Consumer 10.0: Pharmacists take on mail-order

Melanie Kassel of Phoenixville is required to get many of her prescriptions by mail order, and she has lots of complaints about it.

She's had medicine stolen from her porch, tossed away months' worth of drugs when doctors changed her prescriptions, and had to beg her old pharmacist for emergency supplies. As a diabetic, she has had to lean on a neighbor to watch her porch for her insulin shipments, packed on ice. In warm weather, she worries they won't survive.

Ed McCarthy, who lives in the same Chester County community, doesn't have to use mail order, but his company's health-care plan encourages it with the same special deal Kassel gets: a single co-pay for a 90-day supply. And McCarthy is happy with the result.

"I use it for the money I save on a 90-day supply. I think it's great," says McCarthy, who like Kassel has a long-term condition - asthma - that requires so-called maintenance drugs. He also has a son with allergies, and he estimates that the co-payment break saves his family $800 to $1,000 a year.

Kassel and McCarthy are two sides of the same coin - consumers responding to a shifting marketplace and, perhaps, the presence or absence of choice. They were among dozens of readers I heard from after a recent column on the push by some health-care plans to steer prescriptions to mail-order pharmacies, and the push back by Pennsylvania's independent pharmacists for what they consider a level playing field.

Like most aspects of health care, this is a complex, multifaceted issue. But it's worth paying attention to the debate over Senate Bill 616 and its counterpart, House Bill 838, which would give bricks-and-mortar pharmacists the right to offer multimonth prescriptions on a similar basis to those offered by the mail-order houses.

The pharmacists' proposal puts them at odds with insurers and with pharmacy-benefits managers, or PBMs - the intermediaries who oversee much of the nation's prescription coverage on behalf of insurance companies or self-insuring employers.

Over the last decade, PBMs have drawn repeated scrutiny from state and federal officials who have raised basic questions about their business models.

Critics point in particular to the rebates paid to PBMs by drugmakers eager to win "preferred" status for their medicines, and worry that financial considerations may cloud decisions that should be based on drugs' relative therapeutic benefits.

But the debate in Pennsylvania centers on another key aspect of the largest PBMs' businesses: their ownership of mail-order pharmacies, and the tools they sometimes use - typically either mandates or co-payment incentives - to steer prescription business to their own retail outlets.

Insurance companies are generally happy with the role played by PBMs, which they count on to manage a complicated aspect of coverage and keep costs down.

Sam Marshall, president of the Insurance Federation of Pennsylvania, says the pharmacists' proposal "would raise the cost of what we pay for prescription-drug coverage, at the same time we're trying to control costs."

For the other side of the equation, consider the perspective of Daniel A. Hussar, Remington Professor of Pharmacy at the University of the Sciences in Philadelphia.

Hussar, who worked as a community and hospital pharmacist before turning to teaching and research, says the benefits of mail-order pharmacies may be more imagined than real - in part because too little is known about drugmakers' rebates to PBMs.

"It's a numbers game - we are continuously told that mail-order is less expensive," Hussar says. "But when we ask for the data that supports that, we're told it's proprietary."

But Hussar isn't concerned only with the questionable benefits of mail-order prescriptions. His bigger concern is their cost - not in dollars so much as in the lost value associated with face-to-face contact between patients and traditional pharmacists, whom Hussar sees as crucial and undervalued players in the nation's health-care system.

To Hussar, the biggest danger of the push toward mail-order prescriptions is that it treats filling a doctor's prescription as delivering a commodity, not providing an aspect of medical care.

Hussar says patients benefit in numerous ways from a consistent relationship with a pharmacist they choose - a trained professional who knows them and all the drugs they're taking, not just the painkillers or antibiotics prescribed on a short-term basis for acute conditions.

Without that continuity, he says, patients are more at risk of ill effects from drugs, especially the unusual side effects or interactions that can occur. And without access to knowledgeable pharmacists, he says, patients will lose a key resource on the use of the growing number of drugs offered over-the-counter - medicines that may be benign enough to self-prescribe but that can still pose risks.

"If you can head off a drug interaction, if you can head off an adverse reaction, you may be able to avoid a hospitalization," Hussar says.

Above all, Hussar is convinced that a system that values traditional pharmacists more highly - and ensures that they can stay in business - would be more cost-effective in the long run than a system that treats filling prescriptions like buying books from Amazon or sheets from Lands' End.