Surprisingly, the answer is probably yes, and it’s on a topic you likely know very little about, Pharmacy Benefit Managers (PBM).  You may not know who they are, or what they do, but you have almost certainly been affected by them.

What is a PBM?

In its most basic form, a PBM simplifies the transaction between your prescriber, your pharmacy, your insurer, and you. They don’t diagnose any disease, and they don’t make or dispense any medication…the only real value they add to the equation, in theory, is efficiency and/or cost savings. What they have become looks far more like Standard Oil than it does a basic fee-per-transaction claims processor for your prescriptions. The top 3 PBMs (Cigna’s Express Scripts, CVS/Caremark, and UnitedHealth Group’s Optum Rx) control about 80% of the market and have a combined annual revenue of over $1,000,000,000,000…. that’s trillion with a T. That’s not a knock on successful companies or profit, or some pitch for big government or over-regulation, it’s to show A LOT of our healthcare dollars flow through them. They’re often the top expenditure for companies and government entities. Unfortunately, I know far more about them than I wish I did.

** Now I should insert a disclaimer: all PBMs aren’t bad. There are some transparent, fee-based PBMs who we’re happy to work with and actually perform a useful function. **

My wife and I are both pharmacists who own and operate 2 independent pharmacies. At the risk of sounding cliché’, we were drawn to the idea of owning our own business while getting to take care of our friends and neighbors. I’d say this is true of almost all independent pharmacy owners in America. And we’re a unique group…we’re more colleague than competitor and have cobbled together a fairly effective and organized apolitical operation (more on this later), out of sheer necessity and self-survival.

So, what does this have to do with Louisiana leading the nation in something other than obesity? The sacrosanct triangle of care between prescriber, pharmacist, and patient has been so badly damaged by the PBMs that it simply can’t be ignored anymore. Ten years ago, we were explaining to legislators what PBMs were and what we feared they were slowly becoming. Now, we’re all playing whack-a-mole with legislation and regulation (that we wish wasn’t necessary) to try to level the playing field and keep down costs. What’s worse is that we spend a huge part of our day explaining to people why we can’t fill their prescription, and we’re not in the business of turning down prescriptions or denying care. To be frank, it disgusts us but has become a necessary evil to keep our doors open.

For the last 10 years, we’ve passed what we thought was meaningful legislation to ensure quality patient care and a mostly free market….where the patient decides their healthcare providers. Louisiana, surprisingly, has been at the tip of the spear of meaningful Pharmacy/PBM reform and legislation. The PBMs have well-compensated lobbyists in fancy suits; we have unpaid pharmacists in (probably stained) white coats. It’s truly a David vs. Goliath situation. Most of our legislation passes unanimously.

The PBMs have slowly (d)evolved into such a universal problem in our healthcare system, the need for radical and immediate change has become obvious. Don’t believe us, ask the prescribers…. who must hire employees simply to jump through the PBM’s hoops. Don’t believe them, ask PHRMA (almost never not the least liked group in the room) …who are extorted for “rebates” (kickbacks in any other scenario) so their product is included on the PBM’s formulary. Perhaps you’re familiar with terms like “mandatory mail order,” “prior authorization,” “not on formulary,” or have had the privilege of calling the pharmacy help desk. Imagine dealing with this all day, every day.

The silver-lining to this nightmare is that our issue is universal and truly bipartisan. It affects young and old, black and white, men and women, Republicans and Democrats. This is proven by the fact that Louisiana is on the precipice of passing the most meaningful, useful, and transformative legislation in the nation, that will likely start a cascade of dominos that fixes this problem in most other states, and eventually on the Federal level. Jeff Landry (Louisiana’s Republican Governor) and Dustin Miller (Democratic Health & Welfare Chairman) probably don’t often agree on many political issues, but they agree that we need radical PBM reform, and they’re working together to make it happen. We have 2 pieces of legislation that evolved out of necessity and will be voted on as this legislative session ends…..one that’s mostly boring and technical (prohibiting a laundry list of unfair trade practices) and one that prevents the unfair “vertical integration” of PBMs that also own and operate a pharmacy. Arkansas recently passed similar legislation, and Governor Sarah Huckabee Sanders (a close friend of Governor Landry) is slowly becoming one of the loudest and most outspoken advocates of PBM Reform. Maybe their mutual friend, President Trump, will realize this is a universal and populist issue and fix it Federally. When the curtain is pulled back, we’re all going to be shocked by how much we’ve overspent on Medicaid and Medicare, for years. If President Trump truly wants to drive down the cost of prescription drugs, an Executive Order mandating lower drug costs isn’t the answer….real PBM Reform is.

In an attempt at brevity, I tried to keep this as short and simple as possible. It’s a terribly (and unnecessarily) complicated process that really shouldn’t be.  Pharmacies can be paid fairly (as in not below our actual costs), save the patient and insurance provider money, and pay the PBM a reasonable transaction fee. Sometimes things aren’t as complicated as we make them.

If you doubt any of this, call your closest 10 independent pharmacists and ask them.

Help us help you. Tell your legislators too.

T.J. Woodard, PharmD, MBA
Prescriptions to Geaux
Baton Rouge, LA