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NCPA: Pharmacists say PBM audits undermine patient care
September 18th, 2012
ALEXANDRIA, Va. – A study by the National Community Pharmacists Association finds that some auditing and reimbursement practices by pharmacy benefit managers are harming community pharmacists' ability to provide patient counseling and care to seniors.
NCPA said Tuesday that it polled more than 350 pharmacists about their recent experience with audits by PBMs and other Medicare Part D plan intermediaries, as well as about generic drug reimbursement caps, or maximum allowable costs (MACs).
Of respondents, 96% said a typical PBM contract has minimal or no transparency on how generic pricing is determined or what the reimbursement rate will be. Almost half said that more than 10% of the time, PBMs set MAC reimbursement for generics below the pharmacy's drug acquisition cost, not including dispensing and overhead costs.
In addition, 92% of pharmacists said payments aren't increased promptly to reflect a drug's rising market costs.
Also, 76% of pharmacists surveyed said audit requirements across Part D plans aren't consistent, increasing their compliance burden. And about 87% indicated that PBM reimbursement and auditing practices are "significantly" or "very significantly" affecting their ability to provide patient care and stay in business.
According to NCPA, many of the issues that pharmacists raised in the poll would be addressed by the enactment of Medicare Pharmacy Transparency and Fair Audit Act (H.R. 4215). The association said the legislation includes commonsense auditing standards similar to those recently enacted in over 20 states and would disclose how MAC payment limits are set.
"Patients over paperwork and fair reimbursement practices — that's all these pharmacists are asking for," NCPA chief executive officer B. Douglas Hoey said in a statement on the survey findings. "An estimated $290 billion in costs each year are attributed to the improper use of medication. This legislation would help reduce health care costs by ensuring that local pharmacists can spend more time providing expert medication counseling and other pharmacy services to help seniors get the most out of their medication therapy. H.R. 4215 cuts the red tape, while allowing legitimate anti-fraud efforts to continue."
When asked which drugs had MAC limits set below the pharmacy's acquisition cost, more than 600 drugs were identified, including such widely used medications as budesonide (for asthma), atorvastatin (cholesterol), clarithromycin (antibiotic), fentanyl patches (pain relief), hydrocodone (pain/inflammation), and methylprednisolone (steroid for allergic reactions, skin conditions and breathing disorders).
"When a Medicare plan's reimbursement can't even cover the pharmacy's cost of doing business, that plan risks failing at its most basic task: To facilitate the beneficiary's ability to obtain critical prescription medication and counseling on proper use," Hoey stated.