Community oncology clinics say that the military health system’s exclusive relationship with a giant corporation increasingly is putting them at a disadvantage. And that disadvantage is putting the health of veterans and members of the active-duty military at risk, the clinics say.
The Community Oncology Alliance again wrote to the U.S. Department of Defense last week to complain about Express Scripts, the nation’s largest pharmacy benefit manager. The department’s massive health program, Tricare, entered into an exclusive agreement in 2009 to allow Express Scripts to handle pharmacy reimbursements and other prescription-related matters.
But the multibillion-dollar company is using its dominant position in an over-concentrated marketplace to force cancer patients to use its own mail-order pharmacy, leading to long delays and mix-ups for patients receiving lifesaving drugs, said Ted Okon, executive director of the oncology alliance.
In one instance, he said, the program is giving preference to a $7,100-a-month prostate-cancer drug over one that costs $1,100 and that some doctors believe is more effective.
Mark Nelson, CEO of Northwest Medical Specialties in Tacoma, Washington, said his practice has a patient who was forced off the cheaper medication. He said the difference in cost wasn’t even the biggest problem.
“All these patients know is that the drug they’re on is keeping them alive,” Nelson said, describing repeated sessions clinic personnel had with the patient. “And then they’re being forced to switch.”
Okon said the method Express Scripts uses to take pharmacy business away from cancer clinics is simple. The company “is low-balling reimbursement rates for oral cancer drugs to oncology providers, both independent practices and hospital systems, such that it is impossible for them to provide these drugs as the reimbursement is less than the drug cost,” he said in his letter to Assistant Secretary of Defense for Health Affairs Thomas McCaffery.
“Express Scripts is low-balling reimbursement so that patients are forced to get their prescriptions filled by its specialty mail order pharmacy Accredo, which maximizes profits for Express Scripts.”
For its part, Express Scripts says it’s providing its customers with the most cost-effective option.
“Our job is to keep specialty medications affordable and accessible for all of the payers and patients that we serve, and to ensure all patients get the care they need in a timely manner,” spokeswoman Jennifer Luddy said in an email.
“One way we accomplish this is by having patients fill the medication at an in-network specialty pharmacy (not always exclusively an Express Scripts pharmacy or Accredo) rather than obtaining the medication from the physician’s office, where the medications are often marked up considerably.”
Medications for cancer patients often cost more than $10,000 a month. Sometimes a lot more. Nelson said that two or three months ago, Express Scripts reimbursements to his clinic dropped off steeply, many of them to $1,000 or more below the clinic’s cost to provide the medication.
In its investigation of pharmacy benefit managers, The Dispatch has documented cancer patients’ serious problems using mail-order pharmacies — including soldiers using Tricare. Their doctors say cancers can change swiftly and dosages often are complex, so it makes medical sense to integrate the pharmacy into the clinic or hospital where patients receive their care so doctors and pharmacists can nimbly deal with a patient’s disease.
Among the problems associated with using mail-order pharmacies for cancer drugs are weeks-long delays in starting care, interruptions in ongoing treatment and slowness adapting to changes in care. In Ohio last year, Air National Guard officer Charlotte Ortiz and her family said it took more than a month — and the intervention of a U.S. senator — before Express Scripts would cover the prescription for her rare cancer.
They got along with donated drugs until Express Scripts covered them, but Ortiz died later in the year.
Tricare spokesman Kevin Dwyer said his agency hasn’t found problems with mail-order.
“We continuously monitor mail order pharmacy performance,” he said in an email. “There are no indications it is an inferior way for medications to be dispensed.”
But most pharmacies are at a disadvantage in the Tricare system because they don’t receive the big discounts, or “rebates,” that the federal government negotiates with drug manufacturers. Those go only to military health facilities and mail-order pharmacies, Dwyer told The Dispatch last year.
As one of three pharmacy benefit managers that control 80 percent of the marketplace, Express Scripts has immense clout to negotiate big rebates on its own. But Dwyer said federal law mandates that the government negotiates its own discounts from drug makers.
Okon said that, regardless, community pharmacies are at a huge disadvantage both when Tricare is involved and when it’s not.
“Because of the consolidation on the PBM side, they have near-monopolistic power and they can force these rebates,” he said.
Pharmacy benefit managers often aren’t required to account for all the rebates and other discounts they receive from drug makers. And, since they routinely decide which drugs will require no copayment or prior authorization, they often exchange such preferred treatment for big rebates — a dynamic that critics say warps the marketplace in multiple ways.
In October, Okon wrote the defense department about the drug that the patient at Nelson’s Washington clinic was forced to stop using. Even though that drug costs $6,000 less, a patient has to go through “step therapy” get it, Okon wrote. That means the cancer patient had to show he’d tried other drugs and they failed.
Dwyer, the Tricare spokesman, said Express Scripts had no say in deciding which of the program’s drugs get preference. Either way, Okon said, the outcome doesn’t look promising.
“It’s a train wreck and people are going to get hurt,” he said.