This time last year, COVID-19 vaccines felt to many of us like a rather distant prospect. Community pharmacy teams were in the thick of offering home deliveries to patients, working with their drive-thru and curbside services, and compounding hand sanitizer for first responders and patients. Many were also gearing up their COVID-19 testing and scheduling capabilities with an eye toward eventually administering the vaccines in their stores.
As I write this, the Centers for Disease Control and Prevention says that nearly 100 million doses of the COVID-19 vaccine have been administered and reported by retail pharmacies across Federal Retail Pharmacy Programs in the United States. That’s a conservative calculation of pharmacy involvement when also accounting for states’ vaccine rollout efforts but even so, it’s remarkable how far we’ve come. What’s not surprising, though, is how community pharmacy stepped up once again.
In fact, we at the National Community Pharmacists Association repeatedly told federal and state government officials — and it’s come true — that the rollout of the vaccines would not be successful without involving community pharmacies. Neighborhood pharmacists had been giving advice and answering questions about the coronavirus for almost a year before the vaccines were available and, when able to access them, demonstrated they are able to quickly get the coronavirus shots in the arms of their patients. Importantly, the pandemic has shown that community pharmacists are nimble and able to take care to the patient, rather than requiring the patient to come to them. In fact, according to an NCPA analysis, 56.7% of community pharmacies are located in areas that are ranked “high or very high” on CDC’s Social Vulnerability Index. We also know that for 21% of ZIP codes there is only one pharmacy, and that pharmacy is a community pharmacy.
It has never been more obvious that independent pharmacists are trusted, valuable and important health care providers. They’re heroes. Appropriate payment for the administration of the COVID-19 vaccine was a good momentum-builder toward properly recognizing pharmacists for the value they provide, in addition to overseeing safe and effective medication use. But pharmacy owners need help to make sure we can be here for the next public health emergency.
Looking forward, NCPA’s main objective continues to be to help change the pharmacy payment model. NCPA is continuing to emphasize to policy makers that preexisting pressures on community pharmacy didn’t let up during the pandemic. Pharmacy direct and indirect remuneration fees imposed on pharmacies by pharmacy benefit managers remain a top threat, cited by many small business pharmacies that closed over the past few years as a primary cause. According to the Centers for Medicare and Medicaid Services in June, pharmacy DIR fees increased by 91,500% between 2010 and 2019. A $4 gallon of milk increased by that much would cost $3,660.
It’s absolutely unsustainable. Unless Congress and the administration end DIR, more essential community pharmacy health care providers will disappear. NCPA has pursued a fix for years through the regulatory and legislative processes, throughout multiple administrations and Congresses. Because small business independent pharmacies cannot wait any longer, we filed a federal lawsuit in January against the U.S. Department of Health and Human Services alleging that the fees are without reasonable transparency and conceal from patients and taxpayers the true cost of prescription drugs. We have since been joined on NCPA v. Becerra by Fruth Pharmacy, Hi-School Pharmacy Services, Kare Drug, Tyson Drug Co., the Coalition of State Rheumatology Organizations and the American Pharmacists Association, and we’re glad to have their support.
Another case NCPA is involved in — PCMA v. Wehbi — is the first at the federal appellate level to consider the scope of the U.S. Supreme Court’s unanimous decision last year in Rutledge v. PCMA, which upheld an Arkansas law regulating abusive PBM practices. The Wehbi case is a PBM attempt to minimize the impact of Rutledge. For the Wehbi amicus brief, NCPA partnered with the American Pharmacists Association, the North Dakota Pharmacists Association, and every state pharmacy association in the Eighth Circuit to plainly state the conflicts of interest of PBMs affiliating with retail and mail order pharmacies and the impact on patients. The Wehbi case has similarities to Rutledge, with North Dakota asking the courts to determine whether ERISA preempts a state’s authority to regulate PBMs. We are keeping up the fight and are confident the courts will find in our favor.
NCPA has also been actively pushing the Federal Trade Commission to revamp its antitrust policies and enforcement actions. Community pharmacists would agree that monopolistic tactics like below-cost reimbursement and steering harm patients and neighborhood pharmacies, and that the cost of drugs is driven upward by an increasing lack of competition in the PBM industry. Marketplace competition should allow consumers the freedom to choose, but in health care the largest players have often been permitted to manipulate the system and rob patients of choice. Three PBMs control 77% of the market, which we contend doesn’t allow for meaningful competition to drive down drug pricing.
NCPA has reached out to new FTC chair Lina Khan, its commissioners, and a related Multilateral Pharmaceutical Merger Task Force urging them to restore fairness and balance to the pharmacy industry. I’m pleased to report that as part of the FTC’s July 1 open meeting, during which NCPA staff spoke to encourage review of anticompetitive PBM conduct, a resolution was passed to give agency staff more freedom to efficiently launch investigations and enforcement actions into industries including PBMs. It’s good to see the FTC realizing the truth: Bigger isn’t always better for consumers, an increasing lack of competition drives up costs, and PBMs won’t stop unless they’re forced to by policy makers or regulators.
As federal and state investigations into PBMs need to continue, so too must the pharmacist patient care authorities and flexibilities provided during the COVID-19 public health emergency. Recognizing and building on services beyond dispensing remains key in changing the pharmacy payment model. It’s another top NCPA priority and a reason we cofounded CPESN USA, one of the 21 Federal Retail Pharmacy Program partners helping the push to vaccinate America against COVID-19.
We have shared with the Biden administration the need to make permanent:
- Pharmacists’ ability to perform diagnostic testing (including serological and antibody tests) under Medicare.
- Pharmacists’ ability to perform testing under Medicaid.
- The ability of stand-alone accredited diabetes self-management training programs to provide telehealth services to new or established beneficiaries. Retaining services like these is a commonsense approach to ensuring our health care system is ready for the next public health threat.
The bottom line is that patients know and trust their local community pharmacist and value their care. In fact, despite millions of people in quarantine-at-home mode and a corresponding surge in e-commerce, a survey commissioned by the NCPA Innovation Center and conducted by Public Policy Polling late February found that 85% of consumers still wanted to get prescription drugs from a local pharmacist.
In other words, nearly 90% of consumers didn’t want to be forced into using a mail order pharmacy.
More than one-third of the consumers who prefer their local pharmacy said it was because their pharmacist knows them better than a mail order company. Another one-third cited a similar reason: “My pharmacist can answer my questions and counsel me on how to use the drugs.” Probably not surprisingly, 15% of consumers were worried about their prescriptions being exposed to the elements, stolen or lost in the mail.
In 2020 and into 2021, many consumer and business behaviors changed, as did much of the other systems around us. What doesn’t seem to have changed is the basic relationship between patients and local pharmacists.
Pharmacists are accessible and trusted, and, wow, does pharmacy deliver! We now have an opportunity for which our profession has been positioning itself for a couple of generations. Let’s work together to blaze a trail for further progress in changing the pharmacy payment model and protecting patient access to proven, quality pharmacist care.
B. Douglas Hoey is chief executive officer of the National Community Pharmacists Association.