Community Pharmacists
Floor Speech
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Mr. COLLINS of Georgia. Mr. Speaker, before I begin, I ask unanimous consent that all Members have 5 legislative days to revise and extend their remarks and to include any extraneous material on the topic of this Special Order.
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Mr. COLLINS of Georgia. Mr. Speaker, well, we are back at it tonight. We are going to be going at a subject that I have been down here before on and will continue to come down here on until, frankly, I believe that we are moving forward with this issue that affects pretty much every hometown of every Congressman here. It is amazing, though, how much we don't know about it. It is amazing how much it goes unreported and how much it gets looked over.
In the sake of the shiny object of savings, our community pharmacists, our independent pharmacists, are being basically run out of business. Mr. Speaker, I don't tell you anything new.
For my friends who will join me here tonight, this is about hometown America. This is about the healthcare chain that we all talk about. And a forgotten element of that healthcare chain is something that we need to focus on.
Community pharmacists fill an important niche in our healthcare system, serving as the primary healthcare provider for over 62 million Americans. They dispense roughly 40 percent of the prescriptions nationwide and a higher percentage in rural areas, especially mine in northeast Georgia.
Community pharmacists play such an important role in our healthcare system by being that accessible voice at the other end of the phone or at the counter, just being there sometimes to answer those simple questions that are very important to somebody, or to answer the difficult questions that could, frankly, mean the life or death for that patient, knowing how to take their medication, knowing what to get and how to be there and be a part of the community, not just at the pharmacy, but at the ball fields and the community. Some of the best small business employees that we have in our communities are found in our community pharmacies.
When we look at the relationship that communities have with their pharmacies, and especially our community pharmacists, the face-to-face counseling and the work that goes into our community pharmacies, and pharmacists mainly in general, is something that we need to continue to focus on.
Patients' failure to properly take their medication regimen costs the healthcare system nearly $300 billion and contributes to 125,000 deaths each year. The face-to-face counseling that our community pharmacists give is the most important and the most effective way for ensuring that our patients take the right medicine, know what they are taking, and why they take it.
Yet, as I stated before and state here again on the floor tonight, there is a group that believes that our community pharmacists--really frankly if you just look at it--shouldn't exist. Because everything they are doing, the pharmacy benefit manager, the PBM, that middle person--I want to show you this. We are going to talk about this chart more here as we go--but the PBMs control the pharmacy system right now. In fact, if you just take the PPM here in the middle and you look at employers and you look at patients and you look at the pharmaceutical companies and you look at the pharmacies, they sort of circle around here.
We are going to talk about this ``savings issue'' and look at it and ask: Is it actually saving employers? Is it actually helping pharmaceutical companies get out products? More importantly, is it actually helping the patient?
I think tonight you are going to find out that there are a lot of questions to be had here. We will talk about that as we go forward.
As we look at this, we have a lot of things that my friends tonight are here to talk about. We are going to talk about MAC transparency. We are going to talk about generics. We are going to talk about the way this goes, but we are also going to talk about really what I believe is the unfair tactics used by PBMs that are constantly forcing our pharmacies and our community pharmacists out of business.
I think, at some point in time, many of the PBMs ought to change their mission in life into ``saving'' or being a part of the pharmaceutical system and say: our job is to run community pharmacists out of a job. They are the best I have ever seen at doing that.
In one of my small towns just 20 minutes from my house, in the past year, three community pharmacies have closed. Three. They are now in a smaller town being forced into choices they didn't want to have to make, into PBM-controlled pharmacies.
You see, PBMs, when they first started, had a good idea: How do we make sure that we get drugs and medications to pharmacies at a cheaper price so that the patients at the end save money and employers can save money?
Then PBMs decided that they wanted to be a part of all the system. They wanted to start owning pharmacies. They wanted to start owning the supply chain. They wanted to start being a part of it all. And when they did that then everybody else was competition.
I have said it before from here: The problems that we have--and Georgia pharmacists have talked about it, and we have talked about it as well--is when you have your competitors who are able to come in and audit you and they are able to fine you for clerical errors and keep you out of systems and out of payments and things that they give their own pharmacies, that is just wrong. It is wrong when they only come in and audit the name brands and leave the generics behind.
For some of you, if you are watching, if you are thinking about it and hearing my voice for the first time, you are maybe saying: Well, that is okay. They are making sure systems are safe.
PBMs are not auditing pharmacies to make sure they are safe. They are auditing pharmacies to make money because they are going to withhold the cost of the drug from the pharmacist. In other words, if they make a clerical error and the drug costs $100, let's just say, they don't take their profit. They don't take the margin. They take the entire $100 back. I wish I had a racket set up that good.
The sad part about that whole statement there is, at the end of the day, Joe or Suzy or Bob or Bill or whoever came and got their prescription knew nothing about this ``error.'' All they knew is the pharmacist filled the prescription that the doctor had ordered, and they went home and took their medicine and got better.
Yet, on this other end, PBMs are trying to destroy an industry and a group of people who mean so much to our communities. So tonight we are going to talk about it. We are going to talk about it some more, and we are going to keep bringing attention to this until the light is fully shined on this.
Tonight, as we get ready to talk about it, a gentleman who has been such a friend to us as we have been doing these, Representative Loebsack, is here tonight. It is good to share the stage again with him because this is something that needs to be discussed. It needs to be hammered home until every Member of the House and Senate understand this and we find a workable solution.
I yield to the gentleman from Iowa (Mr. Loebsack).
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Mr. COLLINS of Georgia. Well, bring them on.
I yield to the gentleman from Iowa.
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Mr. COLLINS of Georgia. Madam Speaker, Mr. Loebsack hit it. That last little part right there was dead-on. This is about the patient. This is about serving that patient who is used to that trust and faith, who understands it, and also really a part of that healthcare system that has been provided a long time that is now at risk of going away.
It is not too strong to say that if we do not look at this--and some say, well, this is a free market, let them go contract. Government is one of the biggest payers of this, and this is something we have got to get at.
In fact, something Mr. Loebsack brought up as I was listening to him talk, there was a study, TRICARE, in fact. In just a moment, I am going to introduce Mr. Scott here. He is from Georgia. He is on the Committee on Armed Services. He is a friend. But TRICARE did a study where it found that, if it eliminated PBMs from the TRICARE program, it would save roughly $1.3 billion per year. We are up here arguing about problems in our budget, and we could save this much money?
No, this is about profits. This is about consolidation. This is about vertical integration. This is about taking control of a market in which three to four companies control 83 percent of the market. We are not talking about a small little startup. Mr. Loebsack is right on, dead- on. I thank him so much for the work that he is doing, and I appreciate it.
In light of that, especially dealing with TRICARE, again, the bottom- line issue here is how we cost-effectively provide services to those members in our communities who need it the most. And this issue of savings, I know there is a Texas study that also showed if they went away, they would save money as well, in the millions of dollars. It is building, but we have just got to keep pointing it out.
I yield to the gentleman from Georgia (Mr. Austin Scott), my friend, my longtime colleague not only in the House in Georgia, but the House up here, and fighting for the very values we find in Georgia and all across the country.
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Mr. COLLINS of Georgia. Madam Speaker, I thank Congressman Scott. He has highlighted a lot of things, and I think it is something that just matters. Sometimes we go through a lot of the big pictures up here, and we see a lot of issues, but this is one that matters to hometown. This is Main Street USA. This is something that goes on. Especially for districts like mine and for many others in rural communities, the pharmacy, especially the independent community pharmacies, are the lifeblood in these communities
I have said this before, and I have had this asked of me because we have been doing this a while. Let's make it very clear. Pharmacists, I love. I don't care who they work for. Pharmacists are great folks, whether they work in a big-box store or they work for a major chain or they are independent and own their own business. Pharmacists want to help people. That is why they went into it to start with.
I think what we are fighting here is a system. I have talked to many pharmacy students who are now saying they are not sure they want to go into this or they are very concerned about their futures because they are looking at the abusive policies of PBMs, and they are saying: I don't want to follow in my mom or dad's footsteps; I don't want to follow and open up a storefront and hire people because I can't make it this way. And they end up being forced in.
I want to talk a little bit--we have been vague about this, but I am not going to be vague here for the next little bit. I am going to talk about PBMs and this regular auditing of community pharmacists to recruit large reimbursements. Let me go back over this.
There is nothing wrong with audits performed with the intention of uncovering abuse; however, PBMs' auditing has another motivation. Pharmacists have told me that the most expensive prescriptions are always the target during the audit--always.
PBMs used to audit only the most expensive medications looking for clerical errors like typos, misspelled names or addresses, or, better yet, as I just heard recently from one of my pharmacists, in which they dinged one of my pharmacists because the doctor wrote a specific amount for an eye medication--the doctor. Let's make this very clear now. I know Representative Carter is probably going to get into this a little bit more, but the doctor himself wrote the prescription. The prescription goes to the pharmacist. The pharmacist filled the prescription as the doctor said. But when the PBM auditor got there, they said: No, you are not supposed to use that amount. Use this amount.
I want to know what medical school this auditor went to. I want to know when they decided to start practicing medicine without a license where they can come in and say amounts. I can understand swerving to a generic over a name brand or a name brand over a generic. That is within sort of what we have become used to. But when they can actually go in and ding one of our pharmacists for amounts that the doctor said, we have got a system that is a little bit abusive. Well, let me rephrase that. It is downright corrupt.
They go in and they do these audits. They find these clerical errors. And when they do this, they take back, they recoup, all the funding paid for that prescription. Like I said earlier, they don't take back just the profit. They don't take back the cost. They take back everything.
These audits are not intended to end Medicare fraud. The PBMs use them to take taxpayer funds and claim them as profits. If a pharmacist checked the box that said send by fax instead of send by email, the PBM is able to reclaim the entire cost of the drug. They don't just take back the copay or the pharmacist's profit.
Again, I just want you to understand how crazy this is. But, you see, instead of looking and having their time and effort of audits that could be better spent helping local pharmacists do what they do best, they are having to look over this all the time, focusing on improved quality for their patients.
The PBMs, frankly, have shown over the last little bit that they are not interested in the well-being of the patient. They are interested in that other P word, profit, not patient.
It is really concerning, and this is what has happened. In the interest of that profit, the PBMs have engaged in anticompetitive business practices. Certain PBMs own or have ownership stakes in the very pharmacies they are negotiating to lower drug prices with. When a PBM is owned by the entity it is supposed to be bargaining with, there is an inherent conflict of interest. This can lead to fraud, deception, anticompetitive conduct, and higher prices.
Here is a great one. I love this. Many large PBMs own their own mail order pharmacy and financially penalize patients that use their community pharmacist instead of the PBM-owned one. PBMs try to drive customers from community pharmacies into the mail order firms, arguing it saves consumers and drug plans money.
However, a study by the Taxpayers Protection Alliance highlighted waste, fraud, and abuse within the mail order system run by the PBMs. The TPA study noted that 90 percent of patients were moved to mail order due to encouragement or mandate from a PBM.
According to Medicare data, PBM-owned pharmacies may charge as much as 83 percent more to fill prescriptions than community pharmacists. PBM's practices limit consumer choice, increase drug prices by engaging in vertical integration in their ownership of mail order pharmacies, killing competition.
And here was one that was classic. I walked into one of my smaller towns. It had a pharmacist. And the pharmacist said: I got in trouble. I got a letter.
They showed me the letter. They delivered some medicine to some of their customers. They get a letter from the PBM saying, You are not in the mail order business. And they actually were going to have their contract threatened if they sent these people their drugs.
Representative Carter is going to talk in a minute. I just want to break for a second. But that is unbelievable that they actually will get on the pharmacies and say: You can't reach out, you can't contact your customer to tell them that they can be a part of the plan.
One of my pharmacists actually was left off of a plan that they were actually on. The PBM sent a letter to all his customers saying that they are not a part of the plan, when, in actuality, he was. And then, when confronted, they refused to send a letter out to the customers saying: We are wrong.
Just briefly, am I highlighting something that is uncommon? Or is that a common practice?
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Mr. COLLINS of Georgia. You have hit something. You have led into a great example. This is highlight. And if there are problems, let's fix them. You hit on that issue.
We have heard of DIR fees tonight. We have heard about reimbursements. Let me leave you an example from a little company called Humana.
I had a pharmacist call me about proposed amendments to their Pharmacy Provider Agreement. Humana decided to withhold $5 per prescription from initial reimbursements to the pharmacy. Now, you understand what is happening. They are withholding $5 of what they should be sending to the pharmacy. The return of the reimbursements was conditional on the pharmacy meeting certain patient adherence metrics. This is essentially a fee conditional on meeting certain performance standards, and Humana would withhold reimbursements from poorly performing pharmacies.
That sounds good, doesn't it?
It has got a great twang to it. Somebody in the marketing office there thought, This is going to be pretty cool. It sounds so good, but let's talk about it.
Humana's criteria, however, had little to do with patient care and more with driving community pharmacists out of the market. Many of the metrics used, including patient adherence, are beyond the control of the pharmacist.
Humana's amendment unduly burdens small pharmacists and protects large chain pharmacies, many of which they own. Humana enlisted their actuaries to ensure this formula guarantees they will retain 60 percent of the withheld reimbursement moneys, most of it coming from community pharmacists.
Pharmacists in the 80th percentile and up in each category would receive $2 per category. If a pharmacy meets expectations in all three categories, they will earn $6--a $1 profit per prescription. Now, remember, this is what was already withheld from them. Pharmacists below the 80th percentile would receive .67, or 67 cents; and below the 50 percent percentile would receive none of the reimbursement that they withheld. This is a reimbursement that is supposed to go back to the pharmacy. They are not getting any of it. Many of the community pharmacists often can't afford to lose this additional 33 cents to $5 for every prescription they fill. Only big box pharmacies really have that ability.
Humana also favors big box pharmacies by allowing the number of patients to serve as a function of a tiebreaker. This amazed me. For example, a community pharmacist and a big box pharmacist might both have 100 percent adherence to certain performance measures. However, if the big box pharmacy served more patients than the community pharmacist, it will achieve a higher percentile score than the community pharmacy.
Humana disproportionately favors large chain pharmacies at the small pharmacies' expense. Certain pharmacies have enough patients to minimize the effects of patient nonadherence to their ratings. At independent community pharmacies, one patient's nonadherence could cost pharmacies thousands of dollars by moving a pharmacy from the top bracket to one below.
If somebody were listening to us, Representative Carter, they would say we were making this up. We are not. I have been doing this now for well over a year--almost 2 years now. I have never been challenged on these facts. They don't like it. And they are listening probably right now, saying: What can we do to go settle this down?
But it is just not right when they look at these things and they see savings in the State governments. It is like they are saying: Look at the shiny object over here. Don't face reality.
This one is just amazing to me. When you are taking money that should go back to the pharmacist and putting them on this metric scale that they can't compete on; or you are taking their customers, but won't allow the pharmacist to reach out, these are the kinds of things that just really, really are amazing to me.
I wrote a letter with the gentleman urging CMS Acting Administrator Slavitt to review Humana's proposed amendments for their part D Pharmacy Provider Agreement. This is just something that has got to change as we go forward.
There is nobody that knows that any better than Representative Carter, knowing the situation. I have said this all along. I do this because I have been helped so much by community pharmacists and believe when wrong is wrong, you call it. When you can, try and make it right.
You have lived this. And you continue, by your service on the Georgia legislature and up here, to help us continue to be on the front lines, continuing this fight. You are there working it out as well.
Tonight, I think we just need to continue the practice of saying, Here are the facts, and encouraging our committees of jurisdiction to take action on this and just evaluate it.
We have the MAC transparency, the clawback bill. These bills have a chance just to be heard, because I found that every time I share this with Members, they can't believe it. They want to know more. And when we show them the facts, they say: This needs to be discussed.
We have some time tonight. I want to share what you are seeing as we continue this fight for what is right.
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Mr. COLLINS of Georgia. Exactly. What you are saying, every time we do this, we gain Members who begin to look at the issue. They just don't believe what the PBMs bring to them.
All I am asking for me and I know for you is for every Member here to go talk to a community pharmacist. All they have to do is go talk to them. We are not sharing anything that is not real.
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Mr. COLLINS of Georgia. Yet, if you had done that, they would have cut your contract off.
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Mr. COLLINS of Georgia. You can't engage in that kind of practice. It is just amazing.
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Mr. COLLINS of Georgia. I want to thank the gentleman for being a part and providing an insight that is--as I have said, for those of us who see this and call unfair unfair, and we are learning about it every day, you have lived it, and I think providing those insights is valuable.
The more we continue down this path, it just--and again, I spoke about it. I am on the Rules Committee as well. I talked about it in the Rules Committee, and it was amazing when I heard the other members. Some were on Energy and Commerce, some were on others, and they finally said, that deserves a hearing. MAC transparency deserves a hearing. Griffith's bill deserves a hearing. Guthrie's bill deserves a hearing.
These are things that actually save money, except for the coercive, twist-arm tactics of PBMs who just think that 83 percent of the market is not enough, 83 percent, roughly, of the market is not enough, that they get on people about mail order. They want you to turn--and your insight on how they actually know. That wall, that is the flimsiest wall I have ever seen. Maybe they will start building it better. I don't know. In north Georgia, we built them a little harder than that. But I appreciate that.
I want to go into something tonight, and it is something that we have talked about. It just explains how this works, because maybe some aren't as familiar; they haven't studied this and had a great staff. I have actually had a great staff that have put together--you know, Bob's here tonight. I have got a staff member who is still with me in spirit, but she is not with us. Jennifer has been working on this for a long time.
But I also had Daniel Ashworth. Daniel is an intern, a pharmacist intern who helped us out a lot and helped prepare this. I want to show you this. I showed you this at the beginning, and it is sort of--the PBMs are at the middle of the world here, if you will.
So let's just talk about this. Let's just start off with where it should start, and that is with the patient. The patient makes medication decisions, or he gets it from the doctor. And they are typically okay if you go this way, their employer. A lot of times the employee, their health benefit plan, that is where they get that.
So as we start here with the employers, the employers turn to PBMs or the insurance companies for plan decisions. So they turn to them and say here is how the plan is going to work. Here is how the plan operates. They expect the PBM to look after their best interest and to help save them money. That was the whole setup in the beginning, until they began to vertically integrate, to take on and become the main player in the market.
So what happens here is they make a plan decision to entrust the PBM to do that, and the PBMs, in turn, are supposed to give back the savings in this. We have already seen tonight how TRICARE has already saved $1.3 billion. This was their own internal study. We have also seen others where the fraud and abuse are not finding these savings.
So again, let's just continue on.
Pharmaceutical companies have an interesting relationship as well because, through rebates that they give to the PBMs or to incentivize, if you will, the use of drugs, their brand names, their ones under patent--which is very valuable. You are not going to find a stronger proponent of patent and copyright content in this Congress than me. What they are doing here is they are saying, okay, we are going to give rebates back so you can purchase, and we are going to have brand preference so that you will encourage this brand over this generic or, frankly, this generic over this brand. And that is okay. We understand that.
This rebate is supposed to actually go into the savings part, but there is no transparency here. We don't know where it is going. And you are not getting the savings back over here where the rebates could.
And then we get to, really, the one that is interesting, and the pharmaceutical companies, through the pharmacy, and then back to patient care. This is where it gets interesting with the PBMs and their interesting relationships with the independent community pharmacies.
Predatory pricing, such as we are addressing in the MAC transparency list, where the numbers change, they are not sure. We get into the DIR fees. We get into all this stuff that has now become, instead of, for the PBM, the P in patient, the P actually should be--and I am not going to write on this beautiful chart, but I might as well just put ``profit'' because, as I have already discussed earlier tonight, the audits aren't about patient safety.
As Representative Carter said, this is not about giving independent pharmacies or community pharmacies a leg up.
They don't want to be guaranteed a profit. They just want to be guaranteed to be able to open their doors and not be intimidated, coerced, or backed down by threats from PBMs that are much larger than them that basically say: we will put you out of business.
Madam Speaker, that is what they do.
They are supposed to have random audits. One of my pharmacists started laughing when we talked about random audits. They had the same audit about a year earlier. In other words, they are on a cycle. They just come back around the same time. These aren't random. They are not there for safety. They are there for profit.
It is frustrating. I have never seen anything else like this. It is the most amazing thing I have ever seen in which a business model that we have actually condoned--especially with the taxpayer money side-- says that you can extort from pharmacies whatever you want. We will take back fees. We will put you on a metrics like Humana did. We will put you on a metrics that will give you the possibility of making more, but then inherently rig it against the small pharmacies. That is a problem.
They can't answer the question. If they had, they would have said it a long time ago. They just hope I go away and quit talking about this. But there are Members every time we talk, some couldn't come tonight, and every time we come down here and we shine light on this very dark subject, more Members come along and say: that doesn't sound right.
I know you have had those conversations, Representative Carter. I have had those conversations. There are Members all over this Chamber that have experienced this in their own lives.
So I come to you tonight just saying, look, we put this here, and we look at the interaction. I am going to say, this is the most important part right here. It is about the patient. It is about the patient. We want to fix this. Let's look at how our money is spent. We want to fix this. Let's look at being able to come back weeks, months later. Let's talk about what the problems are here, but never forget the patient. It shouldn't be hard for them. Pharmacy benefit manager, the first letter is P. Let's just change it from profit to patient. Let's change it from being a facilitator to help pharmacies and help employers to market drugs to help the patient. Studies after studies show that it doesn't work.
Madam Speaker, we could talk for hours, but this is something we are going to continue to fight on. I appreciate the time we have had tonight, and this is not the end of this fight.
Madam Speaker, I yield back the balance of my time.
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