sheds light on PBM fee and pricing practices in Florida's Statewide Medicaid Managed Care System (SMMC). The analysis confirms that PBMs have taken over $90 Million per year in excess profits through the use of spread pricing.
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.
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 NewsRead More
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 […]Read More
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 […]Read More
Florida Politics, January 16, 2020 Four years after I was diagnosed with heart failure in 2013, I had a heart attack. My heart was failing, and my only option was a heart transplant. I was fortunate when a donor heart became available, and I have lived with my new heart since July 2018. Having a healthy organ is a true gift, and I view it as such. I am diligent about doing whatever I need to in order to take care of this gift that saved my life, including spending the rest of my life taking transplant medications so my body doesn’t reject this gift. […]Read More
Florida Politics, January 13, 2020 Will this be the year that Floridians at long last receive some financial relief from prescription drug costs? Physicians, pharmacists, and patients certainly hope so. One of the major issues heading into the 2020 Legislative Session is the role Pharmacy Benefit Managers (PBMs) play in setting prescription drug prices. PBM detractors often cast them as middlemen behind the rise of prescription prices. To that end, lawmakers have passed legislation eroding their profession in recent years. According to the Pharmaceutical Care Management Association (PCMA), a PBM trade association, their role is a little more nuanced. In their estimation, pharmacists deserve a share of […]Read More
Tallahassee Democrat, January 11, 2020 There are people with no medical training and no obligation to patients who have the power to override medical decisions made by patients and their physicians. These people are pharmacy benefit managers — called PBMs. These pharmaceutical middlemen claim their role is to negotiate savings on prescriptions for patients. But their scope extends dangerously beyond business negotiations. They can decide whether patients can receive the treatments recommended by their physicians. These are businessmen, not medical professionals — and they are altering the care patients receive. Many of my patients in Tallahassee have had their health jeopardized by these dangerous practices. Delays from PBMs recently left one of my […]Read More