CVS Health and other large corporations often use their pharmacy middleman affiliates to force people to purchase the more expensive class of drugs from corporate mail order pharmacies.
Some call the practice âpatient orientationâ.
CVS and companies such as UnitedHealth and ExpressScripts / Cigna say these arrangements save patients money. ButSome patients, oncologists and other healthcare providers say it threatens lives.
Now the United States Supreme Court is ready to step in. In just over a month, she will hear the arguments in a California case in which AIDS patients claim the practice discriminates against them.
Known as âpharmacy benefit managersâ or PBMs, intermediaries work with insurance companies or government programs like Medicare and Medicaid to facilitate prescription drug transactions. They negotiate discounts with drug manufacturers, decide which drugs are covered, and they determine how much to reimburse pharmacies that dispense drugs as part of their health plans.
But the contested function in the California case is the way PBMs structure their pharmacy networks.
Each of the Big Three PBMs is affiliated with a major insurer and each is part of a company that is among the 13 largest in the United States. And combined PBMs are estimated to control well over 70% of the pharmacy intermediary market.
They are also frequently in direct competition with the pharmacies whose reimbursements they control. CVS has the largest retail chain in the country and each of the Big Three has a mail-order pharmacy for “specialty drugs” – the most expensive class of drugs, which can cost up to $ 100,000 per year. .
Increasingly, the Big Three PBMs say they won’t cover very expensive specialty drugs if patients get them from their cancer centers or AIDS clinics. It is increasingly common that the only way for PBMs to cover them is for patients to receive them by mail from a pharmacy owned by PBM.
Critics say the goal is to increase profits, but PBMs claim they are doing it to help their customers.
“To keep costs down, the model plans offered by pharmacy benefit managers often place the most restrictions on ‘specialty’ drugs,” CVS said in its petition asking the Supreme Court to hear the case. âThese drugs have special shipping, administration or storage requirements; treat rare diseases; or are very expensive.
He added: âPharmacy benefit managers often control the disproportionate costs and complexity of specialty drugs by contracting with specialty pharmacies that have expertise in the ‘unique handling, storage and distribution’ requirements of these drugs. . Increasingly, pharmacy benefit managers rely on specialty pharmacies that deliver by mail.
Cancer, HIV patients say mail-order service isn’t working
However, many patients complain that, especially when suffering from complex conditions requiring equally complex treatment regimens, the mail order service is far inferior to the services they get in person from pharmacy professionals. .
In 2018, Elvin Weir, a cancer patient who died today, described to The Columbus (Ohio) Dispatch how late or poorly filled mail-order cancer prescriptions often delayed the rest of his treatment while his illness was getting worse. And oncology center officials said the arrangement disrupts the collaboration between their pharmacists and oncologists treating conditions that can not only be complex, but also change rapidly.
The plaintiffs in the original California case made much the same argument.
âFor people living with HIV / AIDS, lifelong adherence to antiretroviral therapy (ART), consisting of complex combinations of pharmaceuticals consumed daily, is vitally important and can literally be a matter of life or time. of death, âwrote the AIDS Healthcare Foundation. in a memoir from a friend of the court.
“For people living with HIV / AIDS, pharmacies and specialty pharmacists who focus on HIV / AIDS and in-person treatment provide clearly superior care than mail-order and retail pharmacies,” he added. “Forcing people living with HIV / AIDS to use only mail-order pharmacies thus ensures inferior quality of care and poorer health outcomes, and constitutes both intentional and discriminatory disability discrimination. by impact. “
A panel of the 9th U.S. Court of Appeals last December said that among its errors, the lower court in the CVS case failed to recognize that face-to-face interactions with pharmacists were among the benefits to which plan members are entitled.
The Ninth Circuit ruled that CVS’s mail-order policy may discriminate against people with disabilities because it âcharges patients with HIV / AIDS differently due to their unique pharmaceutical needs. Specifically, they claim that drug changes to deal with the continued mutation of the virus require pharmacists to review all drugs in an HIV / AIDS patient for side effects and unwanted drug interactions, a benefit they do not. receive more under the program.
CVS maintains that policies are not intentionally discriminatory
In its appeal to the Supreme Court, CVS challenges the plaintiffs’ legal argument that the mail-order policy violates the law because it has a âdisparate impactâ.
In other words, AIDS-afflicted complainants say that even though at first glance the policy applies equally to everyone, it is still unlawful discrimination if it is discriminatory in nature. effect against part of a protected group: the disabled. CVS, on the other hand, argues that as long as its policies are not intentionally discriminatory, they are OK.
The law warns “recipients of federal funds that intentional discrimination is illegal,” its petition says. âSchools cannot discipline students with Attention Deficit Disorder harder on this basis. Cities cannot target group homes for people with disabilities with particularly onerous zoning requirements. Employers cannot refuse to hire someone just because they are in a wheelchair. And health plans and anyone else subject (to federal health care laws) cannot ostensibly exclude disabled patients simply because they have a disability.
“Courts don’t need to rewrite (the law) and insert a non-existent disparate impact standard to achieve Congress’ goals,” CVS argued.
The healthcare company noted that appellate courts have expressed differing opinions on the matter. This is presumably the dispute the Supreme Court hopes to resolve by hearing the case.
Pleadings are scheduled for December 7.
This story was originally published by Ohio Capital Journal, a subsidiary of States Newsroom.