For more and more pharmacists, using insurance to pay for most generics makes as much sense as taking out car insurance to cover oil changes.
The problem is that if you try to buy generics without a health insurance card in the majority of American pharmacies, you will pay a “cash” price that is significantly inflated by intermediaries, rebates, and cost-crazy systems. .. Shifts imposed on pharmacies by the insurance system.
As a result, although unknown to many consumers, the out-of-pocket costs of many generic drugs are often higher than the overall price if they were available in a truly open market.
Think about it:
A patient in Ohio recently paid a $ 141 copayment through insurance for 180 celecoxib, a generic version of the anti-inflammatory drug Celecoxib. When she went to a new pharmacy avoiding insurance, she was able to get it for $ 23.05.
In other words Self-pay In the case of drugs, even if you add a dispensing fee, it will be six times the cost of the drug in the open market.
And the cash prices of insured pharmacies — almost everything? Approximately $ 1,165, or 50 times more than if a pharmacy were available from a secondary wholesaler equivalent to the open market.
That huge cost difference is only part of why Nate Hax and a few other pharmacists in the United States are setting up pharmacies that exclude insurers and their intermediaries: pharmacy benefit managers, or PBMs. Hacks said it also allows him to be a better pharmacist because it’s a cleaner system that pays him just to practice his profession.
For patients, savings and better health outcomes can be intertwined.Of particular benefit is with uninsured customers Number to increase Those who have plans for high deductions.
Hacks recently leaned against a counter at a Freedom pharmacy on the outskirts of Columbus, saying, “They are ridiculous and don’t take medicine.” “So we opened the door to allow them to take 90% of the medicines there at a reasonable price. A 90-day supply is less than $ 15. A 90-day supply is $ 15. Why do I need insurance? “
After a long period of consideration, Hacks opened in December. Freedom pharmacy In the suite next to Pickerington Pharmacy, he also owns and operates within the insurance system.
“We have pharmacies in both worlds, so we can help guide patients to the best world for them to live in,” he said.
Insurance is essential for patients taking some medications.
The most expensive medicines, branded medicines and specialty medicines, are usually patented and can cost thousands of dollars a month, and in some cases tens of thousands of dollars. So it makes sense to insure yourself for the cost, just as your car does for a collision, or your home for a fire or flood.
But when drugs lose their patents and are flooded with generic versions, they fall below each other, pushing down open market prices. However, most patients do not have access to them on the open market.
That is, you cannot take advantage of the savings created by the generic drug revolution.
In terms of quantity, generics accounted for more than half of the prescription drugs dispensed in 2005. In 2019, generic drugs 86% or more..
“The bottom line is that branded drugs are becoming less and less important,” says Hacks.
Often you don’t know that an insurance company or pharmacy manager is involved. For example, last year the anti-HIV drug Tolbada lost its patent.But when 11 generic versions flooded the market this spring, the cash prices of traditional pharmacies were actually Higher than patented medicine..
This increase is caused by the confusion of manufacturer discounts to pharmacy benefit managers, opaque refunds by PBMs where pharmacies often lose money, and the need to make money at cash prices to offset those losses.
But the point is that one can go to Blueberry pharmacy — Shops that are not insured outside of Pittsburgh — and buy a generic version of Truvada for $ 25 per month.In traditional pharmacies, uninsured customers faced markup Baseline price is $ 2,100..
That’s why blueberry owner Kyle McCormick motivated him to open an uninsured pharmacy last year.
“I’ve seen how cheap these drugs are, so there’s no way to keep them from being insured,” he said.
Greg Lopes, a spokesman for the Pharmaceutical Care Management Association, a PBM industry group, last month claimed that insurers (often as part of the same company) would add value to all types of drug transactions.
“PBM, an American pharmacy benefit manager, has a long history of supporting generics to reduce the cost of prescription drugs for patients,” he said. “The key to lowering the cost of prescription drugs is to increase competition between branded drugs from generics and biosimilars.”
That said, critics say the current manufacturer discounts are raising arbitrary prices more than ever and increasing the distress of many patients. Former Pfizer Vice President Robert Popobian, who currently works as both a pharmacist and an economist, is planning high deductions as well as uninsured, increasing the number of people who have to pay joint insurance. I feel that I am. Consultants and analysts.
When referring to co-insurance (if you need to pay part of your bill), Popobian used the example of a well-known insurance company, Delta Dental. If there is a procedure such as getting a crown, Delta will pay a certain percentage of the price negotiated with the dentist, Popobian said.
This is not the case with prescription insurance.
“The benefits of medicines are the only benefit within the healthcare system that allows patients to pay joint insurance based on retail prices rather than negotiated prices,” Popobian said.
The same is true for uninsured people and those who have to pay the full amount until they are eligible for the deduction. According to Popobian, their payments are based on a list price that manufacturers are inflating to compensate for the opaque discounts they are offering to pharmacy benefit managers.
This is a problem that Chris Johnson has long been accustomed to.He opened his uninsured Medsavers pharmacy In 2005 in Austin, Texas.
Being in a state of having it for a long time Highest rate Medically uninsured, he knew that those people were facing at the pharmacy counter.
“Uninsured people were screwed in and screwed in, not because the pharmacy was doing it to them, but because of the contract the pharmacy had signed with PBM,” he said. “The contract forced pharmacies to raise prices for uninsured patients in order to maximize insurance reimbursement. I felt ethically and incredibly wrong.”
Johnson said he had an active business. But when he started, most of the dozens or so pharmacies in countries operating outside the insurance / PBM territory got lost for unknown reasons, he said.
Currently, the only uninsured pharmacies found by the Capital Journal are Johnson in Austin, Hacks near Columbus, McCormick near Pittsburgh, and Genscripts, Operates 5 locations in Oklahoma.
However, two of them have opened their doors since 2020 and may point the way forward for independent pharmacies.
One of the reasons why independents are important is that independents are the only game in town for many small communities, and their loss can result. Pharmacy desert In some areas.
Still, independent pharmacies Close the store faster than the new store opens Between 2015 and 2019, according to data from the National Community Pharmacists Association.
Kurt Proctor, vice president of strategic initiatives at NCPA, said:
“I think this is a very viable business model,” he said of pharmacists working, at least in part, outside the realm of insurance / PBM.
For Hacks, the economic benefits to the customer cannot be denied. But he said there was an even greater reason to pursue a non-insurance model.
At Freedom Pharmacy, he charges the patient the amount he paid for the drug and charges a dispensing fee of $ 8 or $ 12, depending on whether the supply is 30 or 90 days.
“The pharmacist confirms that the prescription is being properly reviewed, that the patient understands how to take the drug properly, that there are no drug-drug interactions, and calls the doctor. Each prescription is worth it to make sure you do it. If you have a dose problem, “Hacks said. “These are all that are included in every prescription we make.”
Opting out of the insurance / PBM system will radically change the economy. Hacks said he would no longer have to scramble daily to fill out his prescription.
“All our benefits come from services such as prescription confirmation and testing, dose screening,” he said. “I can tell you this: what you pay is what you are good at.”
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