On October 1, pharmacists across Pennsylvania began receiving reduced amounts in reimbursement for certain drugs dispensed to Medicaid patients. In some cases, there may even be a loss compared to the drug inventory.
The amount varied by pharmacy and was often a small but significant amount.
“Two percent of a $5,000 HIV drug is a lot of money,” said Rob Frankil, executive director of the Philadelphia Retail Pharmacists Association. “All of a sudden, we went from making $20 to losing $80,” Frankil said, noting that not all pharmacies were affected.
The change was the result of a complex maneuver involving some of the largest providers of health care services to Pennsylvanians receiving Medicaid. A managed care organization is a company or plan hired by a state to bring together a network of health care providers and reduce health care costs. Possible — Amerihealth Caritas, Keystone First, and Pharmacy Benefits Manager PerformRX.
Pharmacists and the state Department of Human Services argue the change should never have been allowed, citing the terms of the state contract.
A Department of Human Services spokesperson said the agreements with AmeriHealth Caritas and Keystone First require the agency’s approval of changes to pharmacy reimbursement rates. AgencyWe did not approve the Amerihealth Caritas/Keystone First rate change. ”
A DHS spokesperson added:Corrective action plan issuedThis would require insurers to revert to previous reimbursement rates and reimburse pharmacies for items lost after October 1st.
An AmeriHealth Caritas spokesperson said the company believed it met its contractual requirements and notified DHS before the rate change.
“We are working with DHS, our partner who has cared for millions of Pennsylvanians over the past 40 years, to provide further clarity and chart the best path forward,” the spokesperson said. added.
Frankil said pharmacists have not seen any refunds or changes in reimbursement rates.
More than 140 pharmacies have closed in Pennsylvania over the past year, according to pharmacy industry groups. They primarily place the blame on unsustainable drug reimbursement rates.
contract for contract
Here’s what happened in a nutshell: When Medicaid patients pick up their medications at a pharmacy, they sometimes pay a copay, and sometimes they don’t pay at all. The remaining drug costs are covered by insurance, which employs an intermediary called a pharmacy benefit manager to reimburse pharmacies.
Pharmacies have dozens of different contracts with pharmacy benefit managers. Each insurance plan you accept may have a contract with a pharmacy benefit manager employed by that insurance company.
the pharmacist says so Often at the whim of these pharmaceutical intermediaries When it comes to contract terms. “Take-it-or-leave-it” is a term pharmacists often use to describe them. But when dealing with Medicaid, there should be certain guardrails. For example, insurance companies offering Medicaid plans are required to seek state approval for changes to how pharmacies reimburse patients for drugs.
None of the changes will affect drug costs for Medicaid patients.
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The Department of Human Services told the Capital Star that the agency was notified but did not approve the Oct. 1 rate changes for Keystone First and AmeriHealth Caritas. The two companies jointly insure Approximately 35% Total Medicaid enrollees in the state, according to the latest enrollment report. We also use the same pharmacy benefits manager, PerformRX. All three companies are connected through the same parent company, BMH LLC.
An AmeriHealth spokesperson said PerformRX itself did not change the terms of its agreements with pharmacies. Instead, it paid another pharmacy benefits manager, OptumRX, for the “lease of the OptumRx retail pharmacy network.”
What does that mean? Remember, pharmacies have many contracts with many pharmacy benefit managers. And basically, PerformRX believed that OptumRX had a better deal and would often pay pharmacists less for the same drugs. So PerformRX effectively took over OptumRX’s contract and entered into an agreement to pay pharmacists lower reimbursement rates.
AmeriHealth Caritas’ statement has more jargon than clarity. AmeriHealth Caritas said in a statement to the Pennsylvania Capital Star: “This transition allows us to take advantage of OptumRx’s pharmacy terms and conditions, providing competitive rates and cost savings while providing convenience and access for our members. “We can ensure easy-to-use, high-quality care.”
Frankil, a former state Board of Pharmacy director and head of a pharmacist trade association, said he had never heard of the network leasing practice.
“It’s not going to work out like that,” he said. “That doesn’t work at all, and in my opinion, it’s very wrong.”
August, Auditor General Tim DeFoor published a damning report It alleged that the Department of Human Services failed to supervise pharmacy benefit managers and monitor contracts with Medicaid managed care organizations.
Pharmacy benefit managers are also being targeted by Gov. Josh Shapiro. championed bipartisan legislation aimed at curbing them.
The Auditor General’s report said the Department of Human Services told Mr. Defour that he had little authority to rein in intermediaries, but his office disagreed. But in this case, the Department of Human Services says the problem lies with the managed care organization, which agreed not to take any action that would result in a change in pharmacy reimbursement rates.
Federal regulators are also investigating pharmacy benefit managers, and some lawmakers are They are calling for the investigation to be expanded.
