Drugs Now Under Managed Care, Despite Pharmacists' Fear
Texas is expanding Medicaid managed care today to include prescription drugs, despite pharmacists' cries that the likely cuts to their reimbursement rates will be “managed care Armageddon.”
State lawmakers approved the change to save Texas money — an anticipated $100 million over the next biennium. But pharmacists fear that managed care organizations' lower reimbursement rates will drive them out of business.
“I am totally scared to death,” Louis Rumsey, a pharmacist who owns Elam Road Pharmacy in South Dallas, told a joint committee of Texas House and Senate members on Wednesday. Rumsey, who is making plans to sell the pharmacy over ...
Comments (3)
Jan Pattillo
Louis Rumsey's story is absolutely true! My husband and I also own an independent pharmacy in Hamilton, TX. The 1st Texas Medicaid prescription we ran this morning we lost $33.00. The abuse of the medicaid system has not been caused the pharmacist. We simply submit the RX claim and take whatever the state wants to give us. We are tired of "take or leave it contracts" and we are simply speaking up. Pharmacist are just like the bus station attendent. If the Customer wants to ride the bus, they purchase a ticket from the attendant who is working for the bus station. The abuse of "the system" It has been caused by the Texas Government itself by not controlling the abuse of it . There should be a limit to everything, but cutting the practice of pharmacy out of the picture will create more harm then good. We are the professionals that have the patient's best interst in mind. If we lose money on Rx claims that means we are paying money to do all the work. It doesn't make sense but it's true. Who does business that way and stays in business? Why would anyone pay $100.00 wholesale only to be forced to re-sell an item for $50.00. Sounds stupid doesn't it ? Perhaps the Executive Commissioner should take a look at the actual claims adjudicated by the managed care PBM's to the pharmacy. Only then will he and those in charge understand. We tried to fax the commissioner a copy of our $33.00 loss along with a copy of our wholesaler invoice today. The fax numbers we were given by his office did not answer to accept the fax. The lady that answered the phone said she wasn't sure he would look at our fax, but she hoped so. Sooo, it appears he or the rest of the folks in charge do not care about one independent pharmacy or pharmacist? Perhaps the Texas HHSC should put the shoe on the other foot and actual go and visit these pharmacies and meet the people running the front lines for them. Common Sense and cold hard facts should have an effect on their decision, but that makes too much sense. Respecfully, Jan P. Rph
Pamela Baggett-Wallis
Here's what the state's actions regarding Medicaid prescriptions looks like from the patient side.
Seuhs and his PIO claim there are plenty of pharmacies signed up to take Medicaid patients. They both know how misleading that is. They, and the many legislators who supported this move, are hiding behind a curtain of word play and convoluted statements that they know mislead people.
Mislead: to lead in a wrong direction or into a mistaken action or belief often by deliberate deceit
Yes, they are correct that pharmacies are signed up with various insurance companies. However, those contracts were based on the reimbursement rates at that time. These pharmacists did not, nor would they, sign up for the new, reduced-rate Medicaid plan that reimburses at a rate that does not even cover the actual cost of the medicine, much less the salaries and overhead for dispensing.
This Medicaid prescription managed care is a gold mine for health insurance companies and their partners-in-crime, pharmacy benefit managers. They will rake in the cash because the state will pay them even if the covered patient does not get the medicine or physician care they need. It's called "capitation," a term that always makes me think of health plans beheading patients. Actually, that's not too much of a stretch.
Riddle me this:
If the state has the same $xx available for Medicaid prescriptions as in the previous year and they give that money to a health plan that makes a 7 to 10 percent profit, how can there be enough money for Medicaid prescriptions? Let's throw in another entity, the pharmacy benefit manager (PBM) that also will see a 7 to 10 percent profit. Where does that profit come from? The way it's set up now, it comes from the local pharmacist who interacts with the patient.
For those unfamiliar with a PBM, it is the entity between you and your medicine, just as an HMO gets between you and your doctor. Both dictate what medical services are provided, not necessarily what the physician deems necessary.
The Texas Vendor Drug Program operated through Seuhs' agency was the best in the nation. Yes, you read that correctly. They had an overhead cost of 1 percent. Now, with the same money, there is an overhead cost of 14 percent.
How did this happen? Health insurers are the largest lobby in Texas and all states, plus Washington. When you go to the polls this May and November, be sure you know who you are voting for. It's not for a specific candidate, it is for a health insurance company.
It just occurred to me that many former pharmacy patients won't be bringing in scripts. With the death of Women's Health Program and defunding Planned Parenthood, that reduces the number of prescriptions by at least 113,000! At least for now. When those women show up at a hospital with advanced stages of cancer, the state (or hospital) will fork over a lot more money. When they show up to give birth, that's more money. When they are ill and can't work, that's more money.
I'm not a pharmacist. I'm the mother of an adult son with significant disabilities who relies on Medicaid. My son has a job and has worked steadily for the past decade but at minimum wage, plus a few raises. That's still not enough money to live on and I augment his income the best I can. But the day will come when I won't be here to help.
Interestingly, he works as a cashier for a pharmacy that has cut back his hours because of a PBM's unreasonable, self-serving reimbursement rates. We are fortunate that the pharmacy has kept him on the payroll. But for how much longer can they afford that?
It's difficult to find a good, experienced physician who will treat a Medicaid patient. Now, even if we find that doctor, we'll have trouble finding a pharmacy to fill the prescription.
think
This is a very blatant scam where private insurance Zillionaire industries are paid hundreds of millions of dollars to "manage" costs so patients don't get RX and the profiteering insurance industry pockets those same $100,000,000's "cost savings".
The private insurance companies skim off the fat to increase their "assets" and the disadvantaged get less than zero . It is a Ponzi scheme where BIG INSURANCE laughs all the way to the bank ...that is how private insurance "runs" things.