Expert Reviews State-Level Shifts in PBM Legislation

In an interview with Pharmacy Times, Anthony Pudlo, PharmD, MBA, executive director of the Tennessee Pharmacists Association, discussed his presentation at the National Association of Chain Drug Stores (NACDS) 2023 Regional Chain conference. Pudlo’s presentation focused on key shifts in chain pharmacies, including pharmacy benefit manager (PBM) reform, pharmacist-administered vaccine trends, and provider status.

Q: Pharmacies have been at the forefront of many issues in recent years, so your session covers a lot. Can you give an overview of the key issues?

Anthony Pudlo, PharmD, MBA: Yeah, I'm really excited to be able to speak to this group. How I've been looking to frame my comments and what we're going to be focusing on is probably 3 buckets of areas that I would say state pharmacy associations have really been helping the profession in the last couple of years. You know, you can definitely bundle 1 whole area around legislative initiatives, whether it's been looking at effective and enforceable reform of pharmacy benefit managers, to scope of practice expansion, as well as payment for services. Those are kind of where you see a lot of states really driving initiatives for the profession. I think some of the other pieces, too, is that we're going to look at, as we pass legislation at the state level, how do you ensure that that legislation is effectively implemented at the front-line level? Right? So, when it comes down to say, for example, that scope of practice and payment for services, what are pharmacy associations doing with community pharmacies, specifically, in this case, for getting pharmacists comfortable with establishing, say, a collaborative practice agreement, where and how do you go about that? What about getting a pharmacist properly credentialed in order to be recognized and be able to get contracts to bill for medical services, or bill for their services on the medical benefit of some of these insurance companies? And so, we'll talk through some of that. Tennessee has specifically had some success in the last several years, and states like Washington state, as well, have had success on the commercial side. But we're also seeing a lot of states have success with their Medicaid programs. So, we're going to talk through what pharmacists and what pharmacy leadership can do to continue to help drive that.

And then, really, the last bucket is just where are we going and talking about various practice-based initiatives where some states are having success, whether it's a contract directly with their State Department of Health, or if it's with other grant opportunities, to really help look at advancing the profession forward and utilizing the entire team. So, I know we're likely going to spend some time talking about the role of the pharmacy technician, whether it's in workflow models, like technician product verification or pharmacy technicians playing roles with immunization expansion. In some states we've seen a lot of these opportunities come forward because of the pandemic, but so much was there before the pandemic. And now, you know, where do we go? How do we kind of come out of the pandemic stronger in these pharmacy practice settings?

Q: PBM reform is always front-of-mind for pharmacists. How do you see this issue shifting, and is real change happening?

Anthony Pudlo, PharmD, MBA: So, great question. You know, unfortunately, I think we always have to talk about PBM reform as a whack-a-mole type mentality—the old game at the fair where, basically, once you think you figured out what is going on with PBMs, something else is going to arise. And so, I would say, you know, the conversations that are happening at the state level are very much like that. But really, the messaging and the focus isn't just bringing PBM reform at the state level into law.

Similarly, we've seen great success across the whole country. You can, you know, point to the fact of the Rutledge v. PCMA Supreme Court ruling that really dictated that states can regulate PBM reform at the state level. So, a lot of state associations have been driving this, really trying to spotlight every type of detrimental practice that we've seen by PBMs. But the problem is enforceability, and that's where a lot of states are spending a lot of time right now. Whether it's messaging to their state legislature, whether it's messaging to their commerce insurance division, or if some states regulate underneath the Board of Pharmacy, how do we actually see the regulatory agencies go to bat for the profession and hold PBMs accountable for the laws that are on the books? We've had some really great success in Tennessee in the last year and even in the last few weeks, as our law took effect. We have been seeing our state commerce and insurance division actually actively pushing back on PBMs for once on the rhetoric that they share [about] why they don't need to comply with the law. And so, you know, I think the tide is turning for once, that these PBMs will finally start adhering to the laws that are on the books. But at the same time, I think what we're always going to have to address is, while the microscope is very much on PBMs, there's a lot of other players in the whole drug distribution system, that there needs to likely be a little bit more magnifying glass on those. And that goes for manufacturers to wholesalers to PSAOs, the PBMs, to the pharmacies themselves. And so, likely, the moment you open Pandora's box, this question is going to arise about every aspect of the drug supply chain. It’s going to have to have a little bit closer look and see, should there be regulation on certain things? Should there not be? And that's going to be some of the conversation that I think everyone's going to have to start having at the state level.

Q: How can pharmacists get involved in PBM reform efforts?

Anthony Pudlo, PharmD, MBA: Well, definitely get involved. This conversation on PBM reform is happening in every state, and I don't think there's anyone that's not having to talk about this, whether they want to or not. I think some of us want a little bit of a break from time to time to talk about some of these other exciting things. But I would say what we really have been encouraging our members to do is, well, first and foremost, they have to work to develop a relationship with their elected officials on the Senate and House side, at the state and even federal level, to be a voice. Be a voice for what's happening in your practice, be a voice for your patients, and really start filing complaints. That's really where I think a lot of concern comes into play. Is if you pass a piece of legislation or even if you don't, is the state actually hearing from pharmacists about it? Or are we just talking to each other that these are concerns? So, take the time to file a formal complaint with your state insurance division or whoever regulates PBMs. Be a voice for your practice. Those kinds of complaints are actually extremely helpful for us at the state association level, to then carry that message as we work and meet with those regulatory boards or as we're testifying in front of an open hearing with them, [to show] that pharmacists are seeing this. And so, we need pharmacists to be a loud voice in that process.

And then at the same time, I think what we're starting to see is how and what is the messaging to patients in terms of engaging them in their defense, if you will. Why did they want to still keep coming to their local pharmacy? What is the value that that local relationship, when they get to choose which pharmacy they go to? And so, I know for us, we're going to start having to drive messaging to the media and to the public about what are the rights of a patient? When should they take that letter that they got in the mail from a PBM and take that and file a complaint themselves to the insurance division? So those are the kinds of things that I say pharmacists need to understand the process and the messaging, and that's where the state associations, international associations can all help in that process.