Pharmacy ratchets up pressure on PBMs

Community pharmacy’s high-stakes pushback against the powerful pharmacy benefit management lobby continues.

Last Wednesday, independent pharmacy owners rallied with lawmakers on Capitol Hill in support of several “patient-friendly” bills now before Congress. Among them: the bipartisan Pharmacy Competition and Consumer Choice Act (S. 1058), co-sponsored by Sen. Mark Pryor, D-Okla., and Rep. Cathy McMorris Rodgers, R-Wash. The bill, which includes provisions requiring transparency by PBMs in pharmacy audits, also has the strong backing of the National Association of Chain Drug Stores.

On Capitol Hill, independents also voiced support for the Preserving Our Hometown Independent Pharmacies Act (H.R.1946), introduced in the House by Rep. Tom Marino, R-Pa. The National Community Pharmacists Association's CEO Doug Hoey called both legislative proposals “common-sense, bipartisan bills” that would “rein in some of the most egregious behavior of pharmacy benefit managers [and] help level contract negotiations between PBMs and pharmacies.”

On Friday, the chain pharmacy lobby again weighed into the debate over the power of PBMs, endorsing the newly enacted Pharmacy Audit Integrity Act in Alabama. NACDS president and CEO Steve Anderson asserted the new law also would “ensure transparency in the PBM audit process.”

Meanwhile, retail pharmacy operators will have to be vigilant in their efforts to keep their own houses in order while they draw attention to PBM industry practices and billing methods. The Department of Health and Human Services' Office of the Inspector General is looking at possible fraud by a relatively small proportion of community pharmacies that fill prescriptions for seniors under the Medicare Part D drug benefit program.

The OIG issued a report last Thursday under the disturbing title, “Retail Pharmacies with Questionable Part D Billing.” That prompted a quick response from Hoey, who noted that “for approximately 96% of community pharmacies the OIG report identified no ‘questionable’ billing.”

What’s more, NCPA’s top executive said, “Regarding the small percentage of pharmacies that the OIG report focuses on, it lacks sufficient detail to evaluate the medical legitimacy and appropriateness of the claims reviewed.”

Let us know what you think. Is pharmacy fraud a widespread and legitimate cause for concern by Medicare administrators and federal budget overseers? Or is much of the problem due simply to factors outside the control of pharmacies, particularly independent owner/operators, who “struggle to comply with a wide array of inconsistent oversight and auditing requirements,” in Hoey’s words?

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