Q&A: Unveiling the Current State of PBMs’ Role in Independent Pharmacy

In the past few months alone, the role of pharmacy benefit managers—or PBMs—in the drug supply chain has garnered an amount of attention that the public has never seen before. Along with educating the public on PBM practices, a specific population of independent pharmacists have been more outspoken than ever before, trying to shine a light on the issues affecting the pharmaceutical industry.

One of the pharmacists joining the fight for PBM reform is Tom DePietro, PharmD, owner of DePietro’s Pharmacy in Dunmore, Pennsylvania. As an independent owner for the past 12 years, his business has been subjected to unfair and opaque PBM practices. After years of allowing third-party companies to determine what his pharmacy receives in revenue and how his patients receive their medications, DePietro is taking a stance against the pharmaceutical middlemen that hold massive amounts of leverage within the industry.

"Now, with the state of reimbursements, it's very hard to continue to give the service that I want to provide because our margins are so tight," said DePietro. | image credit: chuck / stock.adobe.com

Drug Topics: Can you start by explaining the current state of community pharmacy from your perspective as an independent owner?

Tom DePietro: Yeah, it's very challenging to operate. So we're extremely busy. We have tons of patients. We offer a lot of unique services. The one thing that I often say is not everybody needs a pharmacist; some people just need a pharmacy. Some people just need to grab one prescription on their way home, jug of milk, some shampoo, toothpaste. The big box corner pharmacy might just fit them well. Our patients need more service, from medication organization, free delivery, open enrollment will be coming around the corner here, so we can help patients navigate. What plan might suit them best? So that's what sets us apart. But now with the state of reimbursements, it's very hard to continue to give the service that I want to provide because our margins are so tight.

When I talk to patients and educate them on the battle we're up against, they can't believe it. It's kind of un-American that we're expected to operate our business under the thumb of a third-party company. So, my biggest example I'll say is, if I was a pizza business and the price of cheese goes up, and maybe it doubles, I'm forced to raise the price of my pizza and my customers would understand it because they're buying cheese at the grocery store as well. We operate in such a convoluted dysfunctional space that they don't get to see behind the curtain of what we're up against.

I feel [as] though it's my job to kind of educate them because there are times where, if the copay for a brand-name drug is very expensive, I play the game with my customer and educate them like, “Hey, you're probably going to get this very cheap if you use your mail-order pharmacy.” Do I want to lose that prescription or do I want to lose that patient's prescription? Absolutely not. But I know at the end of the day, my patients going to have a decision to make whether they pay for this medicine or pay for their bill—their light bill, their gas bill, their grocery bill. I have to do right by my patient all day long. But then I also know that there's a jeopardy in place because now they're going to be using multiple pharmacies. I won't be able to properly screen their drug interactions. [There are] so many layers of this that the public needs to understand. But you [have] to break it down so they can understand it because it's so complex. I'm 12 years into ownership and I'm still learning stuff today.

READ MORE: NCPA Representative Discusses Role in Influencing PBM Reform

Drug Topics: For our audience members who might be unaware, can you give us a summary of pharmacy benefit managers and the role they play in the pharmaceutical supply chain?

Tom DePietro: Yeah, because often times people don't even know that they exist. I guess the easiest way to explain it is, to the consumer, when you go to fill your prescription and you use your insurance card, that is in essence a pharmacy benefit manager, that's a third-party company that is managing the benefit of your prescription drugs, not only on the behalf of you, but maybe on the behalf of your employer. They determine what I get paid to dispense the prescription. They determine what you as the consumer pay at the pharmacy counter. They also determine if your drug is covered, if it's not covered, then they also will determine if there's a copay differential from using a mail-order pharmacy or a pharmacy that they also happen to own.

In essence, they control the transaction from A to Z. If your drug’s not covered, if your copay is expensive, if you're forced to use the mail order; that's all the pharmacy benefit manager. Often, I will say, our patients choose us. Our patients choose their doctors. They often will choose their health insurance company but what they don't get a chance to choose is their pharmacy benefit manager because it's always just wrapped into the plan. Patients, they don't have a choice. If it's getting their prescription covered with their insurance, they're going to use the card that's in their wallet, and it's just not fair that they have no visibility to the behind-the-scenes part.

Drug Topics: Was there a specific event that brought PBM practices to light?

Tom DePietro: One of the things I often get asked is, “Doesn't it feel kind of empty to just keep advocating for something but nobody hears it?” For, I would say, the past 10 years—so I've opened my own pharmacy 12 years—but 2 years into it is probably when I got really accustomed to be like “What is going on?” and “How is this even legal [or] ethical?” I think as more owners become educated, and I would just say every year I often think to myself, well, it can't get any worse than it currently is. But somehow the insurance contracts get worse. And I think over time, pharmacists have just gotten a little bit louder, almost to the point where we used to be fearful to talk about it because we didn't want to violate one of their arbitrary contract clauses. But at this point, I don't think we have anything to lose.

I just think the rubber is meeting the road. We're either going to get change from the federal government or we're not going to get change and then most of these independent pharmacies are going to be out of business. I talk to pharmacies [around] the country on a weekly basis and we know what it means if we go out of business for our patients. We're serving a different clientele that really needs our services. I just think the evolution of the contracts somehow getting worse every year [and] less pharmacists [are] around, and there’s just more of us that are outspoken because we know what's at stake here.

And I do think advocacy takes a while. For the past 10 years, I felt like I was talking to a wall, but then suddenly it just seemed, “Wow, now we have some traction here.” I’ve built relationships with my state representatives, state senators, and then federal officials. But for the longest time, I think we were telling the wrong story. I think we were telling a story of like we're getting paid under cost. So, we buy the drug for X and we're getting paid less than that. But I think the story that needed to be told is “How does it impact the consumer?” I think we're doing a good job of that from a national standpoint. We have great groups. NCPA is doing a great job advocating for us. State associations are doing a great job advocating for us. I think advocacy takes time, energy, effort, [and], unfortunately, money.

I think our country is yearning for this personal touch and we're getting farther and farther away from it in all aspects, not just the pharmacy industry. [If] you look at health care, our hospital systems locally, they just keep getting bought out by bigger companies, but then the service is not there. I finally think we have consumers frustrated; we have legislators frustrated. Not sure if you had the opportunity to watch the Congress Oversight Committee hearing, but we had bipartisan support of frustrations when they were talking with the 3 executives for these PBMs. Consumers are frustrated and I just think it has hit a head.

READ MORE: New Report Scrutinizes PBM Spread Pricing Practice

Stay tuned for more content from our interview series with Tom DePietro.

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