What is causing the discontent?
CVS and Walgreens pharmacy staffs are in the midst of protests over working conditions in their stores. The concerns they are expressing have been growing over many years in the pharmacy community. One upcoming documentary in particular, "Would You Like Shots With That?" appears to highlight the "fast-foodication" of the pharmacy industry. While corporate drive for market share and profit among the big pharmacy chains is certainly a major cause of the conditions that lead to the walkout, I believe there is another culprit equally guilty of harming patient care and pharmacy operations; Pharmacy Benefit Managers.
Who could have guessed that empowering anonymous middle men would have gone so wrong?
What is a Pharmacy Benefit Manager?
Pharmacy Benefit Managers (PBM) are hired by insurance companies to manage the pharmacy benefits of your health insurance. Considering the thousands of medications and therapies that are prescribed today, it's easy to see why the insurance companies would need help to manage it all. Most people don't realize that their pharmacy isn't regularly dealing with their health insurance company at all, but are rather interacting with the PBM. This is surprising to most people when they realize that they have no idea who their PBM is.
What's the problem?
In their role for health insurers, PBMs determine the coverage and reimbursement for claims. That means if your doctor decides that a particular medication or therapy is right for you, your PBM will then make its own decision about whether or not it's right for you. They won't have a physician speak with you, and they won't ask any medical professional who has seen you. They will simply use a spreadsheet to decide if you get coverage. That is problematic enough, but it doesn't stop there. If you are lucky enough for the spreadsheet to approve your (already doctor prescribed) medical treatment, your pharmacy will then get to find out if the spreadsheet will actually pay for the service.
How PBMs are the problem
It makes sense to assume that if your PBM approves a treatment and claims to "cover" it, that they would actually be paying for it. This, shockingly, is not true. Often times PBMs will "cover" a medication only to then reimburse the pharmacy less than the cost of the medication. In fact, some pharmacies are now dealing with negative reimbursements (reimbursements below the cost of acquisition) on up to 50% of their claims. To be clear, pharmacies are losing money on up to 50% of prescriptions they dispense. That is astounding.
PBMs have been lowering reimbursements for years. This is sold as a benefit to the healthcare system since it is "lowering costs." However, PBMs and insurance companies are the only ones benefiting from these "savings." Patients aren't seeing the savings and payors are absorbing huge increases in costs. This is because PBMs take advantage of spread pricing and they pocket the difference.
This new hidden cost combined with the always lower reimbursements have lead to a number of negative outcomes. First, PBMs contractually restrict pharmacies from disclosing to a patient that their insurance coverage doesn't cover the cost. That means most pharmacies are forced to lie and tell patients their medication is out of stock. Second, the negative reimbursements that result in pharmacies actually losing money when they fill a prescription results in cuts in order to keep the doors open. That is what we are seeing with Walgreens and CVS. Even Walmart recently had to cut hours, due to negative reimbursements on popular medications like Ozempic.
Corporations will always find ways to cut costs. However, PBMs, are the real culprit here. I recommend making life simpler for yourself by finding a cost+ pharmacy that has chosen to break ties with PBMs that harm patient care and pharmacy operations. Let the healthcare professionals you chose, such as your doctor and pharmacist, make the decisions they are trained for. Otherwise you'll be stuck with the PBM who is rewarded for denying you coverage, underpaying healthcare providers and raising costs to employers. Most medications are very cheap and don't need the assistance of insurance. Check our Price Checker tool and see for yourself. We can ship anywhere in Texas and offer 90-day supplies on medications. (Both of those are services PBM's restrict pharmacies from offering, but they are available here at Forest Park Pharmacy where we have chosen to step away from anonymous bureaucratic world of PBMs and insurance, and focus on YOU and the healthcare plan that you and your doctor create for your health ad well-being.)