Pharmacies pushing for more data on Medicaid managed-care deals
But they hope to pass legislation in the
The new information, pharmacies and their supporters say, could unveil what they suspect are profit padding and unnecessarily steep reductions in what pharmacies receive for serving Medicaid patients compared with what pharmacies received under "fee-for-service" rates.
Pharmacy owners say cuts in payments for the medicines they dispense and per-prescription "dispensing fees" aren't saving the state money on health care for low-income Illinoisans.
But the reductions threaten to push many pharmacies out of business with no backup plan for patients, especially in rural and downstate areas, pharmacy owners say. The impact of those cuts mandated by PBMs has grown with the reboot of the managed-care program this year and its expansion to all 102 counties on
"We had a tough lift with getting the bill as far as we did,"
"We will continue to work on this over the summer," he said last week. "It's the political process. This is going to be a long fight."
But Olds Frey said the amended bill is "much closer" to an acceptable form. "As Medicaid health plans, we are not opposed to transparency," she said.
The national
A spokesman for the association didn't respond to a request for comment for this story.
Independent pharmacies in
He said the impact could be reduced somewhat by
Supporters of independent pharmacies said the version of HB 3479 that passed the House in April would have forced the
Reynolds said pharmacies have seen their dispensing fee drop from
PBMs such as CVS Caremark, Prime Therapeutics and Meridian RX have contracts with the state's seven managed-care organizations, most of them for-profit companies.
Manar said the
But Manar, the bill's
Lack of data also could be a problem if the
"I want to expose these contractual relationships to complete transparency," he said, adding that public hearings will be held on the issue in coming months.
An amendment to HB 3479 removes the previously proposed boost in reimbursement rates but adds requirements for public disclosure of financial dealings among MCOs, PBMs and pharmacies.
Information required to be reported to the state, and available to the public, would include "the average reimbursement per contract by drug ingredient cost, dispensing fee and any other fee paid by a pharmacy benefits manager to licensed pharmacies."
Manar said the legislation, if enacted, could produce data that leads to public outrage and political will in the
"Shining a light on these things will drive public policy in the future," he said.
Reynolds has said at least one PBM, CVS Caremark, which works with the huge
CVS spokesman
DeAngelis said independent pharmacies are reimbursed by CVS Caremark at a higher rate, on average, than chain pharmacies, including CVS pharmacies. This higher rate, he said without providing specifics, "reflects the importance we place of having independent pharmacies in our network."
The amended legislation also includes protections against "gag clauses" so pharmacists are free to share more information about a patient's coverage, medication prices and cheaper alternatives, Reynolds said.
The original bill, according to Olds Frey, "would increase the cost of the Medicaid program by hundreds of millions of dollars."
The amended version, she said, still could allow pharmacies to withdraw from Medicaid managed care networks while remaining in private insurance networks serving state workers and other employer groups.
The potential for certain patients to see their pharmacy choices dwindle is a concern, Olds Frey said.
Manar said it's likely that the legislation will be tweaked yet again before it is considered for final passage.
Reynolds said it appears that the systemic problems independent pharmacies are facing with Medicaid managed care won't be addressed for at least a year. In the meantime, he said, some may face closure, though the critical-access payments could help.
"I don't think we're done by any means," he said. "Long term, something's going to have to be done."
The information disclosure requirements in the amended bill would be a positive step, Falk said.
"We want to see what the middleman is keeping," he said.
Falk, 48, said he doesn't know whether he would qualify for the critical-access payments. Budget document say the payments could go only to owners of fewer than 10 brick-and-mortar pharmacies.
About 70 percent of the pharmacies' patients were insured by Medicaid, said Adeoye, 61, who testified in favor of HB 3479 in a House committee in April.
Lawmakers should protect pharmacies from "bullying" by pharmacy benefit managers, he said.
"They need to do the right thing and let us have our dignity," Adeoye said. "It's not that we can't compete. It's because these people are allowed to do whatever they want. PBMs don't do anything. They take money away from us to make their bottom line look good."
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