Healthcare advocates raise awareness of unfair practices
ALBANY, Ga. (WALB) - Many people, especially in small, rural areas rely on their local pharmacies to fulfill their needs. But many pharmacist and healthcare advocates say this is being made difficult because of Pharmacy Benefit Managers (PBM).
Greg Raybold is the General Counsel and Director of Healthcare Policy with American Pharmacy Cooperative. He says PBMs are often times hired by insurers and governmental entities to administer prescription drug benefits.
“They create networks, they set reimbursement amounts that pharmacies are going to be reimbursed,” Raybold said. “They set reimbursement amounts that patients are going to have to pay at the counter for drugs. Some of them are amongst the biggest companies on Earth.”
However, he says many of them are not doing their roles ethically and often target demographics like senior citizens and people with chronic illnesses like cancer or HIV.
“There was one study that came out earlier this year, and it looked at Medicare Part D. And what it found is it looked at your generic drugs in Medicare Part D, and while generic drugs deflated over a 36-month period around 9%, they inflated the price for seniors around 51%,” Raybold said.
He says this isn’t the only way patients are being taken advantage of.
“Another example that we see is clawbacks. There are PBMs that are gaining practices where they’re charging patients a certain price at the pharmacy counter for a drug, and then they’re clawing significant portions of that money back,” he said.
He says another way is what’s called “steering.”
“Where a patient, you know, who’s battling cancer may want to get their drug from their trusted oncologist, instead they’re being told ‘Oops, sorry. Even though the drugs are at the oncology practice, and you can get it today. Now you got to wait two or three weeks.’ And sometimes they’re even paying more for it,” Raybold said.
He says these practices have huge negative impacts on both local pharmacies and patients. But he says action is beginning to be taken through things like the Pharmacy Benefit Manager Transparency Act.
Ashley Kunkle is the Pharmacy Manager at U Save It Pharmacy.
“Most Medicare Part D plans have middlemen that they call them Pharmacy Benefit Managers and they own pharmacies,” Kunkle said. “A lot of big pharmacy chains have these Pharmacy Benefit Managers and they also have mail-order pharmacies. Most plans are operated by these people.”
She says she has seen a tremendous amount of patients be taken advantage of by these PBMs even after a patient says they do not want mail-ordered medicine.
“Sometimes they call the community pharmacies to get the prescriptions transferred to them. Other times they’ll call the doctor’s office directly and say ‘this patient wants their prescriptions filed through us, so I need you to send me prescriptions’,” she said.
Not only are people like the senior citizen community being overcharged and forced or “steered” to use the PBMs pharmacy, but they also send unnecessary medication.
“The biggest problem I have seen with my patients is a lot of times, they send in prescriptions that the patient is no longer taking,” Kunkle said. “Or they send in a 90-day prescription before they need it. So after 68 days have passed, they send in another 90 days of that same prescription.”
Kunkle says they do this so that community pharmacists are unable to step in and refill the prescription for their usual patients.
She says these practices often leave patients with excessive amounts of medication that usually expire which she says she and Albany’s coroner have often seen. She even tells me that patients have brought in trash bags full of expired insulin before.
Greg Raybold says PBMs will even overcharge the client and under reimburse the pharmacies.
“Community pharmacies are there because they care about their patients, and so often times they’ll continue to dispense and care for those patients. Even though it’s putting them out of business to do so,” he said.
Kunkle says she has had to do this before. She adds that it is not about losing patients to PBMs, but advocating for the terrible treatment she sees in disadvantaged communities like the elderly, low-income, and chronically ill receiving.
Raybold tells me if people believe they are receiving unfair treatment, they can contact the Georgia Commissioner of Insurance to file a complaint.
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