{"id":12693,"date":"2018-02-19T04:33:37","date_gmt":"2018-02-19T04:33:37","guid":{"rendered":"http:\/\/arknews.org\/?p=12693"},"modified":"2021-11-22T18:28:31","modified_gmt":"2021-11-23T00:28:31","slug":"pharmacy-reimbursement-fight-prompts-special-session-request-from-legislative-leaders","status":"publish","type":"post","link":"https:\/\/arknews.org\/index.php\/2018\/02\/19\/pharmacy-reimbursement-fight-prompts-special-session-request-from-legislative-leaders\/","title":{"rendered":"Pharmacy reimbursement fight prompts special session request from legislative leaders"},"content":{"rendered":"
<\/div>\n

Since Jan. 1, Brandon Cooper, a pharmacist at Soo\u2019s Drug Store in Jonesboro, has turned away a number of patients seeking to fill routine prescriptions. The problem is not that the pharmacy lacks the drugs in question or that the patients don\u2019t have insurance, Cooper said. It\u2019s that the state\u2019s largest insurance carrier, Arkansas Blue Cross and Blue Shield, recently changed the way it pays for pharmaceuticals.<\/span><\/p>\n

Blue Cross, like most insurers, handles prescription drug claims through a middleman company known as a pharmacy benefits manager, or PBM. When someone covered by a Blue Cross plan fills a prescription, Blue Cross pays its PBM to pay the pharmacy a reimbursement. Blue Cross\u2019 PBM, CVS Caremark, began slashing reimbursement rates for generic drugs at the beginning of this year.<\/span><\/p>\n

Now, Cooper said, Soo\u2019s Drug is losing money. \u201cSome you may lose a dollar or two on, and some of them it\u2019s upward of $50, $80. That\u2019s just not a sustainable business model,\u201d Cooper said. <\/span><\/p>\n

The business sometimes eats the loss, he said, but other times, it turns people away. <\/span>\u201c<\/b>We\u2019ve had to send them down the road, and a day or two later a patient comes back and says, \u2018We tried three other pharmacies and they wouldn\u2019t do it either.\u2019 \"<\/span><\/p>\n

Many of the medicines in question aren\u2019t exotic. For the generic equivalent of Tamiflu, an antiviral used to treat influenza, Soo\u2019s Drug Store now receives a reimbursement from Blue Cross that is $50 less than what the pharmacy pays a wholesaler for the drug. Monthly birth control pills are also reimbursed below the pharmacy\u2019s cost, Cooper said, as are certain dermatological creams and ointments. About a third of his store\u2019s patients have Blue Cross insurance, he said.<\/span><\/p>\n

Scott Pace, CEO of the Arkansas Pharmacists Association, said CVS Caremark\u2019s reimbursement cuts are hitting his members hard. \u201cThere have been several pharmacies that have closed \u2026 [and] I will tell you that there are layoffs galore that have happened,\u201d Pace said.<\/span><\/p>\n

On Friday afternoon, leaders of both chambers of the state legislature <\/span>sent letters to Governor Hutchinson asking him to call a special session of the General Assembly to address the pharmacy issue. A spokesperson for Hutchinson said on Friday the governor will respond to the request from Senate President Pro Tempore Jonathan Dismang (R-Searcy) and House Speaker Jeremy Gillam (R-Judsonia) early next week. <\/span><\/p>\n

The legislature is in the middle of the 2018 fiscal session, during which it typically only handles budgetary matters. But some members, such as Sen. Ronald Caldwell (R-Wynne), have threatened to hold up the budget process if they don\u2019t get assurances of action on the pharmacy issue. That has prompted Dismang and Gillam to take the unusual step of requesting legislative session when one is already ongoing.<\/span><\/p>\n

\"It\u2019s been pretty difficult to have a conversation about the budget \u2026 [because] most of the conversation has been centering around policy issues,\" Dismang said. \"We felt like we needed to recenter and refocus the session on what we were sent here to do, which is fiscal matters.\" The fiscal session typically lasts about a month, meaning a special session could occur in mid-to-late March at the earliest. <\/span><\/p>\n

If the governor calls a special session, it remains to be seen what legislation will be filed to address reimbursements. Caldwell has introduced a measure that would make PBMs subject to regulation by the Arkansas Insurance Department, but he said he was in the process of revising the bill. \u201cWe\u2019re trying to make it shorter and more concise,\u201d he said. A companion bill was introduced in the House by Rep. Michelle Gray (R-Melbourne).<\/span><\/p>\n

The executive branch has gotten involved as well, with state Attorney General Leslie Rutledge announcing on Feb. 8 that she would be investigating whether CVS Caremark\u2019s pricing violated the state\u2019s Deceptive Trade Practices Act.<\/span><\/p>\n

***<\/span><\/span><\/p>\n

Blue Cross maintains that it was compelled to switch to a more competitive pricing model. The insurer\u2019s mandate is to hold down premiums and other costs for members, which include tens of thousands of Arkansans who buy individual plans on the health insurance marketplace and hundreds of thousands of beneficiaries of Arkansas Works, the state\u2019s hybrid public-private approach to Medicaid expansion.<\/span><\/p>\n

\u201cWe were paying a lot more in [drug] reimbursement than our competitors,\u201d Blue Cross spokesperson Max Greenwood said, referring to rivals QualChoice and Ambetter, the two other carriers in Arkansas\u2019s individual marketplace. That effectively meant Blue Cross customers \u201cwere subsidizing the marketplace\u201d by paying a higher rate to pharmacists, according to Greenwood. \u201cSo, effective Jan. 1, we selected an approach that was offered by our pharmacy benefits manager that \u2026 was being used by other carriers in the marketplace.\u201d <\/span><\/p>\n

CVS Caremark is at the center of the reimbursement dispute. Though most consumers never interact directly with PBMs, these entities play a crucial role in the health care system by negotiating prices with pharmaceutical companies on behalf of insurers. By pooling together many carriers, PBMs have the necessary volume to leverage better deals from big drugmakers. CVS Caremark\u2019s website says the company boasts some 90 million plan members, or over one-fourth of the population of the U.S. Nationally, PBMs have also attracted widespread criticism for a lack of transparency and alleged profiteering.<\/span><\/p>\n

Before January, Cooper said, QualChoice and Ambetter were using a pricing model that reimbursed pharmacists for generic drugs at a much lower average rate than the one used by Blue Cross. But those carriers have a far smaller share of the Arkansas market, so pharmacies could tolerate losing money on the occasional claim. When Blue Cross directed CVS Caremark to switch to the new pricing model, pharmacists\u2019 losses shot through the roof.<\/span><\/p>\n

Things were made worse by the fact that most of the state\u2019s 285,000 Arkansas Works beneficiaries are covered by a Blue Cross plan, subsidized by Medicaid expansion. When Arkansas chose to expand Medicaid under the Affordable Care Act in 2013, it created an unusual hybrid program that used private carriers as the vehicle for providing coverage to the newly eligible population. Under the program \u2014 now called Arkansas Works \u2014 the state\u2019s rate of uninsured residents has plummeted.<\/span><\/p>\n

\u201cLast year on Blue Cross [Arkansas] Works plans, we were getting an average margin of anywhere from $10 to $15 on prescriptions,\u201d Cooper said. \u201cFrom Jan. 1 to the 13th [2018], that margin dropped to an average of 99 cents. And then, Jan. 14, they had another round where they lowered it even more, and it went down to 18 cents on average.\u201d<\/span><\/p>\n

Soon after the pricing change was made, Greenwood said, \u201cit was brought to our attention that \u2026 pharmacists were getting reimbursed on a lot of their prescriptions below their cost. Way below their cost. And they were appealing those [to CVS Caremark], and those appeals were not being resolved in their favor.\u201d<\/span><\/p>\n

A 2015 state law prohibits PBMs from reimbursing pharmacists at a rate below the cost of a drug, but Pace, of the pharmacists association, said the law is not being followed. <\/span><\/p>\n

\u201cAppeals are not being responded to, or there\u2019s no resolution to the appeal that\u2019s happening,\u201d he said. \u201cSo of the appeals that occur \u2026 about one percent are resulting in any change in pricing.\u201d<\/span><\/p>\n

It is unclear how much profit CVS Caremark is making in the process \u2014 that is, the size of the spread between the amount it charges Blue Cross and the amount it pays retail pharmacies for a given claim. \u201cI think the problem was that the amount of money that the PBM was taking as their share versus what was being disseminated down to the pharmacy \u2014 there was a wide gap,\u201d Greenwood said.<\/span><\/p>\n

Christine Cramer, a spokesperson for CVS Caremark, said in an email that the PBM was working on introducing a rate structure that would \u201cprovide independent pharmacies in Arkansas with generic reimbursement predictability. This will balance the need to fairly compensate pharmacies while providing a cost-effective benefit for our clients and will reimburse independents in Arkansas at a higher rate than larger national chains.<\/span><\/p>\n

\u201cWe also have a well-established appeals process for network pharmacies regarding reimbursement, and our responses to those appeals comply with all applicable laws,\u201d Cramer wrote.<\/span><\/p>\n

Blue Cross has been meeting with the pharmacy association, Greenwood said, and it is reevaluating its switch to the new pricing model. In a Feb. 13 letter to legislators, the carrier stated it intended to return to a model \u201csimilar to a fee for service structure that we have used in past years.\u201d <\/span><\/p>\n

Pace said it remains to be seen whether that will solve the problem. \u201c[Blue Cross has] made zero definitive statements to us on what the financial impact would be to the pharmacists,\u201d he wrote in an email. \u201cWe are hopeful that there will be a true positive difference, but they have not shown us anything to indicate the financial impact.\u201d<\/span><\/p>\n

Greenwood acknowledged that Blue Cross won\u2019t simply be reverting to the same reimbursements it paid last year. That\u2019s partly because of Arkansas Works. Under the hybrid program, carriers are paid to cover those low-income beneficiaries that qualify for Medicaid expansion. They must stay beneath a certain average per-patient spending cap, and Greenwood said returning to the 2017 reimbursement rates for pharmacy costs would put Blue Cross over that cap. <\/span><\/p>\n

\u201cThere [is] a finite amount of dollars for Arkansas Works,\u201d she said. \u201cWhat we are trying to do is work within the cap that has been set by the state, but also make sure that we provide transparency and that [more of] the dollars that are being used for the prescription drug aspect of the program \u2026 will go to the pharmacy than to the PBM\u201d when compared to the rates now in place.<\/span><\/p>\n

Meanwhile, as the pharmacy dispute plays out, the future of Arkansas Works is itself in question. Each year since the program began, a group of conservative Republican legislators opposed to Medicaid expansion has attempted to block funding for its reauthorization; the appropriation has typically passed by only a one- or two-vote margin. Sen. Caldwell, the sponsor of the legislation that would regulate PBMs, was one of seven senators who refused to vote for Arkansas Works in 2017.<\/span><\/p>\n

This year, three vacancies in the Senate will make it even harder for the governor to reach the necessary threshold of votes to reauthorize the program. The empty seats won\u2019t be filled until elections are held in May. That\u2019s led to speculation that the Arkansas Works appropriation may itself need to be tackled in a special session that would take place only after the new senators are seated.<\/span><\/p>\n

This reporting is courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan news project dedicated to producing journalism that matters to Arkansans. Find out more at\u00a0arknews.org<\/a>.<\/i><\/p>\n

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Since Jan. 1, Brandon Cooper, a pharmacist at Soo\u2019s Drug Store in Jonesboro, has turned away a number of patients seeking to fill routine prescriptions. The problem is not that the pharmacy lacks the drugs in question or that the patients don\u2019t have insurance, Cooper said. It\u2019s that the state\u2019s largest insurance carrier, Arkansas Blue Cross and Blue Shield, recently changed the way it pays for pharmaceuticals.<\/p>\n","protected":false},"author":2,"featured_media":12694,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[22,111],"tags":[],"class_list":["post-12693","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-arkansas-general-assembly","category-health-care"],"yoast_head":"\nPharmacy reimbursement fight prompts special session request from legislative leaders - Arkansas Nonprofit News Network<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/arknews.org\/index.php\/2018\/02\/19\/pharmacy-reimbursement-fight-prompts-special-session-request-from-legislative-leaders\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Pharmacy reimbursement fight prompts special session request from legislative leaders - Arkansas Nonprofit News Network\" \/>\n<meta property=\"og:description\" content=\"Since Jan. 1, Brandon Cooper, a pharmacist at Soo\u2019s Drug Store in Jonesboro, has turned away a number of patients seeking to fill routine prescriptions. 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