NCPA Continues Push for Congressional PBM, Health Care Reform

In an interview with Pharmacy Times^®, Ronna Hauser, SVP of policy and pharmacy affairs at the National Community Pharmacists Association (NCPA), discussed the urgent need for congressional reform to the practices of pharmacy benefit managers (PBMs). Hauser explained the NCPA's advocacy efforts towards legislators and their constituents to fight for PBM reform. Additionally, Hauser spoke to the importance of pharmacists as American Pharmacist Month approaches.

Pharmacy Times: What specific reforms does NCPA advocate for to ensure fair and equitable compensation for community pharmacies?

Ronna Hauser: We've been fighting very hard for years at NCPA to expose the egregious practices that unfortunately, the PBMs instill on our members. It's very difficult as a small business owner when you are getting squeezed from PBMs on many of the prescriptions that you fill to be profitable. So, we've been fighting for many years for some policies that would bring more fairness and more transparency and more equity to the pharmacy payment model. I will say that we have been fighting very hard this Congress, which actually started in 2023, and this current version of Congress will end at the end of this year. So, there's been so much work done to date that we do not want to let this opportunity pass us by. We are in the final stretch of an all-out fight for PBM reform that must pass by the end of the year. And the policies that we're fighting very hard for and we're advocating that Congress pass include reforms to both the Medicaid Managed Care program and the Medicare Part D program. So, we have two very important priorities. The first is related to Medicaid Managed Care prescriptions and ensuring that those prescriptions are paid in a pass-through manner. So, the Medicaid Managed Care prescriptions would be paid very similar to the Medicaid fee-for-service prescriptions, where you would be paid based on acquisition cost, plus a commensurate professional dispensing fee that would be in line with each state's cost to dispense amount. So, these practices of “spread pricing” that the PBMs have employed at the state level that are very egregious practices that many states have taken action against and exposed. We're trying to get fair and equitable payment for pharmacist-dispensed prescriptions throughout the country, for all Medicaid Managed Care prescriptions. So, there would be one approach which is – passing would be required – all pharmacies would be paid according to acquisition plus the commensurate professional dispensing fee, and PBMs would only be paid at administrative fee for the prescriptions. And then our second priority is related to Medicare Part D, where we desperately need Congress to require Centers for Medicare and Medicaid (CMS) to define what reasonable and relevant contract terms are. We all know in Part D right now that it's very difficult for our members. They have very difficult decisions to make when faced with these take-it-or-leave-it contracts from the Part D plans and PBMs. So, we desperately need Congress to reform the way that prescriptions are paid for in Part D and to require, once and for all, that PBMs reimburse pharmacies in a fair manner and a reasonable and relevant manner. So those are the top 2 priorities, Medicaid Managed Care reform and Medicare Part D reform.

Pharmacy Times:How does NCPA highlight the essential role of community pharmacists in providing patient care, especially in underserved areas?

Hauser: Yeah, absolutely. And we all know that in many underserved areas and many more rural or urban areas, that an independent pharmacy may be the only choice for patients in that community. So, it's very discouraging to see when an independent pharmacy closes, a pharmacy desert may form, and that is definitely not a good thing for patient access. So, we've been working very hard to promote the role of the pharmacist, not just in dispensing prescriptions, but in the services they provide. So, you know, for example, we have many different programs. We work collaboratively with Community Pharmacy Enhanced Services Network (CPESN) to ensure that pharmacies are being paid, not only for the prescriptions, again, that they dispense, as I mentioned, but also for the clinical services they provide. So, I think COVID and the pandemic really shined a light on all the positive impact that pharmacists can have in their communities with not just vaccine administration, but with medications such as nirmatrelvir and ritonavir (Paxlovid; Pfizer) and then many of the positive services they're providing in their communities to keep patients out of the hospital, right? It's a win-win for the pharmacies and the health plans. So, we've been very, very focused the last few years on ensuring that a network of clinically integrated pharmacies can go to the health plan directly itself, the medical side of the benefit, and work to ensure fair payment for those services on the medical side of the benefit, instead of the pharmacy side of the benefit.

Pharmacy Times: What initiatives are in place to support and strengthen community pharmacists’ role in patient care?

Hauser: Similar to what I mentioned on the last question, CPESN is the only nationwide, clinically integrated network of pharmacies. Again, working very hard on behalf of members of that network to have direct contracts with the health plans themselves versus the PBM side of the business, and work to ensure fair and equitable payment for services. Again, our members are doing amazing things in their communities each and every day to keep patients healthy, to keep them on their drug regimens, and first and foremost, to keep them out of the expensive you know, models of care, such as hospitals and emergency rooms. As much as the benefit of those services and keeping patients healthy are recognized and appreciated by the payers, we're working diligently to ensure that we are paid for providing those services.

Pharmacy Times: What are some of the recent initiatives NCPA has undertaken to address the challenges faced by community pharmacies? What impact they have had so far?

Hauser: Sure, our most recent initiative, as I mentioned earlier, is to get Congress to pass PBM reform. So, our most recent campaign has been very well received. We have a “Finish the Fight campaign; it started a few months ago, really gearing up for when Congress was about to leave for August recess, and then Congress has been back in their home district a lot, because we're in an election year. So, Congress right now is back in DC for approximately 3 weeks, and then they're they'll leave again and won't come back until after the election. So, we targeted our “Finish the Fight” campaign to follow the members of Congress where they are. You know, we kind of started it as a campaign inside the beltway in DC, and then we've expanded it into key districts and areas across the country where key members of Congress are located. So, the goals of this campaign are to really have not only pharmacists, not only our members that own and operate their local community pharmacists, but to have their patients realize how important it is for PBM reform to allow patients to remain, you know, with the pharmacy and the pharmacist of their choice. So, it's been an all-out effort. We've been very successful. We've had TV ads, ad buys, we've had social media outreach, print outreach, etc., with the ultimate goal being for patients to contact their members of Congress and advocate to get PBM reform across the finish line. And I'm happy to report that as of today, we've had nearly 40,000 patients of local independent pharmacies reach out to their members of Congress to urge PBM reform. So, “Finish the Fight” campaign is alive and well, we'll continue it up until the point where Congress comes back to town after the election and has a has a slate of policies that they must get across the finish line. And our ultimate goal is to ensure that PBM reform is included.

Pharmacy Times: How does NCPA work to improve patient access to affordable medications, particularly for those with chronic conditions or in rural areas?

Hauser: Yeah, we work very hard to make sure that there's an understanding of where pharmacy shortage areas are located. We unfortunately see a clip of over one independent pharmacy closing a day in our country this year, and that's net, so that does account for openings as well. But we're still losing pharmacies each and every day, and every time you lose a pharmacy, you lose access to care in a community, which is a huge concern. So, we've partnered with the University of Southern California, and we have a pharmacy access mapping tool where we'll look at pharmacy shortage areas, and when did they become a shortage area? And why did they become a shortage area? Is it because an independent closed? Is it because a chain closed? Our research has shown that the vast majority of the time, an area becomes a pharmacy desert because an independent pharmacy closed. And then on the flip side, it will, you know, stop being a desert because an independent pharmacy may go into business in that area. So, it's very important to keep independent pharmacies strong and vital. And we really try to add to the discussion about pharmacy deserts and how to ensure we don't have more of those in our country with our collaborative project with USC.

One of the ultimate goals of our project and our pharmacy shortage areas mapping tool is to have active dialog with CMS, which we do, have active dialog with CMS to show them that the Part D network access standards really need to be changed. The pharmacy network access standards in the Part D program have been the same since the inception of the program, right? So, we've looked at, you know, the access standards that we've set for our research project versus the current CMS standards, and shown that the current CMS standards don't account for a lot of areas and lack of access in our country. So unfortunately, you know, we have many patients who don't have access to a pharmacy, and for the most part, those patients are underrepresented, and they're in communities with under-representation, marginal populations, and low-income populations. So, we're working very hard to try to have active dialogue and continue that dialogue with CMS to show the importance of a future where we update access standards in Part D so we have more true access to pharmacy services.

Pharmacy Times: What are key challenges and opportunities that NCPA anticipates for community pharmacies in the coming years? How is the organization preparing to address them?

Hauser: Yeah, we desperately need PBM reform. You know, I think that's the whole goal that, again, 100%, doing everything we can to ensure this gets across the finish line this Congress. If it doesn't, we have a new Congress next year. Potentially – well, either way, we'll have a new administration whoever wins [the] president[ial election]. But, you know, we'll either flip parties or not. So, we're at a point now where the work… if we don't get the work done this year, it has to restart right on day one, completely wipe the slate clean and restart. No one wants to have to do that. There's been so much bipartisan work, and bicameral so again, House has done so much on both the Republican Democratic side. Senate has done so much on both Republican and Democratic side. It's, in essence, the most you know, the most important topic in health care reform right now that is not a topic where people take sides and bicker and argue with each other, right? Everyone agrees that this has to be done. So, we desperately need to get PBM reform across the finish line. We need these commonsense reforms that will pay our members adequately to dispense the prescriptions that their communities need. And that's our number one goal right now. Again, if Congress, for some unfortunate reason, does not get PBM reform across the finish line, you know, we do have plans in the future on how we would address these concerns. You know, NCPA always works on several fronts, right? We work on the legislative front. We're an advocacy-based organization in Washington, DC. We're here to influence, you know, and advocate on behalf of our members to members of Congress. We also work on the policy side, right? On the administrative side. Constantly meeting with the agencies that are implementing rules and that have a lot of sway over our members practices. And then, you know, we work on the legal side. Sometimes you can't get what you need through Congress. You can't get what you need through the administration or through the regulatory bodies. You have to go the legal route. And we do have several lawsuits that we're involved in right now, and that's always an option. It's an option that you don't want to take. It's an expensive option. But it's something that, at the end of the day, we have to do that on behalf of our members, and we're always willing to go to bat for them any way we have to. So more to come, but I guess I'd say the ultimate goal here is to focus on the next few months ahead and get this done.

Pharmacy Times: Is there anything else that you would like to add, considering the approaching American Pharmacist Month?

Hauser: I think it's super important to realize the value that pharmacists bring to the health care system. You know, I always tell all my friends and family that aren't necessarily as close to pharmacy as I am. Whenever you're in your local pharmacy picking up prescriptions or you have a need where you need to go to your pharmacy, thank them for all they do. I think for a long time, pharmacists have and are still providing uncompensated care. They're there for their patients day in and day out. They may not always get compensated for those services, but they care so much. And you know, health care reform is desperately needed in our country. The way that prescription drugs are paid for absolutely needs to be reformed. It's an opaque system. The middlemen are, you know, pulling a lot of money out of the system, and unfortunately, the providers are the ones who get the short stick, and it's unfortunate when they're the ones that are touching patients and caring for patients each and every day. So, realize the value of the pharmacist. Tell them thank you for all they do. And let's help get PBM reform across the finish line so they can see a little light at the end of the tunnel.