Describing what they call a corporate takeover of health care, members of the state House Special Committee on Access to Quality Health Care proposed legislation that they say will bring more transparency and fairness to a health care process that could only be called Kafkaesque, that would appear to exist in such a way as to make health care for people who need it as expensive and inconvenient as possible, without much actual concern for their well-being.
“For all the good work that’s been done, many of the (pharmacy benefit managers) themselves have proceeded to ignore and make every effort to find loopholes in our laws, while at the same time other practices harmful to patients continue to grow and spread across the prescription drug landscape,” said House Majority Caucus Chairman Matt Hatchett, R-Dublin.
State Rep. David Knight, who will be leading the push on this legislation, said the system as it stands now prevents freedom of patient choice of pharmacy, obscures prescription drug prices with complex methodologies, leads to refusing coverage for cheaper generics and reimbursing PBMs and managed care organization-affiliated pharmacies with far more money than retail independents.
For instance, Knight referred to statistics that showed Georgia paid $4.29 billion to Medicaid managed care organizations in 2018, with more than $500 million going to administrative services. There was a $170 million net gain from three of four companies, and dividends paid to their parent companies of around $120 million.
Using the leukemia drug imatinib as an example, the reimbursement fee per pill for an independent pharmacy was $34.50, while an MCO affiliate pharmacy received $279 and a PBM affiliate received $302. For the cancer drug capecitabane, a clinic pharmacy received $4.39 per pill, as opposed to $27.63 for an MCO affiliate.
“The unifying theme that you will hear throughout today’s testimony is that patients and providers are being harmed by huge corporate interests that put their profitability over the lives of Georgians,” Knight, R-Griffin, said at Tuesday’s hearing.
There is existing law, passed last year under H.B. 233, that should prevent pharmacies from receiving self-dealing referrals from their affiliates, but according to letters provided to the committee, that practice continues. Knight referred to one that stated a woman must use a certain pharmacy or mail order provider or she would have to pay for 100 percent of the drug’s cost herself.
“We’re going to seek a carve-out of prescription drug benefits for Medicaid managed care,” Knight said. “West Virginia did this and in ’18, an actuarial study showed that the carveout saved over $50 million, while at the same time paying community pharmacies fairly.”
Dr. Melissa Dillmon, an oncologist from Rome, Ga., said she discovered this behavior a few years ago.
“About three to five years ago, my ability to give those drugs to my patient the same day I prescribe them or the same day I change the dose was dramatically changed,” Dillmon said. “I remember the first day I was told by one of my nurses, ‘We can’t fill that here anymore.’ And I said, ‘Why — it’s sitting over there on the shelf.’ And they said, ‘Well, we’re being told they have to get it through a mail-order pharmacy,’ something I had never even heard of before.
“I want to say this has led to significant stress within my practice. I’ve had to employ two full-time employees (whose) entire job is to get medications for my patients. But more importantly, it’s become a stress for my patients, and that’s what I’m here to do today, is to make sure my patients receive the care that they need.”
Dillmon also related several stories about patients she’s treated who’ve been significantly adversely impacted by these restrictive actions.
Dr. Jean Sumner, dean of the Mercer University School of Medicine, said she’s seen the same sort of thing.
“The same as the first speaker mentioned, patients who use CVS Caremark continually get letters that they must use a CVS — there’s not a CVS in Johnson County, and depending on where you live it may be 45 miles (away),” Sumner said.
She added that such a distance may be manageable for someone who’s younger and employed and has reliable transportation, but can be a serious problem for those who are older and whose family or access to help his far away.
Those people may have to wait more than a week for their medications from a more-expensive mail order pharmacy, and not be able to get the immediate access to their medication or assistance in understanding the system they could receive if their insurance allowed them to use a local independent pharmacy instead.
“I should be able to write for the cheapest, safest, most effective drug,” Sumner said. “I can’t anymore. I have to write what’s on your list, and what’s on your list is the most profitable.”
Katie Groover, a cancer survivor and Jennifer Shannon, a Johns Creek pharmacist, described the sort of corporate bureaucratic framework that appears to stand between patients and pharmacists at PBMs.
“The PBMs often tout that their pharmacists are trained for speciality drug management,” Shannon said. “However, I sometimes wonder if there is even a pharmacist in their building, because if you talk to any patient, they can attest — as Ms. Groover did — that they never even get to speak to a pharmacist. Instead, speaking to customer service representatives time after time who are unqualified to make medical decisions.
“They make it nearly impossible for a local pharmacist to provide uninterrupted care. They are stripping patients of the opportunity to speak face-to-face with a health care provider and forcing patients who are fighting for their life to keep fighting to get their medications. The only thing special about specialty drugs is that they are expensive and that PBMs make more money for themselves, all the while causing harm and leaving patients to wonder if they will be able to get their medicine.”
The General Assembly reconvenes Monday.