Every Thursday I hop in my 1987 pickup truck to deliver medicines to South Sound patients who have trouble leaving their homes to get to my store.
As a small-town pharmacist, I see it as my duty to ensure patients have access to the medicine they need, when they need it and at affordable prices.
But the tangled web of the healthcare industry – from medicine middlemen to increasing insurance premiums - can make it hard for me to do my job and help care for my patients.
Take pharmacy benefit managers (PBMs). They are a type of insurer that basically act as a middleman between drug makers and pharmacists.
For years, PBMs have implemented practices which have increased drug costs for patients and made doing business for local pharmacies difficult.
These practices come in the form of “clawback” and “gag order” provisions – and while the details are wonky, it basically goes like this:
Clawbacks enable PBMs to instruct a pharmacy to collect an elevated copayment from a patient. PBMs can then recoup the surplus amount from pharmacies like mine.
This reduces the amount my business collects and causes prescription costs for patients to skyrocket.
Meanwhile, my customers assume these PBM-prescribed copay amounts are the cheapest drugs available – which is not always the case.
Unfortunately, gag orders prohibit me from recommending cheaper prescriptions that my customers could obtain by paying out of pocket.
These middlemen have also been a burden on Washington state’s budget by the way they play our state’s Medicaid program: Apple Health.
Case in point: Let’s say my pharmacy pays $85 per tablet to acquire a generic cancer drug, but Apple Health paid the PBM $110 per pill. The $25 per pill spread between these figures is essentially the profit that PBMs collect to pad their own pocketbooks.
That’s a clear example of how our state is getting bad deals on prescription drugs.
You’d think insurers would stop there, but it only gets worse. Last year, Washington health insurers asked for a 19-percent increase in premiums while sitting on billions in reserves.
How can they ask patients to pay more out of pocket when they’re already struggling to purchase their lifesaving medications? If it’s not clear already, I can tell you: It’s about the money.
Recently, Congress took steps to address PBM practices by curtailing gag orders. Additionally, the federal government recently proposed a rule to cut down on PBM price-gouging practices.
While these proposals are a step in the right direction, there is still more that can be done at the state level.
Senate Bill 5422 and House Bill 1911 would have strengthened further prohibition of any contract clauses restricting a pharmacy’s ability to disclose information to its patients. They also would have placed restrictions on PBM interactions with pharmacists.
Unfortunately, both of these bills died before the legislative cutoff in February.
I hope state lawmakers realize that patients are anything but insurers’ top priority and reexamine their approach to addressing harmful PBM practices. The stakes are too high.
Ian Warren is a pharmacist at Gig Harbor’s Costless Pharmacy. He’s served South Sound patients for more than 30 years.