Chucking Insurance-Ohio Capital Journal – Ohio News Time
For more and more pharmacists, using insurance to pay for most generics makes as much sense as purchasing auto insurance to cover oil changes.
The problem is, if you try to buy generics without a health insurance card from the majority of drug stores in the United States, you will be paying a “cash” price that is drastically inflated by middlemen, discounts and mad systems. .. Travel imposed on pharmacies by the insurance system.
Therefore, although unknown to many consumers, the reimbursable costs of many generic drugs are often higher than the overall price if they were available in a truly open market.
Think about it:
An Ohio patient recently paid a co-payment of $ 141 through insurance for 180 celecoxib, a generic version of the anti-inflammatory drug Celecoxib. When she went to a new pharmacy avoiding insurance, she was able to get it for $ 23.05.
In other words Self-pay In the case of drugs, even if you add a dispensing fee, it will be six times the cost of the drug on the open market.
What about the cash prices of insured pharmacies – almost everything? About $ 1,165, which is 50 times more than if a pharmacy were available from an equivalent secondary wholesaler on the open market.
This huge difference in cost is only part of the reason why Nate Hax and a few other pharmacists in the United States are setting up pharmacies that exclude insurers and their intermediaries: community pharmacists or PBMs. Hacks said it also makes him a better pharmacist because it’s a cleaner system that pays him just to practice his profession.
For patients, savings and better health outcomes may be linked. Uninsured customers are particularly advantageous. Number to increase Those who have plans for high deductions.
Hacks recently leaned against the counter of a Freedom pharmacy on the outskirts of Columbus, saying, “They are ridiculous and don’t take drugs.” “So we opened the door to allow them to take 90% of the drugs there at a reasonable price. A 90 day supply is less than $ 15. A 90 day supply is $ 15. Why do i need insurance? “
After a long period of reflection, Hacks opened in December. Liberty pharmacy In the suite next to the Pickerington Pharmacy, it also owns and operates within the insurance system.
“We have pharmacies in both worlds, so we can help guide patients to the better world they live in,” he said.
Insurance is essential for patients who take certain medications.
The more expensive drugs, brand name drugs and specialty drugs, are typically patented and can cost thousands of dollars per month, and in some cases tens of thousands of dollars. So it makes sense to insure yourself for the cost, just like your car does for a collision, or your house for a fire or flood.
But when drugs lose their patents and are inundated with generic versions, they fall below each other, driving down free market prices. However, most patients do not have access to it on the open market.
In other words, you cannot take advantage of the savings created by the generic drug revolution.
“Ultimately, brand name drugs become less and less important,” says Hacks.
Often times, you don’t know that an insurance company or a pharmacy manager is involved. For example, last year the anti-HIV drug Tolbada lost its patent. But when 11 generic versions flooded the market this spring, traditional drugstore cash prices were actually Superior to patent medicine..
This increase is caused by the confusion of discounts from manufacturers to pharmacy benefit managers, opaque reimbursements by PBMs where pharmacies often lose money, and the need to earn cash to compensate for these losses. .
But the point is that we can go to Blueberry pharmacy – Uninsured stores outside of Pittsburgh – and buy a generic version of Truvada for $ 25 per month. In traditional pharmacies, uninsured customers faced a surcharge Base price is $ 2,100..
That’s why blueberry owner Kyle McCormick motivated him to open an uninsured drugstore last year.
“I have seen how cheap these drugs are, so there is no way to prevent them from being insured,” he said.
Greg Lopes, spokesperson for the Pharmaceutical Care Management Association, a PBM industry group, claimed last month that insurers (often part of the same company) would add value to all types of drug transactions. .
“PBM, a US pharmacy benefits manager, has long supported generics to lower the cost of prescription drugs for patients,” he said. “The key to reducing the cost of prescription drugs is to increase competition between brand name drugs, generics and biosimilars. “
That said, critics say the current manufacturers’ discounts are raising arbitrary prices more than ever and increasing distress for many patients. Former Pfizer vice president Robert Popobian, who currently works as both a pharmacist and economist, is predicting high deductions as well as uninsured deductions, increasing the number of people who have to pay for joint insurance. I feel that I am. Consultants and analysts.
When referring to coinsurance (if you have to pay part of your bill), Popobian used the example of a well-known insurance company, Delta Dental. If there is a procedure such as getting a crown, Delta will pay a certain percentage of the price negotiated with the dentist, Popobian said.
This is not the case with prescription insurance.
“The drug benefits are the only benefit within the healthcare system that allows patients to pay for joint insurance on the basis of retail prices rather than negotiated prices,” Popobian said.
The same goes for uninsured people and those who must pay the full amount until they are eligible for the deduction. According to Popobian, their payments are based on a list price that manufacturers inflate to compensate for the opaque discounts they offer to pharmacy benefit managers.
This is a problem that Chris Johnson has been used to for a long time. He opened his Medsavers pharmacy In 2005 in Austin, Texas.
To be in a state of having it for a long time Highest rate Without medical insurance, he knew these people were facing the pharmacy counter.
“Uninsured people got screwed and screwed up, not because the pharmacy did it to them, but because of the contract the pharmacy signed with PBM,” he said. “The contract required pharmacies to increase prices for uninsured patients in order to maximize insurance reimbursement. I felt ethically and incredibly bad.
Johnson said he had an active business. But when it started, most of the dozens of pharmacies in countries operating outside of insurance / PBM territory got lost for reasons unknown, he said.
Currently, the only uninsured pharmacies found by the Capital Journal are Johnson in Austin, Hacks near Columbus, McCormick near Pittsburgh, and Genscripts, operates 5 sites in Oklahoma.
However, two of them have opened since 2020 and could lead the way for independent pharmacies.
One of the reasons that independents are important is that independents are the only game in town for many small communities, and their downfall can result. Pharmacy desert In certain regions.
However, independent pharmacies Close the store faster than the new store opens Between 2015 and 2019, according to data from the National Community Pharmacists Association.
Kurt Proctor, vice president of strategic initiatives at NCPA, said:
“I think it’s a very viable business model,” he said of pharmacists working, at least in part, outside of the insurance / PBM field.
For Hacks, the economic benefits for the customer cannot be denied. But he said there was an even bigger reason to pursue an uninsured model.
At Freedom Pharmacy, he charges the patient the amount he paid for the drug and charges a prescription fee of $ 8 or $ 12, depending on whether the supply is 30 or 90 days.
“The pharmacist confirms that the prescription is well reviewed, that the patient understands how to properly take the drug, that there is no drug interaction, and calls the doctor. Every prescription is worth making sure you do. If you have a problem with the dose, ”Hacks said. “That’s all that’s included in every prescription we make.”
The withdrawal of the insurance / PBM system will radically change the economy. Hacks said he would no longer have to scramble daily to fill his prescription.
“All of our benefits come from services such as confirmation and prescription testing, dose screening,” he said. “I can tell you this: what you pay is what you’re good at. “
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