Monday, March 18, 2013

Free Choice Pharmacy Debate A Smoke Screen

Does it matter whether injured workers have a choice as to where they get their prescriptions filled?

To me the answer to the question depends upon whether any particular choice is tainted by some special interest profiteering at the expense of the system.

In theory, open competition for the business of filling a prescription seems to make sense - after all a competitive marketplace should, according to theory taught me in business school, offer the best prices for the best products and services.

But this is workers' compensation, and workers' compensation is not a competitive marketplace. It is a regulated marketplace, which means that, for the most part, free market concepts are hindered by the mandatory nature of comp.

In other words, because nearly every employer must be subject to workers' compensation, and nearly every employee must submit to workers' compensation, there is no true market competition (except in Texas where work comp is optional). Consequently, any "free choice" in workers' compensation is tempered by the fact that in truth neither the employer nor the employee can go outside the system.

So workers' compensation is really a captive market, and thus requires regulation, because captive markets are very, very easy to manipulate and game.

There is a nascent trend, that started and failed in New York last year, for free choice pharmacy benefits, or right to choose. Proponents tout that the free market competition that would be permitted by "free choice" will control costs and provide better outcomes.

Proponents of pharmacy choice legislation, led by Injured Workers Pharmacy (IWP), a national mail-order pharmacy specializing in prescriptions for injured workers, are pursuing legislation in New Hampshire, Senate Bill 95 by New Hampshire Sen. Sharon Carson, R-Londonderry, that would give injured workers the right to choose where they get their prescription drugs.

This group attempted similar legislation in New York last year but the bill did not get passed.

IWP, which relies on referrals from claimant attorneys as opposed to networks, views the successful passage of pharmacy choice legislation as critical to its business. That makes sense.

The opposition in New York was led by pharmacy benefit management companies, and a right to choose pharmacy bill would certainly impair the PBM business model, so I can understand the opposition too.

The New Hampshire bill would also introduce a fee schedule for pharmacy benefits. Currently, in New Hampshire, fees for pharmaceuticals are based on a usual and customary rate system - and believe it or not that is where some opposition is coming from.

According to the WorkCompCentral story on the topic this morning,  George Roussos, a lobbyist for the New Hampshire Association of Domestic Insurance Cos., who was the only person to speak in opposition to SB 95 at a committee hearing last Thursday, said, "Why is it that these pharmacies need to be protected by having assurances of a certain price which translate to mean a certain profit?"

I think Roussos has it backwards. As we have seen in other states that have already grappled with "usual and customary" pharmaceutical fees, eventually because of the captive market of work comp, prices get out of control. A fee schedule helps control excess profiteering.

The PBMs and insurers who oppose pharmacy choice legislation believe routing a prescription through a network increases patient safety and could potentially alert the pharmacist and payer to harmful medication issues. They argue prescriptions filled outside pharmacy networks and PBMs do not undergo these safeguards.

I think the arguments on both sides are much more basic than patient safety, convenience, protection or pharmaceutical safeguards. 

The real issue is simply special business interests protectionism.

My guess is that one in a hundred injured workers, if even that many, gives a rat's derrière about where their medications come from, how much they cost, etc. 

There is nothing about the patient's interests that is driving this argument. Anyone proffering that argument is engaging in a diversionary tactic, also known in more common parlance as a "smoke screen."

The first thing that needs to be acknowledged in the debate is that such proposed legislation is all about money - who gets what, when and how.

If the parties can come to terms with that basic fact then perhaps some reasonable compromise can be achieved. Otherwise, leave the injured worker out of the debate because it has nothing to do with their best interests.

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