Consumer 10.0: Pa. pharmacists push for parity with mail order

Bob Schreiber's business in Morrisville, Burns Pharmacy, was briefly famous as the setting for a scene in Signs, the M. Night Shyamalan movie that depicts a scary alien invasion threatening a Bucks County farm family.

Nearly a decade later, the disturbing threat to Schreiber and at least some of his customers isn't an alien.

It's the growing efforts by health insurers, desperate to cut costs, to bypass bricks-and-mortar businesses such as Burns Pharmacy in favor of mail-order prescription fulfillment - efforts that have led to growing push-back in Harrisburg by independent pharmacists.

The Pennsylvania pharmacists are campaigning for equitable treatment - particularly for Senate Bill 616 and its counterpart, House Bill 838, which would give them the right to fill multimonth prescriptions for a single co-payment, just as mail-order pharmacies typically can.

As they have before, the state's independent pharmacists argue that wider customer choice will save money, not cost it - the contention of the biggest pharmacy-benefit managers, or PBMs, and at least some state projections.

The PBMs are doing their own push-back. When I asked about Senate Bill 616, here's what I heard Friday from Mark Merritt, president of the Pharmaceutical Care Management Association, which represents many of the nation's largest PBMs:

"Make no mistake, this is a multimillion-dollar bailout for wealthy independent drugstore owners that will be paid by Pennsylvania consumers and taxpayers," he said in an e-mail statement.

Of course, each of the three largest PBMs runs its own mail-order pharmacy, which critics say creates an obvious conflict of interest. And one of them, Caremark, is owned by CVS, the large drugstore chain, which the critics say creates another kind of conflict. This is a complex issue that I'll explore more in a later column.

For now, it's worth ratcheting back the rhetoric and starting at ground level at a store such as Burns, where Schreiber and some of his customers readily rattle off a litany of complaints.

To Schreiber, the financial hit is the biggest concern: He estimates he's lost about 25 percent of his prescription volume, up from 5 percent a decade ago.

But Schreiber, who scoffs at the "multimillion-dollar bailout" rhetoric, says money isn't his only objection to the growing push for mail-order prescriptions.

There's also the diminished contact with patients, which he values as a health-care professional trained to warn against drugs' side effects or potentially deadly interactions.

And then there's the sore spot that gets rubbed each time customers need help because their urgent needs for medication fall through the mail-order system's cracks.

"We've already lost the business, but then they come back to us when the mail order gets lost, is late, or whatever," he says. Sometimes, Schreiber is on the phone 20 minutes with an insurer, trying to get permission to provide a 10-tablet emergency supply.

Customers find that embarrassing, too, but they don't stop there.

Some complain about how long it takes to get prescriptions filled - delays that they say can punish their own forgetfulness or errors, or their doctors' miscues. Some worry about the waste when a doctor changes their medications in the middle of a multimonth supply. Some just find the whole system confusing. And some, just like Schreiber, miss the interaction between pharmacist and customer.

Ed Politi is 70, a retired teacher, and a cancer survivor with failing kidneys. His drug regimen is complex, and even missing a single dose of some medications can be dangerous. "I'm like Gulliver on a tightrope," he says.

Above all, Politi likes the security from dealing with a familiar face at a pharmacy that will deliver even at odd hours.

"I know my local pharmacist. I know what he's going to do for me. I don't want to talk to someone I can't see face-to-face and shake their hand," he says.

So is this just misguided yearning for a bygone era?

That's pretty much the position of the PBM industry. Merritt says mail-order pharmacies offer "24/7 pharmacist counseling" and reliable processing.

"Mail-service pharmacies are a more affordable, more convenient, and safer option than brick-and-mortar pharmacies for chronic-care medications," he said via e-mail.

But to David Balto, former policy director at the Federal Trade Commission and now a senior fellow at the Center for American Progress, the PBM industry's leading companies face conflicts that undermine a competitive market.

Balto has represented community pharmacists and smaller PBMs, and he says he has no objections to insurers' using the companies to oversee prescription plans.

But Balto says the three largest PBMs have come to control more than 80 percent of the market, and have developed business models that harm the insurers that hire them and the customers forced to rely on them. And he says a key issue is their steering business to their own mail-order pharmacies.

"It's very important for a consumer to have that interaction with a pharmacist - especially a good pharmacist," Balto says. "PBMs offer you assembly-line drug distribution."

Balto says two central issues are competition and choice - choice consumers don't have if PBMs require them to use their own mail-order pharmacies or drugstore outlets.

"The lodestar for making a market work is that consumers have the greatest number of choices possible," Balto says.

Otherwise, they're just captive customers.