In this final of a three-part look at the Express Scripts’ (ESI) 2011 Trend Report, we consider the pharmacy benefit manager’s (PBM) attitude toward both pharmacies and patients proper utilization of their medication, or “adherence.”
“The U.S. now has about twice as many pharmacies as grocery stores. When it comes to filling prescriptions, there is clearly an oversupply of pharmacy access. Not every pharmacy must be included in a plan sponsor’s retail network to ensure sufficient access.” – Express Scripts 2011 Drug Trend Report
Go to any grocery store on Saturday morning, and there in the fruit and vegetable aisle, you’ll see seniors on complex nutrition regimes lined up to discuss with the grocery clerk the potentially dangerous interaction between their broccoli and apples. But seriously, aren’t grocery stores and pharmacies different?
For instance, should the Patient Protection and Affordable Care Act or even a “replacement” to it be fully implemented, there is a high likelihood that nearly 37 million more patients will have access to healthcare, including pharmacy care. Additionally, there is a virtual “Silver Tsunami” of baby-boomers that will need close-to-home pharmacy care. Is this really the appropriate time to reduce patient access to care?
We understand the profit motivations of ESI—making money off retail spreads, below cost reimbursements, etc.—are key components of the company’s revenue streams, and it wishes to continue them despite the fact that it has virtually squeezed every available penny out of the traditional 60,000 store retail pharmacy network.
ESI now proposes to funnel more prescriptions to fewer pharmacies in exchange for lower reimbursements. The company insists that this can be achieved with “minimal member noise”.
“According to the American Diabetes Association, only about 75% of the 25.8 million Americans with diabetes have been diagnosed; approximately 7 million are undiagnosed and untreated. Additionally, 79 million others may have pre-diabetes.” – Express Scripts 2011 Drug Trend Report
“Member noise” is PBM slang that is applied to beneficiaries that express concerns about PBM practices that impact access and quality of care. For example, an elderly patient explaining why she can’t drive 20 miles to get her diabetes medication and asking why she can’t just have her prescription filled at the corner pharmacy where she can receive face-to-face counseling from her pharmacist, would be considered “member noise” by ESI.
The ESI Trend Report clearly demonstrates the critical need for more rather than less face-to-face pharmacist counseling to address member care issues such as non-adherence—a $317.4 billion savings opportunity annually.
The report shows that across the major disease categories, ESI needs to do more to drive patient adherence. Forty-one percent of ESI’s diabetes patients don’t take their medications as directed by their doctors; 44 percent of patients with Mental/Neurological Disorders and 56 percent of Asthma patients are non-adherent.
In the area of specialty drugs, those high cost drugs used by patients with serious conditions whose non-adherence can cost patients their lives and cost payers millions in additional medical cost, there are high rates of non-adherence by ESI managed patients. In the area of inflammatory conditions, 49 percent of patients are non-adherent, 33 percent of MS patients are non-adherent and even cancer has a 37 percent non-aderence rate. There is a compelling need for more pharmacist intervention not less.
The 2011 Express Scripts Drug Trend Report sends an unmistakable signal to patients, retail pharmacists and payers that the trend for them is most certainly pointed down while ESI profits are pointed up.