Friday, January 9, 2015

Putting the Patient First: Let Deserving Community Pharmacists into Preferred Pharmacy Networks


Imagine as a patient, you have been frequenting one particular pharmacy for many years. As a senior citizen whose memory isn’t what it once was, you appreciate the way the pharmacy packages your many prescriptions, even designating the time of day you should take the medicine. Perhaps you’re an immigrant and don’t speak English well, so the routine of going to this particular pharmacy is familiar, comforting. Then one day, you receive a letter stating that this pharmacy’s services will no longer be covered under your Medicare Part D plan.

Imagine as a community pharmacist, you spend time packaging the prescriptions for your patients to encourage adherence. You counsel patients thoroughly, even though your pharmacy fills hundreds of prescriptions per day. You perform full Medication Therapy Management services, despite the fact that the reimbursement rate for such services does not even cover your hourly rate. Even given your hard work, you will no longer be able to treat and fill prescriptions for patients like this senior citizen without Medicare reimbursement.

This scenario is becoming very real since the advent of the healthplan star ratings system. Created by the Centers for Medicare and Medicaid Services (CMS), this system rates the Medicare Part D plans by a metric of one to five stars.

CMS introduced the star ratings into an environment where patient medication non-adherence costs the healthcare industry approximately $300 billion per year. With the dawn of the Affordable Care Act, pay-for-performance became the new healthcare model. Medicare Part D plans can realize significant bonuses from CMS based on high star ratings. Plans with high star ratings also can pitch more powerful marketing messages, enjoy a longer enrollment period, and charge higher premiums.

The plans are rated according to four different criteria: drug plan customer service; member complaints, problems getting service, and choosing to leave the plan; member experience with the drug plan; and drug pricing and patient safety.

The Part D plans also contract with preferred pharmacy networks to which they direct their patients. When pharmacies enter into a PPN contract, they accept not only a lower reimbursement model, but also a lower co-payment for the patient and thus a hopefully greater volume of business. (www.ncpanet.org).

So, the Part D plans have a vested interest in choosing a network, and pharmacies, that help them to earn high star ratings. However, the data collection process that the plans and PBMs use is arduous and potentially prone to error.

As networks increasingly become the conduit to patients, participation in these institutions grows more crucial for pharmacies. Yet, not all high-performing pharmacies are part of a network, and it can be difficult and time-consuming to sort through the red tape to determine if they are.

Karen Horbowicz, Pharm.D, a Manager of Clinical Pharmacy at Inman Pharmacy in Cambridge, has experienced the network issue first-hand. She recently had three customers receive letters stating they would no longer get their prescriptions covered at Inman. One of these patients is enrolled in Inman’s medication packaging plan, where she gets her multiple medications prepackaged in dosage cards by the day and time they are to be taken. To do this, Horbowicz gets a detailed medication list and communicates directly with the patient’s physician. The process takes at least an hour.

Horbowicz fears that this patient will be reluctant to visit another pharmacy, and even if she does, a chain pharmacy may not be willing to go through the same process with her medication. Though the star ratings are designed to improve patient medication adherence, they will indirectly contribute to the opposite effect if this particular patient, and others like her, get lost in the shuffle.

Currently, there is a not a simple way for community pharmacies like Inman to learn of their performance according to the health plans’ star ratings. Inman’s would likely score highly on criteria such as customer service and member experience —due to the comprehensive Medication Therapy Management services the pharmacy offers with specialty packaging and patient follow-up.

Horbowicz has persistently contacted the health plan and pharmacy network, which has not led to a resolution. Given that the plan year is already underway, it does not appear that gaining admittance to this network is going to be possible. This is important since not belonging to a network will cost Inman patients, and its experience may is shared by many urban community pharmacies. A recent study issued by the Centers for Medicare and Medicaid Services (CMS) found that “fewer urban beneficiaries have convenient access to pharmacies offering preferred cost-sharing than beneficiaries in suburban and rural areas.”

The study went on to assign some accountability to the way the plans health plans contract with the preferred pharmacy networks, acknowledging the very problem Inman is encountering. “While we appreciate the importance of providing lower costs to beneficiaries, these findings reinforce CMS’ concern that plans are offering access to pharmacies with lower cost-sharing in a way that may be misleading to beneficiaries, in violation of CMS requirements. In addition to providing meaningful levels of access, plan sponsors must also provide a uniform set of benefits throughout the plan service area.”

Horbowicz’s manager pursued this issue and contacted CMS to issue a formal complaint, as did the National Community Pharmacists Association (NCPA). Following this, CMS created a “special enrollment period” for beneficiaries to choose a new Part D plan – specifically, a plan that would allow the patient to have drug coverage at his/her preferred pharmacy.

While helpful, this action still doesn’t impact the networks that exclude the deserving community pharmacies. For Inman, the very core of the business model of their community pharmacy, and many others like it, is at stake. “If we don’t get reimbursed {by Medicare}, we can’t do this anymore,” says Horbowicz.