WNY providers, pharmacies brace for Medicaid shift

Thu, 20 Apr 2023 20:32:00 GMT

Concern over funds for safety-net sites

BY JON HARRIS
Mar 1, 2023
Mar 1, 2023
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Pharmacist Kazeem Azeez fills orders for patients in the pharmacy at the Jericho Road Community Health facility, one of the organizations that could see its budget impacted by a looming Medicaid shift.

Derek Gee/News file photo

BY JON HARRIS

BUFFALO NEXT: HEALTHCARE

There's a high-stakes battle ongoing in Albany as New York prepares to implement a long planned, cost-saving overhaul of its Medicaid pharmacy benefit program.

On one side, independent pharmacists are pushing for the transition to go through as planned April 1 – a change that would come with the state paying higher dispensing fees that would provide a boost to small pharmacies often stuck filling prescriptions at a financial loss under the current system.

But on the other side is a politically connected contingent of safety-net health care providers, opposed to the transition because it will disrupt their access to hundreds of millions of dollars from a federal program that props up money-losing, but crucial, services such as behavioral health.

In Western New York alone, it could threaten about $30 million in annual revenue across the area's health centers such as Evergreen Health, Community Health Center of Buffalo and Neighborhood Health Center.

How it all shakes out over the next month will affect how some 7.7 million Medicaid members across the state access their pharmacy benefits.

Aside from saving money, the state argues this planned shift of the pharmacy benefit program out of managed care and back to a fee-for-service model has the potential to boost access for members, align coverage and improve transparency.

Critics are skeptical the state will save much money and also believe it could further fragment the health care system.

This controversial carve out was originally planned under Gov. Andrew M. Cuomo, but the implementation was delayed two years ago when similar concerns were raised.

That delay is now coming to an end, and the battle over the carve-out is picking up steam as crunch time approaches.

Sen. Gustavo Rivera, chair of the Senate Health Committee, late last week introduced legislation that would block the transition due to the "unintentional harm" it would cause to certain safety-net providers.

The bill also claims it would maintain protections for pharmacy operations, though the Pharmacists Society of the State of New York said Rivera's legislation would lead to them taking a cut in payment while other providers are made whole.

More developments are likely in the month ahead, with one-house budgets due to be unveiled in a couple of weeks and the state budget deadline looming April 1 – the same day the carve-out is scheduled to take effect.

A necessary 'side hustle'

The reason the planned carve-out is controversial with certain safety net health care providers is because it would hinder their ability to access revenue from the federal 340B program, which started three decades ago as a way for safety-net providers to stretch federal resources as far as possible to serve more patients.

In the program, manufacturers participating in Medicaid provide drugs at steep discounts to covered providers that serve vulnerable communities. The provider, often a hospital or clinic, then bills the retail cost of those drugs to the health plan, allowed to keep the difference between the discounted price and the reimbursed retail price. They then use that money to expand programming, bring in new services and cover gaps in care.

The planned carve-out would take those benefits and redirect them to the state. The state, in turn, has promised to create pots of funds to make the affected providers financially whole, though clinics have doubts about the state's ability to do that in a timely manner.

The funding is important to safety-net providers. Buffalo-based Ever green Health counts on 340B to bring in about $14 million, or about 12%, of its annual $120 million budget.

"This is $14 million of flexible resources that we can use because we're not getting enough reimbursement," Lee said. " The reality is this program helps prop up primary care, behavioral health, transportation, nutrition, dental, housing."

And that's really what the 340B program does, Lee said. It helps organizations such as Evergreen fill budget holes and fund services that are not sufficiently reimbursed.

Without 340B, local federal qualified health centers are "looking at a fiscal cliff," he said.

That is certainly true at Neighborhood Health Center, which has six sites across Western New York and treats about 29,000 people a year on a $40 million annual budget.

It countson340Bformore than$3.5 million, or about 9%, of its budget, noted President and CEO Joanne Haefner.

"The 340B reinvestment is a side hustle that primary care providers have to do because primary care doesn't get paid well enough in New York State," she said.

Several of Neighborhood Health Center's departments struggle to sustain themselves. The 340B dollars have helped support the organization's behavioral health, dental and obstetrics and gynecology departments, Haefner said.

If the carve-out does go through, Haefner said Neighborhood Health Center plans to live off its savings for awhile as it waits for the state's promised payments to make community health centers whole.

But, she cautioned, "I don't have a year and a half of reserves to keep our organization the same size that it is right now."

The state's rationale

Amir Bassiri, the state's Medicaid director, said there are four main reasons for the long-planned transition of the Medicaid pharmacy benefit program from managed care to the fee for-service model, called NYRx.

For one, he said, NYRx should improve alignment and coverage. It would have one list of prescription drugs covered by a plan. That would create more consistency, since each managed care plan currently has its own formulary, Bassiri said.

Second, he believes the transition would boost access for the state's 7.7 million Medicaid members since NYRx has a statewide network of more than 5,000 enrolled pharmacies.

The transition also would give the Medicaid program enhanced purchasing power, with the state negotiating with drug manufacturers for additional savings, Bassiri said.

Last, he said the switch would "inject transparency and program integrity into the Medicaid pharmacy program." One longstanding concern, Bassiri noted, is over intermediaries such as pharmacy benefit managers (PBMs) that have siphoned money from the program. He cited a lawsuit last summer by Attorney General Letitia James against CVS Health Corp., which alleged CVS required New York safety-net hospitals and clinics to exclusively use a CVS-owned company, Well partner, to process and obtain federal subsidies on prescriptions filled at CVS pharmacies.

"What we've seen is that the intermediaries who are not delivering services to Medicaid members – the PBMs, the third-party administrators – have increasingly perpetuated the rapid growth of the program as well as diverted the funding intended for safety-net providers away from them," Bassiri said. "And this has been documented both in New York and around the country, especially recently."

Given that, Bassiri said the state's plan to give money back to the safety net providers to account for their 340B losses is a "far more efficient and direct way to reimburse those providers." For the hospitals that would be affected, the state is planning a 5% increase in Medicaid reimbursement rates.

"We are very committed to ensuring that the providers are held harmless in every way possible," Bassiri said. "Our priority is ensuring that there's no disruption to the services in these communities, and we believe that the reinvestment should mitigate any risk to that occurring."

Independent pharmacies

One group hoping the transition to NYRx goes through as planned is the Pharmacists Society of the State of New York.

At least one reason is because the state will pay higher dispensing fees to pharmacies than what they are getting out of the managed care companies. Under the current Medicaid managed care model, the Pharmacists Society notes, pharmacies are paid a rate that often has them filling prescriptions at a financial loss.

Brad Arthur, pharmacist and owner of Black Rock Pharmacy in Buffalo, also believes the transition could be good for Medicaid members by putting their pharmacy benefit on one formulary, establishing consistency.

With all the different formularies under managed care, Arthur said it's often up to the pharmacy at the point of sale to help the members understand what drugs are covered.

"It's very confusing for patients," he said. "And oftentimes, the only opportunity is to navigate that while they're standing there in the pharmacy."

Arthur understands why safety-net providers are upset about the planned carve-out, noting those providers are doing valuable work and expanding services for vulnerable populations. But he's also seen up close the funds that managed care entities have extracted from the system and knows more transparency is needed.

"I understand why these entities are up in arms because it's a lot of money, and their budgets are dependent upon these funds in order to continue to provide services," he said. "And I don't begrudge them for that. I just wish the government would come up with a better way of doing it."

Health

Insurance

April 1, 2023

Albany, NY

Governor Hochul Launches New Statewide Medicaid Pharmacy Benefit Program

Long-Awaited Transition to NYRx Provides Eight Million Members Expanded Access to Prescription Medications at More Than 5,000 Pharmacies Statewide

Change Invests $705 Million in Medicaid Funding Directly to 340b providers, including Ryan White HIV/AIDS programs, Federally Qualified Health Centers and Hospitals

Governor Kathy Hochul today launched NYRx, the state's new pharmacy benefit program, which will improve prescription drug access and coverage for the eight million New Yorkers enrolled in Medicaid statewide. The long-awaited transition will enable Medicaid recipients to access more prescription medications with fewer restrictions, reduce confusion over the brand-name and generic drugs covered by the program, and create the largest pharmacy network in New York State.

"The transition to NYRx today is in the best interest of those New Yorkers relying on Medicaid for affordable prescription medication," Governor Hochul said. "In addition to expanding coverage and access through this program, we are also committing hundreds of millions of additional Medicaid dollars to reinvest in critical providers, including Ryan White programs and Federally Qualified Health Centers, to ensure this change is seamless and has positive impacts across our state."

Under the NYRx model, New York State's Medicaid program will pay pharmacy costs directly, eliminating the need for managed care organizations to administer this benefit through pharmacy benefit managers. The new process creates transparency in reimbursements to pharmacies, leverages the state's purchasing power to negotiate with drug manufacturers, and streamlines administration for practitioners.

NYRx also improves coverage for Medicaid recipients by opening access to a statewide network of more than 5,000 pharmacies. In addition, the change establishes one comprehensive list of the brand-name and generic medications covered under the program, including all FDA-approved medications, which will broaden prescription drugs coverage for Medicaid recipients.

Additionally, NYRx will streamline the process for practitioners. Instead of working through varying rules and limitations for coverage under managed care organizations, pharmacists and physicians will be able to prescribe medication based on a uniform list that is less restrictive and governed by an independent public board of experts.

Acting Health Commissioner Dr. James McDonald said, "Today's shift back to a fee-for-service pharmacy benefit model is the right move for New York and ensures all communities across the state will have continued access to low-cost prescription medications. I thank Governor Hochul for her continued commitment as a champion of New York's diverse communities and fully support her proposal to add $705 million in the FY 2024 budget to provide the state's non-profit organizations and hospitals —including Ryan White centers that serve patients enrolled in HIV/AIDS programs —with the funding they need to continue offering essential services to some of the state's most vulnerable populations."

New York State Medicaid Director Amir Bassiri said, "The eight million New Yorkers enrolled in Medicaid will receive their same prescription medications, only from a larger network of pharmacies at no extra cost and with fewer restrictions and less confusion than before. With this transition, our Medicaid program will now pay all pharmacies directly rather than relying on corporate middlemen who do not always act in ways that that align with the interests of Medicaid members. This will create both transparency and efficiency that will work to the benefit our members and ensure access to patient-centered, high-quality health care."

Bassiri reiterated the patient-centered benefits of the transition in an opinion piece published this week in the Buffalo News. The transition is also supported by pharmacological organizations and various health care providers, including the state's largest Federally Qualified Health Center.

In anticipation of NYRx being implemented, Governor Hochul committed $705 million in Medicaid dollars in her FY 2024 budget to ensure 340b health care providers that received critical funding through their pharmacy programs aren't negatively impacted by the transition. Of the $705 million, the budget reinvests $30 million in state Medicaid funding to Ryan White HIV/AIDS programs, $250 million in state and federal Medicaid funding into Federally Qualified Health Centers, and $425 million in state and federal Medicaid funding into hospitals.

Initially adopted in 2020 in the FY 2021 Budget, the transition will also help address New York State's rapid growth in Medicaid pharmacy costs, which has been driven primarily by pharmacy benefit managers and other intermediaries in the prescription medication supply chain. The transition was delayed by the FY 2022 Budget, which pushed implementation until today, April 1, 2023.

Medicaid recipients or others with questions or in need of assistance with NYRx may visit the program's website, email [email protected] or contact the Medicaid Helpline at 1-855-648-1909 or TTY 1-800-662-1220. The Helpline is available 8 a.m. to 8 p.m. Monday through Friday, and 9 a.m. to 1 p.m. on Saturday.

The state Department of Health also prepared a fact sheet available in multiple languages for consumers answering basic questions about the transition. Additional information is available at the on the eMedNY website.

State Senator James Skoufis said, "Under NYRx, our taxpayers, providers, and independent pharmacies will finally receive the Medicaid network they've long deserved. The previous system was financially unsustainable and inherently unjust to our healthcare professionals on our community's front lines - and the savings generated by this new carveout will be directly reinvested into our hospitals and health centers to ensure the strongest possible transition. This move is a win for everyone involved except the drug company middlemen who will no longer be able to rip off the state's taxpayers, patients, and providers. My thanks to Governor Hochul for her leadership on this important issue."

Pharmacists Society of the State of New York President Heather Ferrarese said, "PSSNY is proud to join with fellow pharmacists in recognizing and rejecting efforts to undermine NYRx. The shift to NYRx today will greatly enhance patient access to lifesaving medications and other pharmacy services in both rural and urban areas across the state. It will increase transparency, and Medicaid patients will have one expansive drug formulary and access to one of the largest pharmacy networks in the country so they can use their pharmacy of choice. For New York's eight million Medicaid patients, NYRx is the right prescription to meet their pharmacy care needs."

Community Pharmacy Association of New York State President Michael Duteau said, "We commend Governor Hochul and the state Legislature for this lifesaving reform to expand access and quality of pharmacy care for all with Medicaid. Patients will no longer be forced to follow restrictive pharmacy network requirements set by pharmacy benefits managers and will have one consistent statewide drug formulary which covers 100 percent of FDA-approved medications. This will improve care for New Yorkers in underserved communities with HIV, Hepatitis C, diabetes, asthma, mental health and substance use disorders and other serious and chronic conditions."

Sun River Health Chief Financial Officer James Sinkoff said, "New York State's NYRx program achieves many of the goals of the 340b program. Importantly, the patient-physician relationship will go unimpeded under this new program. Sun River Health thanks Governor Hochul for recognizing the need to sustain essential resources to assure patients can continue to receive high quality, affordable healthcare without interruption."

Refuah Health CEO Chanie Sternberg said, "Over the past several years, New York State has faced unprecedented challenges in delivering high-quality health care and ensuring access to services for those who need it most. While there are still many barriers that need to be addressed as we work together to achieve health equity, today we would like to take the opportunity thank the Governor's office for their support and taking crucial steps to ensure continuity of care and access to services for medically vulnerable and underserved New Yorkers."

New York State Academy of Family Physicians Dr. Andrew Symons said, "On behalf of our 6,000 family physician members across the State, we applaud Governor Kathy Hochul and State Legislators for expanding patient access to pharmacy care under Medicaid on April 1st. This critical policy, known as NYRx, will provide one formulary covering all FDA-approved medications, provide one set of rules for prescribers to follow to get needed coverage for patients and provide better access to lifesaving therapies for Medicaid patients. We commend their leadership in making this transformative step toward improving health care overall in New York State."

ACCESS TO COVID-19 TESTING AT MORE THAN 50 NY PHARMACIES IN COLLABORATION WITH CPESN NY

Wed, 22 Jul 2020 12:10:58 GMT

ENZO BIOCHEM TO PROVIDE ACCESS TO COVID-19 TESTING AT MORE THAN 50 NY PHARMACIES IN COLLABORATION WITH CPESN NY

NEW YORK, NY, July 21, 2020 – Enzo Biochem, Inc. (NYSE:ENZ), a leading biosciences and diagnostic company, and Community Pharmacy Enhanced Services Network (CPESN® NY), the New York division of the clinically integrated, nationwide organization of pharmacy networks, announced today they are partnering to provide COVID-19 testing at 52 of the network’s 155 pharmacies across New York State. This initial pilot was made possible in strong collaboration with Pharmacists’ Society of the State of New York (PSSNY).

“This program aligns with our goal to promote the strong relationship between independent pharmacies and patients in their communities by addressing needs related to COVID-19 testing, one of the most important health challenges in a generation,” said CPESN Facilitator Chris Daly. “This program will bring easy access to testing to more New Yorkers through a health resource that they know and trust, with the ability to provide faster turnaround times and results.”

“Enzo is providing effective testing solutions for many schools and other institutions through our School and Institution Testing (“SIT”) Program, and to New York based nursing homes through a collaboration with the State of New York. This new testing program with independent pharmacies is the next step in our goal to being the leading provider of easy-access testing products and services throughout our region,” said Barry Weiner, President of Enzo. “As this pandemic continues to escalate, even in areas where we have made positive progress, large-scale testing is a critical component of keeping people safe and informed and stopping the spread of COVID-19.”

Through this program, the Enzo Center of Excellence will provide the high-level products and services to support effective testing in locations across the State. Relying on over 40 years of research and manufacturing expertise, Enzo’s emergency use authorized (EUA) AMPIPROBE® SARS-CoV-2 swab molecular test is manufactured at its Farmingdale, New York GMP facility with state of the art technology for use in Enzo’s own CLIA-certified (high complexity) clinical laboratory and distribution to other authorized clinical laboratories.

Through this program, NY residents will have access to testing at participating independent pharmacies beginning immediately. Enzo provides the full range of services to support rapid and accurate testing, including reagent manufacturing capabilities, proprietary diagnostic instruments, and clinical laboratory services. Results from the swab test should be provided within two to three days from sample collection. Patients will also have access to guidance and information from the leading independent pharmacies participating in this program. Enzo Clinical Labs is a New York State Department of Health-regulated, full-service clinical reference laboratory serving the needs of patients and other clinical laboratories in the region.

Enzo diagnostic and laboratory services are backed by extensive data and research. A white paper titled “Enzo’s Emergency Use Authorized AMPIPROBE® SARS-CoV-2 Test System” is currently available on the ENZO website at https://www.enzo.com/coronavirus, along with two previously published white papers detailing Enzo’s COVID-19 Product and Platform.

About Enzo Biochem

Enzo Biochem is a pioneer in molecular diagnostics, leading the convergence of clinical laboratories, life sciences and intellectual property through the development of unique diagnostic platform technologies that provide numerous advantages over previous standards. A global company, Enzo Biochem utilizes cross-functional teams to develop and deploy products, systems and services that meet the ever-changing and rapidly growing needs of health care today and into the future. Underpinning Enzo Biochem’s products and technologies is a broad and deep intellectual property portfolio, with patent coverage across a number of key enabling technologies.

About CPESN® USA

CPESN® USA a clinically integrated, nationwide organization of pharmacy networks structured to advance community-based pharmacy practice. They empower community-based pharmacies that are deeply rooted within their community by fostering their ability to provide high quality, patient-centered enhanced services. CPESN® pharmacies integrate with the other providers on the patient’s care team and coordinate medical treatment, which has led to better medication adherence, higher patient satisfaction, and lower healthcare costs. You can now find CPESN® Networks of pharmacy providers in 45 states across America. To learn more, please visit http://www.cpesn.com/.

About PSSNY

The Pharmacists Society of the State of New York (PSSNY), a not-for-profit incorporated society, represents pharmacists in all practice settings and is the largest pharmacy association in New York State. In addition to legislative advocacy, PSSNY provides pharmacists, pharmacy owners, students and faculty with educational programming, interprofessional collaboration and a statewide voice for professional and practice matters. A membership organization founded in 1879, PSSNY has a diverse and active membership, and opportunities for corporate and community involvement.

Forward-Looking Statements

Except for historical information, the matters discussed in this release may be considered "forward-looking" statements within the meaning of Section 27A of the Securities Act of 1933, as amended and Section 21E of the Securities Exchange Act of 1934, as amended. Such statements include declarations regarding the intent, belief or current expectations of the Company and its management, including those related to cash flow, gross margins, revenues, and expenses which are dependent on a number of factors outside of the control of the Company including, inter alia, the markets for the Company’s products and services, costs of goods and services, other expenses, government regulations, litigation, and general business conditions. See Risk Factors in the Company’s Form 10-K for the fiscal year ended July 31, 2019. Investors are cautioned that any such forward-looking statements are not guarantees of future performance and involve a number of risks and uncertainties that could materially affect actual results. The Company disclaims any obligations to update any forward-looking statement as a result of developments occurring after the date of this release.

###

Contact:

For: Enzo Biochem, Inc.

David Bench, CFO
212-583-0100
dbench@enzo.com

For CPESN NY, LLC

Chris Daly, Network Facilitator, CPESN NY, LLC
cdaly@cpesn.com

Media:

Lynn Granito
Berry & Company Public Relations
973-818-3732
lgranito@berrypr.com

Investors/Media:

Melanie Solomon
The Blueshirt Group
415-217-4964
melanie@blueshirtgroup.com

Steve Anreder
Anreder & Company
212-532-3232
Steven.anreder@anreder.com

Pharmacists, patients rally at NY State Capitol to fix Rx distribution system

Thu, 5 Mar 2020 15:26:53 GMT

Chain Drug Review

NEW YORK — Hundreds of pharmacists dressed in white lab coats, together with patients and elected officials rallied at the State Capitol in Albany to support new proposed regulations on prescription drug middlemen known as PBMs. The legislation (A9902/ S7828), if enacted in the upcoming New York State Budget, will ensure critical protections for patients, taxpayers and community pharmacies.

The calls to regulate prescription drug middlemen persist as PBMs continue to draw scrutiny for rigging drug prices, eliminating patient choice, ripping off taxpayers and destroying community pharmacies.

“New Yorkers can’t wait,” said Steve Moore, president of the Pharmacists Society of the State of New York (PSSNY). “Enacting the proposed legislation (A9902/ S7828) as part of the New York State Budget is the most expeditious way to ensure critical protections for patients, taxpayers and pharmacies, and to end the indefensible abuse by prescription drug middlemen.” Read more

Can Independent Pharmacies Survive?

Sat, 7 Dec 2019 13:39:36 GMT

Independent pharmacies say they’re being squeezed to the brink of closing by the sharp rise in prescription drug prices. We’ll discuss how pharmacy benefit managers affect the flow of customers to big and small drugstores, with guests:

David Reich-Hale, business of health care reporter, Newsday
Christopher Hoffman, reporter, Connecticut Health I-Team
Bob Grisnik, Pharm.D., pharmacist and owner, Southrifty Drugs
Alok Bhatt, R.Ph., pharmacist, and Charul Bhatt, owners, Trumbull Pharmacy
Janice D'Angelo, owner, Sag Harbor Pharmacy
Steve Moore, Pharm.D., owner, Condo Pharmacy, and board president, Pharmacists Society of the State of New York
Nathan Tinker, Ph.D., CEO, Connecticut Pharmacists Association

Listen to the interview

Urge Governor Cuomo to sign PBM Licensure bill S6531 into Law!

Tue, 6 Aug 2019 13:56:30 GMT

This is PSSNY's first Call to Action for PSSNY members to write to the Governor about the PBM bill. S6531 is one of many bills that have passed both houses and have not yet gone to his desk. Please take this opportunity to tell the Governor why licensing PBMs is urgently needed. Your messages are an important part of PSSNY's ongoing campaign to raise public awareness and get a law on the books in New York. The Society is actively monitoring developments and will keep members informed.

New York legislators passed the strongest PBM licensing bill in the country according to policy analysts who track activity in state capitols. S6531 was a clear legislative win. Soon the bill will be on Governor Cuomo's desk and he will decide whether to sign it into law. This is where every pharmacist's voice is important.

The opposition is formidable, but so are we. It's time to step up!

Pharmacists must be active and visible in this effort. YOU need to tell the Governor why this bill is so urgently needed. YOU need to bear witness to what you see and what you know about the harm caused every day by these unregulated behemoths.

What the PBM licensing bill S6531 does:

Places PBMs directly under the NYS Departments of Health and Financial Services for registration, licensure and regulation;
Specifically prohibits conflicts of interest as well as deceptive and anti-competitive practices;
Prohibits PBMs from requiring additional pharmacy accreditations and certifications more stringent than or in addition to federal and state requirements for licensure as a pharmacy;
Gives patients and pharmacies legal relief for any injury or loss;
Specifies that PBMs have a duty to perform with care, skill, prudence, diligence and professionalism and "for the best interests primarily of the covered individual, and the health plan or provider;"
Compels PBM disclosures to NYS agencies under penalty of perjury;
Requires PBMs to fully account to payers for rebates, clawbacks, fees, chargebacks and pharmacy reimbursement; and
Requires PBMs to disclose terms of contracts including pharmacy dispensing fees.

Once signed, the new law would take effect within 90 days. Read the bill S6531/A2836 here

The Governor's office limits electronic messages to 100 characters or less sent from platforms such as PSSNY's Voter Voice. Click here to send this short message to the Governor: Save local pharmacies. Sign S6531.

If you wish to send a longer, more detailed message, click here to download a sample or compose your own. Send an email to Gov.Cuomo@chamber.state.ny.us or letters to:

The Honorable Andrew M. Cuomo

Governor of New York State

NYS State Capitol Building

Albany, NY 12224

PSSNY Applauds NYS Legislature for Passing the Nation's Toughest Bill to Regulating PBM Middlemen

Fri, 21 Jun 2019 17:38:34 GMT

S6531 and A2836-A Sets New Standards for PBM Transparency, Requires Pharmacy Benefit Managers to be Fair in Their Dealings with Patients, Health Plans, and Pharmacies

ALBANY, NY (June 21, 2019) – The Pharmacists Society of the State of New York (PSSNY) applauds the New York State Legislature for passage of legislation aimed at reining in pharmacy benefit manager (PBM) “middlemen”, widely seen to be the toughest bill passed to date in the U.S. regulating PBMs.

“We thank the members of the New York State Legislature for passing these bills, the leadership of Speaker Heastie and Senate Leader Stewart-Cousins, as well as Health and Insurance Committee Chairs Senators Breslin and Rivera and Assembly Members Gottfried and Cahill, who took the time to understand the issues and act in the best interest of New York’s patients, consumers, tax payers and healthcare providers,” said Debbi Barber, PSSNY President. “Today’s victory is a testament to the power of communities coming together to work for the greater good, and an acknowledgement of years of effort that will ultimately result in a better, healthier New York. We look forward to working with Governor Cuomo so New York can lead the way in regulating PBMs and protecting patients.”

The new legislation would require PBMs to act in the best interests of covered individuals and health plans and to be more transparent in dealings with payers by disclosing more information to them, including:

Discounts, rebates, clawbacks, chargebacks or fees PBMs receive on behalf of or in service to the health plan. Under the new law, PBMs would be required to pass rebates, discounts and other savings on to the health plan.

Details of “spread pricing” - the difference between the amount PBMs reimburse pharmacies and the amount billed the health plan - contained within the health plan.

Conflicts of interest that may affect the health plan. In the past, PBMs have included “gag clauses” contractually mandating pharmacists to remain silent when less expensive medications are available, and engaged in patient-steering and self-dealing to PBM-owned pharmacies -- activities which directly influence PBM profitability but are in conflict with the best interest of health plans and their enrollees. The new law would prohibit any such conflicting or anticompetitive practices, ensuring patients and their pharmacy providers are afforded a fair and equitable environment in which to receive or deliver care.

Other provisions under the new law would include authorization of the Department of Financial Services to license and regulate pharmacy benefit managers, and provision of rights for individuals and pharmacies to sue a PBM for harm resulting from a PBM policy or decision.

The bills were introduced within two weeks of the Senate Investigations and Government Operations Committee Releases Full Report on Pharmacy Benefit Managers by the Senate Investigations and Government Operations Committee, chaired by Senator James Skoufis. The Committee’s 69-page report listed several findings underscoring the need for immediate PBM reform in the State of New York.

The Pharmacists Society of the State of New York (PSSNY) has served as the society for the state’s pharmacists for more than 138 years providing advocacy and resources to pharmacists to improve patient care. To learn more about PSSNY, visit www.PSSNY.org.

PSSNY Commends Senators James Skoufis & Senate Committee on Investigations on PBMs

Thu, 6 Jun 2019 23:11:55 GMT

PSSNY Commends Senators James Skoufis and Senate Committee on Investigations and Government Operations for their Pharmacy Benefit Managers Investigative Report

The Pharmacists Society of the State of New York (PSSNY) would like to thank Senator James Skoufis, Chair of the Senate Committee on Investigations & Government Operations, and all of the Committee members and Staff for their work leading to the publication of a report detailing the practices of Pharmacy Benefit Managers (PBMs) in New York State. The report, titled Senate Investigations and Government Operations Committee Releases Full Report on Pharmacy Benefit Managers, confirms PSSNY’s long held position that the practices of the PBM industry are not in the best interests of New York taxpayers, pharmacies or most importantly, patients. Rather, PBMs operate as the only unlicensed and unregulated entities in health care and take advantage of a lack of oversight, accountability, and transparency to act in their own self interests. Read more

States Should Follow New York’s Lead to Rein In PBMs

Wed, 5 Jun 2019 21:26:14 GMT

Morning Consult

By Steve Moore

Earlier this spring, Gov. Andrew Cuomo (D) and the New York State Legislature took an important first step toward eliminating a particularly insidious tactic pharmacy benefit managers use to generate outsized profits for themselves. Effective immediately, Medicaid spread pricing — the practice of retaining any amounts billed to the state in excess of what is reimbursed back to the pharmacy — is illegal.

PBMs defend their spread pricing tactics, of course, saying there’s nothing inherently wrong or even illegal about marking up the cost of goods sold. But the type of spread pricing New Yorkers, and indeed all Americans covered by Medicaid, Medicare or almost any commercial health plan, have been exposed to is above and beyond what’s appropriate “markup” for services rendered — as much as $300 million or more, according to a study the Pharmacists Society for the State of New York commissioned late last year.

At a time when drug prices are so high the nation’s most vulnerable patients are making choices that include rationing medications or skipping filling prescriptions altogether, the question we asked in New York was “how much profit is enough?” New York’s anti-spread pricing law was accomplished by examining data and recognizing that exorbitant spread pricing was costing the state’s Medicaid millions of unnecessary dollars each year. This is money that was not going to help patients but straight into PBM coffers.

New York isn’t alone in looking at the high prices that PBMs exact on Medicaid. Ohio, Texas, Illinois, Arkansas, Kentucky and West Virginia are also investigating the pricey impact PBMs may be having on their Medicaid programs.

PBM executives were recently in Washington in front of a Senate panel answering questions about their role in rising prescription drug costs, and the issue of spread pricing was front and center. Sen. Ron Wyden (D-Ore.) hit the nail on the head when he referred to spread pricing as “plain old price gouging.” We couldn’t agree more and urge Congress to continue to take a hard look at how spread pricing affects patients and taxpayers.

How have we gotten here? Until very recently, PBMs — the middlemen who design the prescription drug benefit plans, process claims and promise health plan sponsors medication cost “savings” for their participants by negotiating with drug manufacturers — operated with very little regulation.

Now states are becoming wise to the tactics PBMs use to profit at nearly every stage of the chain between drugmaker and pharmacy counter. This could mean patients and taxpayers seeing some relief as long as other states follow New York’s lead.

Early estimates are that New York could save at least $43 million a year under the new law. Based on what we see behind the pharmacy counter every day, pharmacists believe it could be far more. Either way, this was a smart move by New York, one we hope other states will take steps to enact, too.

There are myriad ways PBMs create shareholder value for private corporate conglomerates, resulting in billions of dollars not going toward lowering health care costs. Though they loudly protest otherwise, it is the PBM industry that needs continued critical examination — and stricter regulation.

States don’t typically get a lot of praise when passing their budgets these days, but in the case of New York, patients, and all of us who pay for health care, should be giving Cuomo and the New York General Assembly a round of applause.

Steve Moore is a pharmacy owner and president-elect of the Pharmacists Society for the State of New York.

Drug Middlemen Got Hefty Markup in New York, Pharmacy Group Says

Thu, 24 Jan 2019 16:49:34 GMT

Pharmacy-benefit managers are taking increasingly large markups on generic drugs in New York, according to an analysis of Medicaid prescriptions at independent pharmacies in the state.

In Medicaid, private insurers are paid by the state to cover low-income citizens. The insurers in turn usually contract with pharmacy-benefit managers, or PBMs, paying them to provide drug coverage. PBMs run by CVS Health Corp., Cigna Corp. and UnitedHealth Group Inc. then bill insurers for coverage, and reimburse pharmacies for drugs.

For years, small pharmacy owners have been complaining that PBMs have been shortchanging them, cutting to unsustainable amounts the reimbursement they get for dispensing prescriptions to millions of Americans. Drugstores have also claimed that PBMs are charging larger per-prescription amounts to their insurer and employer clients -- and sometimes pocketing the difference.

A Bloomberg analysis this year of 90 frequently prescribed generic drugs in Medicaid managed-care plans in 31 states found wide variations in reimbursement and drug cost from state to state. In some states, Medicaid plans appear to be getting a good deal, Bloomberg reported earlier this year. In others, plans pay markups of threefold or more on some treatments, the Bloomberg analysis found. But Bloomberg’s analysis couldn’t tell how much of the markup was going to PBMs and other middlemen, versus how much was going to pharmacies.

Pharmacist Study

The new analysis sponsored by the Pharmacists Society of the State of New York is one of the first efforts to quantify that spread in private Medicaid plans that cover about 4.3 million New York state residents. The state society has been a critic of the PBM industry and represents pharmacy owners upset over declining reimbursements.

In 2017, PBMs paid independent New York pharmacies in the analysis an average of $10.85 per generic-drug prescription. Private health plans that provide state-financed Medicaid coverage reported a cost of $14.34 per prescription. That represents a markup of 32 percent over what pharmacies were paid. The markups by PBMs more than doubled from 2016, according to the analysis.

Drug costs have become a major national issue for patients and politicians. Along with scrutiny of pharmaceutical companies that manufacture drugs, distributors, insurance companies and middlemen like PBMs have attracted attention for their role in health costs. State officials, in particular, have looked at how PBMs function in Medicaid, which relies on getting low prices to cover as many low-income people as possible.

Middlemen “are taking an increasing share of the margin on generic drugs” in New York, said Eric Pachman, a consultant at 3 Axis Advisors and former pharmacy executive who conducted the study. While PBMs often keep the spread on generic drugs, the analysis can’t rule out that some of the spread was shared by PBMs with their health plans clients, Pachman said.

PBMs, including CVS’s Caremark unit and Cigna’s Express Scripts unit, have said that spread pricing adds stability and predictability to drug costs for their clients. Health plans freely choose the spread arrangements over other fee-based options, they have said.

Read full article.

PSSNY Files Joint Motion with PUTT to Intervene in December 18th CVS-Aetna Hearing

Sun, 16 Dec 2018 23:21:50 GMT

ALBANY, NY (December 14, 2018) -- Today the Pharmacists Society of the State of New York (PSSNY) jointly filed a motion with Pharmacists United for Truth and Transparency (PUTT) with U.S. District Court Richard Leon to intervene in the CVS-Aetna merger with the intention of attempting to prevent the two organizations from further integrating while the Court determines the merger’s potentially harmful effect on consumers and smaller competitors.

“With Judge Leon’s resistance to being treated as a ‘rubber stamp’ in the process, we see an opportunity to take a chance to tell our side of the story on how this merger will truly play out if allowed to proceed,” said Roxanne Richardson, PSSNY chair. “CVS has shown a precedent for making big promises then failing to follow through. The result is consumers pay more, but service and quality suffer. Past behavior is a good indicator of future behavior. We cannot stand by and let the ill effects of previous CVS acquisitions be ignored.”

PSSNY and PUTT have been outspoken advocates against the merger, and join the Medical Society of the State of New York (MSSNY), the American Medical Association, as well as numerous consumer and trade association organizations opposing the merger. Since announcing the acquisition a year ago, PSSNY, PUTT, MSSNY - even the New York Department of Financial Services have pointed to the loss of one more choice for consumers and decreased access to local their local providers as reasons to block the merger. Additionally, all organizations have addressed the dangers the merger of the nation’s largest pharmacy retailer and third-largest health insurer presents to smaller healthcare providers to maintain access to, and care of, their patients.

“Every day community pharmacists struggle to provide the best service and lowest prices to consumers, often times facing coercive and exclusionary conduct by CVS’ PBM Caremark,” said PSSNY President Debbi Barber. “Permitting this merger will almost certainly continue past precedent, with CVS finding new ways of denying consumers access to the healthcare professionals they value.”

To comply with federal requirements to complete the merger, Aetna sold its Medicare Part D business to WellCare Health Plans, Inc. What was not reported is that Wellcare, who purchased Aetna’s business at a ‘fire sale’ price, contracts with CVS Caremark to administer the Medicare Part D portion of its business. CVS Caremark is owned by CVS Health and as such, renders the point of the spin-off useless - a primary cornerstone of the argument PUTT and PSSNY are making as part of today’s filing.

“The Department of Justice (DOJ) claims the only competitive problem is in the Medicare Part D market. But even their proposed remedy is a ‘pig in a poke’ solution that won’t benefit consumers,” said David Balto, the attorney representing consumers groups who are also filing a motion to intervene in the December 18 hearing. “Spinning off a Part D business is notoriously difficult and the half-a-loaf solution is doomed to failure. Wellcare, the hand-picked acquirer of the assets, will have to more than double in size to succeed. It has failed to pull off much smaller acquisitions. DOJ’s light handed acceptance of a weak buyer at a fire sale price is contrary to sound antitrust policy and the DOJ’s actions in blocking the Aetna/Humana merger.”

PUTT and PSSNY have expressed deep concerns in the past that health care consolidation is running amok, with focus and attention on providing healthy shareholder return rather than a duty of care to patients and consumers who are already stretched thin with rising healthcare costs and concerns for affording reasonable healthcare coverage. CVS-Aetna is perhaps the highest-profile of these so-called “mega mergers”, drawing attention away from other equally-distressing healthcare mergers including Cigna-Express Scripts.

“We are asking the Court to stop the consolidation so that the concerns of patients, providers and consumers can be heard,” said Ms. Barber. “We believe in due process and the right of small business - but especially small businesses who provide medical care to patients and individuals - to have fair and equal access to patients, and to be able to maintain our relationships with our patients. To that end, we will continue to voice our dissent for this merger and use every tool at our disposal to be heard.”.

State regulators probe CVS drug price fluctuations

Wed, 24 Oct 2018 18:08:18 GMT

PSSNY continues to fight to save community pharmacy. Below is the most recent media story, featuring PSSNY Member Thomas D'Angelo on the egregious tactics of PBMs.PSSNY working for you! #SaveCommunityPharmacy

State regulators probe CVS drug pricefluctuations

Lisa Fickenscher, New York Post

Drugstore giant CVS's puzzling fluctuation in pricing for meds have been hitting mom and pop pharmacists hard - and they've caught the notice of New York regulators.

PSSNY Member Tom D'Angelo, who owns a pharmacy on Long Island, claims he has lost "hundreds of thousands of dollars" over the past couple of years because of tough tactics from Caremark, CVS's pharmacy-benefits manager, or PBM.D'Angelo claims Caremark, which is a prescription middleman that dictates its reimbursement pricing, has subjected him to wild, unpredictable fluctuations in reimbursement rates for prescription drugs."It's like dealing with the mob," D'Angelo told The Post, declining to give his pharmacy's name for fear of retaliation. "I can leave my business and return the next day to learn that I'm being paid 70 percent less for the same drug I sold just 24 hours ago."

Another pharmacist in upstate New York told The Post his business is losing on average $4 per prescription, which amounts to a $300,000 annual loss.Read more

PSSNY's Recent Actions in the Fight Against CVS-Aetna Merger

Last week PSSNY leadership testified at NYS DFS hearing on CVS/Aetna Merger.PSSNY outlined its serious concerns by pointing out the impact to patients through limited networks, limited formularies, the Medical Loss Ratio and the reimbursement environment pharmacies are enduring. See testimony here.

DFS Superintendent Maria Vullo asked CVS lawyer Elizabeth Ferguson in a booming voice: "Will you vocally support the [PBM regulation] bill?""We would not oppose it," Ferguson said, not going any further.

Comments on the merger can be sent to to DFS until October 25.Pharmacists should tell their personal stories and experiences by emailing their comments to public-hearings@dfs.ny.gov with subject "CVS/AETNA MERGER."

Check out more PSSNY generated media coverage on the hearing:

New York earns blocking of $68bn CVS and Aetna merger
(Verdict: Life Insurance International - October 19)
The Justice Department Approved the CVS-Aetna Merger, But It's Still Not a Done Deal. Here's Why?
(Fortune - October 19)
New York threatens to block $69B CVS-Aetna Merger
(NYPost - October 19)
New York State Considers Blocking Parts of CVS-Aetna Merger
(Bloomberg - October 19)
Report: NY eyes blocking parts of CVS-Aetna deal
(HartfordBusiness.com - October 19)
NY regulators consider blocking parts of CVS, Aetna deal
(New York Business Journal - October 19)

How are YOU Fighting to Save Community Pharmacy?!?!

Your voice is strong, but our collective voice is stronger!!

Contribute now to PSSNY's Fight the PBMs campaign TODAY.

www.PSSNY.org/FightPBMs

PSSNY Testifies at NYS DFS Hearing on CVS/Aetna Merger

Fri, 19 Oct 2018 15:48:17 GMT

Roxanne Richardson, Chair and Kathy Febraio, Executive Director, testified yesterday at the NYS Department of Financial Services' hearing exploring the impact of the pending merger of CVS Health and Aetna Inc.PSSNY outlined its serious concerns by pointing out the impact to patients through limited networks, limited formularies, the Medical Loss Ratio and the reimbursement environment pharmacies are enduring. See testimony here.

A total of ten testifiers opposed the merger including Assemblyman Gottfried. Only the NYS Business Council approved of the merger.

DFS Superintendent Maria Vullo asked CVS lawyer Elizabeth Ferguson in a booming voice: "Will you vocally support the bill?" "We would not oppose it," Ferguson said, not going any further.

Check out the media coverage on the hearing as of this morning:

New York threatens to block $69B CVS-Aetna merger (John Koshman, NYPost)
New York State Considers Blocking Parts of CVS-Aetna Merger (Blake Doge, Bloomberg)

How are YOU Fighting to Save Community Pharmacy?!?!?!

Your voice is strong, but our collective voice is stronger!! Contribute now to PSSNY's Fight the PBMs campaign: www.PSSNY.org/FightPBMs

#SaveCommunityPharmacy

ASSEMBLYMEMBER ANTHONY BRINDISI HOLDING NEWS CONFERENCE, CALLING ON DOJ TO BLOCK CVS-AETNA MERGER

Tue, 18 Sep 2018 12:17:04 GMT

WATCH LIVE AT 2:00 PM TODAY 9/18/18

For the second time, a New York State Assembly member is calling on the U.S. Dept. of Justice to block the CVS-Aetna merger. Assemblymember Anthony Brindisi will address journalists, patients and community members at Parkway Drugs in Utica, NY. Parkway owner and and PSSNY Member, Vincent Chiffy will also speak at the conference.

New York joins California in opposing the CVS-Aetna merger. In June, the New York State Assembly held a hearing to review the merger, hearing testimony from CVS, Aetna, PSSNY, and the Medical Society of the State of New York. Concluding the newly merged entity would be "too big to regulate", the Assembly came out against the merger.

Livestream the news conference at the PSSNY Facebook page here.

Let your voice be heard! Write to Attorney General Jeff Sessions, requesting him to block the CVS Health/Aetna Insurance merger!

#BlocktheMerger

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