Some of the most difficult problems pharmacists face are not clinical. The problems I am referring to are generally related to dealing with insurance plans and their corresponding Pharmacy Benefit Managers. Consider an example: We have a patient taking an older, single source medication. This patient is stable and responding well to this therapy. I should point out that this was not the drug the patient started on, and it took a lot of time to find therapy that worked well for the patient.
In early January, the prescription was adjudicated, and a MAC price was applied. The MAC based reimbursement resulted in a loss of about $1000 based on our invoice cost. The loss was still very significant after our rebates from our buying group. Shortly after this claim was adjudicated, I sent an appeal to the plan to have them revise the MAC price of 20 products, including this medication.
Before continuing, I want to warn you: this story doesn’t end in a typical manner. Much like Frederick Forsyth’s The Day of The Jackal, I am going to tell you how the story ends before embarking on the rest of tale. Not only does plan / PBM corrects an underwater MAC price for the drug, but they actually over-correct, resulting in extreme overpayment.
When I received my response about 10 days later, the MAC price was doubled. The response also contained a reminder:
We would like to remind you of your overall GER guarantee with [Part D Plan]. While some MAC prices may be under your acquisition cost, [Part D Plan] will ensure that you are appropriately reimbursed overall, according to agreed-upon overall generic effective rates.
Note that the patient’s drug (and most of the other 20 drugs) would still represent significant losses going forward at the new, updated rate. Not being deterred, I responded to the MAC increase notification:
To whom it may concern:
Please note I understand the contracted GER. It is my understanding, however that the contract also does not explicitly state that I can be reimbursed for product below the prevailing acquisition cost. Severely underwater MACs are never acceptible, even in the context of this contract’s terms. I require supporting documentation each of these decisions, including source and availablilty of a lower priced product on the market. Please forward these promptly. Before these MAC appeals were sumbitted, a comprehensive search was preformed revealing no available products that would support the current MAC price. Your statement to the contrary should be accompanied by supporting documentation.
The February and March claims continued to show significant losses. I did not hear back from the plan, and frankly did not expect anything more. At this point, I had done what I could, and was resigned to continue to provide this drug at a substantial loss to the patient. It would not be ethical to withhold the medication or, to refuse to stock the medication: our patients depend on us.
Unexpectedly, last week, I received another correspondence from the plan. I do not know if the response was to my initial, or follow-up correspondence. The letter informed me that MAC price was again increased. This time, the increase was much, much higher. Reimbursement at the new rate went from abysmally low, to stratospheric levels.
Now don’t get me wrong: I have no problem making money on a prescription. In this case, however, we went from the bottom of the Mariana Trench (about 10,000 meters below sea level) to the top of Mt. Fuji. (3,776 meters high). At this rate, my losses for this drug (year to date) would quickly evaporate. Despite my elation at recouping my losses and not losing money going forward, the updated price makes as little sense as original underwater price for this drug.
What does this story say about the state of our current system? Instead of retroactively updating the previous claims to represent reasonable reimbursement going forward, the company instead overcorrected the price. It is also unfortunate that a provider had to point out the price problem in the first place. As a pharmacist, I am supposed to be focused on the patient, their drug therapy, and their therapeutic outcomes. The Plan and PBM are in charge managing reimbursement. If they were doing their job, reimbursements would not be so askew, in either direction, in the first place. Also remember, this one drug was corrected. There are still a large number that have not been addressed satisfactorily to date.
This is yet another example of our broken system. Providers have to spend time with problems outside their expected role of patient care in order to ensure they are reimbursed fairly. Reinbursement, is either feast or famine: more recently is is more famine than feast. It is a lot like climate change: we have far too many extremes and too few nice days.
