The pharmacy "pro-choice" movement — specifically the bill to allow consumers in Colorado to use the pharmacy of their choice — has been voted down by a Senate committee.
The news comes as a relief to big PBMs and managed care businesses, as they claim the law would have prevented important negotiations that help reduce healthcare costs. But patients and many local community pharmacies were sorely disappointed as they will continue to be locked out of using their own preferred pharmacy by their health plan.
What is pharmacy choice?
For those unfamiliar with this topic, the issue revolves around whether your insurance can dictate where you must fill your prescription drugs.
Sometimes this involves requiring patients to use mail-order pharmacies to handle all the maintenance medications they take. Under this arrangement, patients sometimes get their initial prescription filled at their local pharmacy, but are required to obtain future refills from the plan-preferred mail-order pharmacy.
Other times the issue involves locking patients into a particular pharmacy chain or at least excluding certain smaller chains or independent pharmacies from the plan. In this scenario, patients can get their prescriptions filled locally, but not necessarily at the pharmacy of their choice.
The pharmacy choice movement, also sometimes expressed as the "any willing provider" issue, argues that patients should have the right to access any pharmacy they want to use and that a pharmacy, willing to accept the reimbursement rates of the health plan, should be able to participate.
The problem with choice
Health plans and PBMs have an interest in lowering coverage costs to employers who have options when it comes to selecting a health plan to work with. Part of reducing those costs involves negotiating with pharmacy networks for lower reimbursement rates in exchange for exclusive rights to fill prescriptions for their members.
The concept isn't complicated. Pharmacies agree to narrower margins in exchange for volume.
I usually compare it to a magazine subscription. If I wish to purchase a single issue of Sports Illustrated, then I'm going to have to pay about $5. However, if I agree to purchase every issue for a year, I can get that same magazine for substantially less money. We all understand it.
The problem with eliminating these arrangements and opening the playing field to every pharmacy is that the PBM loses the ability to leverage volume for lower prices. Pharmacies with large buying power and resources that are operating at less than 100 percent capacity can afford to accept a lower margin in exchange for the promise of more patients. Without the promise of volume, the deals simply wouldn't be as inviting.
Arguing for choice
Like many patients and pharmacists, I would like to see an arrangement where my patients can choose whichever pharmacy they prefer to use. I believe relationships matter in healthcare, and building a relationship with your local pharmacy is a part of a healthy life.
I also believe being forced to switch pharmacies, just like being forced to switch doctors, is detrimental overall to patient health. A change in pharmacies is a "transition of care" and subject to all the mishaps and problems that occur with other similar transitions in healthcare.
The best way to advocate for pharmacy choice is to push for full disclosure and transparency about the pharmacy benefit to employers and employees. People should know what they are getting into.
A health plan should have to clearly spell out which pharmacies will be available to members and which pharmacies will not. When employers look for health plans for their employees, they will then be better informed about how a particular choice will impact a local pharmacy with which they have built a relationship.
This same principle should apply to Medicare Part D plans as well. Currently it is unclear to patients, when they join a Medicare Part D plan, whether their pharmacy will be able to participate.
When patients and subscribers receive clear and easily understood information about the pharmacy network they will be getting, then — and only then — will pharmacy choice be fair.
