To say that the Medicare prescription drug (Part D) benefit hasn’t exactly been a walk in the park for community pharmacists would be putting it mildly. During its rather chaotic implementation four years ago this month, local pharmacists spent countless hours online and on hold, trying to resolve coverage problems for their patients. Often they were “rewarded” with long waits for reimbursement from plan administrators, typically pharmacy benefit managers (PBMs).
These payment delays became so elongated that they created a credit crunch that led, at least in part, to thousands of community pharmacies closing in the year or so following the launch of Part D. At NCPA’s urging, Congress enacted a “prompt pay” requirement that became effective Jan. 1, 2010, but that’s another story.
This post is about the growing market share of one family of Part D plans, Universal American, and the lesson it offers.
In recent years, the insurer’s plans have increased in popularity among seniors. This month Medicare reported that Universal American is now the second largest Part D plan sponsor, ahead of Humana and trailing only UnitedHealthcare.
Driving much of that success are Universal American’s Community CCRxSM plans. Offered through an agreement with NCPA, these plans take the view that medication therapy works best when it’s built on the patient’s relationship with a trusted, local pharmacist.
Or, as the plan’s core message to patients states: “Your pharmacist is an important member of your personal health care team, and Community CCRx understands, supports and encourages that relationship. The highest quality medicines, the lowest possible cost and personal care from your trusted pharmacist. It’s a healthy prescription for a healthier you.”
Three aspects of the Community CCRx plans illustrate that commitment in action. They do not offer mail order (most independent community pharmacies already provide home delivery services); they grant prompt pay status to long-term care claims as well as traditional drug claims; and they offer medication therapy management (MTM) services that partner patients and local pharmacists to maximize the therapeutic benefits of prescription drugs.
It’s a surprisingly “contrarian” notion for a drug benefit. Instead, most plans are built on a model in which PBMs aggressively work to divide patients from their community pharmacist, such as through tiered co-pays favoring the PBM’s mail-order pharmacy (even when it’s more expensive for the plan overall).
In addition to rising enrollment figures, Community CCRx was “the highest rated Medicare Part D plan in overall member satisfaction, reenrollment and recommendation intentions,” for two years running, according to Wilson Health Information, LLC.
To be sure some of CCRx’s changes over the years have not always been met with open arms by community pharmacists. But they have helped keep the plan competitive with other Part D plans and allowed premiums to remain low.
Or as the Kaiser Family Foundation put it: “Among the six PDPs with the highest enrollment in 2008, only one has an average monthly premium in 2009 that is lower than its 2006 premium: Community CCRx Basic plan, sponsored by Universal American, with a 2009 average monthly premium of $30.18, 3 percent lower than the $30.94 monthly premium in 2006.” The same report documented one of Humana’s plans premiums increasing fourfold over that same period. The report’s 2010 edition offers similar findings.
Low costs have also helped Community CCRx become the leading “benchmark plan” operating in 30 of Medicare’s 34 regions (the most of any Part D plan sponsor). Zero-premium benchmark plans serve low-income beneficiaries, many of whom need extra pharmacist attention as well as additional financial assistance. Medicare determines benchmark plans each year through a silent bidding process that weeds out pricier plans. Humana bowed out in late 2008, citing insufficient profit margins, and others may be following suit.
Sometimes it’s a checkered path that leads to progress, rather than the straight and narrow. In this case, out of Part D we’ve seen the success of a plan that partners patients with their community pharmacists for great value and positive health outcomes amid competing drug “benefits” built to maximize PBM mail order revenue above all else.