Benefit Managers Reinterpret Medicare Rules for Financial Gain

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A new White Paper from the Community Oncology Alliance (COA) looks at recent moves by Pharmacy Benefit Managers (PBMs) to increase corporate profits by declaring all physician dispensing to be out-of-network.

Prepared for COA by attorneys at the law firm, Frier Levitt, LLC, the White Paper “Pharmacy Benefit Managers’ Attack on Physician Dispensing and Impact on Patient Care”, examines recent PBM actions, notably CVS Caremark’s announced intent to restrict patient access to physician dispensing, effective January 1, 2017.

After decades of classifying and paying claims for physician dispensing as “in-network,” the PBMs are playing a dangerous game with patient care in order to capture revenue in the growing specialty drug market.

Despite a strong record and data showing positive patient outcomes from physician dispensing, the nation’s PBMs have begun a disturbing trend of systematically limiting patient access to outpatient medications from their dispensing physicians, according to a press release. Since 2011, PBMs have consolidated into just five major corporations that control 80% of the covered lives in the United States today; limitations, such as those proposed by CVS Caremark, would disrupt the care of tens of millions of patients.

“During my 26 years as an oncologist, I have witnessed a vast improvement in the quality of life as cancer care has moved from the hospitals to physician offices, and now, to oral drugs patients can take at home,” said Bruce Gould, MD, COA president and a practicing oncologist at Northwest Georgia Oncology Centers, Marietta, Ga. “Now new actions by PBMs, such as CVS Caremark, would set cancer care back immensely. Today, oral drugs are often the best option for cancer patients. If the planned PBM restrictions are implemented, then patients needing oral therapies will find their access to drugs limited and their care fragmented. Meanwhile in many cases, they will also have to deal with delays in obtaining their drugs and costlier care.”

“Patients taking many of the newest and most-effective oral cancer drugs require careful monitoring by their physicians and pharmacists,” said Josh Cox, Pharm.D., BCPS, Community Oncology Pharmacy Association (COPA) co-chair and director of pharmacy at Dayton Physicians Network, Dayton, Ohio. “Community oncology practices have added in-office dispensing to provide that timely treatment and maintain critical monitoring and care management. Other pharmacy models do not have access to important medical records nor a
face-to-face relationship with the patients. No PBM can provide the level of care cancer patients require. CVS Caremark, or any other PBMs considering similar action, will make more money, but patients will suffer because of it.”

As the White Paper notes, currently the only PBM that has stated its intention to restrict patient access to physician dispensing is CVS Caremark. Earlier this month COA submitted an appeal to CVS Caremark to delay or cancel their proposed action.

The appeal stated that if CVS Caremark does not reverse its position, or the January 1, 2017, implementation date is not postponed, COA, on behalf of patients and the community oncology providers it represents would have no choice but to take affirmative action to prevent CVS Caremark from implementing the change.

The Community Oncology Alliance (COA) is a non-profit organization dedicated solely to preserving and protecting access to community cancer care, where the majority of Americans with cancer are treated. COA leads community cancer clinics in navigating an increasingly challenging environment to provide efficiencies, patient advocacy, and proactive solutions to Congress and policy makers.

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