New ‘behemoths’ in healthcare changing how you get meds

Jul 21, 2023, 3:52 PM

Seattle Pharmacist...

Pharmacists in the Puget Sound region are dealing with a new challenge, Pharmacy Benefit Managers. (Getty Images)

(Getty Images)

The only pharmacy within 30 miles of Darrington is closing its doors Friday after a century of doing business.

Residents will now have to travel an hour roundtrip to pick up their meds.

The family-owned business said it is paying more for medications than it can sell them for.

The slim profit margins are mainly due to pharmacy benefit managers (PBMs). PBMs link the pharmacies with insurance companies and often decide how much customers pay “out-of-pocket.”

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“Your health insurance company contracts with a company that manages your pharmacy benefit,” Dr. Jenny Arnold of the Washington Pharmacy Association said. “And these managers decide which medications you can get and decide when and how much of those prescriptions you can fill and how much a patient pays out of pocket.”

Arnold said PBMs have become huge behemoths in the healthcare industry.

“They’re the tail wagging the dog in healthcare,” she explained. “They own insurance companies, they own provider groups, they own specialty pharmacies, and they even own community pharmacies. Walgreens and CVS, they’re two that have their own pharmacy benefit managers. They often require patients to go to the pharmacies that they own or are affiliated with.”

Arnold said that often makes it less convenient for the customer.

“Maybe you can’t get a 90-day prescription unless you go to one of their pharmacies, or you can only get a 90-day prescription if you don’t go to one of their pharmacies, or you can only get a 90-day refill if you go to mail order, for instance. And these are barriers that don’t serve patients.”

State lawmakers introduced a bill earlier this year to better regulate PBMs and give more authority to the insurance commissioner. That bill failed, but its sponsor plans to reintroduce it during the next legislative session.

The Federal Trade Commission has withdrawn its support for PBMs.

The Commission is now investigating if practices are hurting the public.

But, Arnold said PBMs are only one of the reasons it’s more difficult to get a prescription now.

“Sometimes staffing in pharmacies is challenging either because they don’t have a pharmacist for one reason or another for that day,” she said. “And legally, a pharmacy has to have a pharmacist to be able to open the store.”

She said drugstores are also facing a shortage of other key staff members.

“Like every other area of health care, workers are burned out and some left the profession temporarily,” Arnold said. “However, we’re seeing many come back to pharmacy practice.”

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Additionally, there are a lot of network restrictions that your plan has put in place that sometimes limit which pharmacies you can go to and which prescriptions you can get filled there.

“We’re seeing a lot of steering of patients away from the pharmacy that they have normally gone to, to pharmacies all across the state, to mail order pharmacies outside of our state. And that’s providing a barrier for patients as well.”

Whatever happens to create more efficiencies, it will be too late for residents in Darrington, who won’t have a pharmacy starting this weekend.

KIRO Newsradio’s Diane Duthweiler contributed to this story

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New ‘behemoths’ in healthcare changing how you get meds