Retail pharmacies excluded from Medicare Part D networks with higher contracting risk

Retail pharmacies excluded from Medicare Part D networks with higher contracting risk

Retail pharmacies excluded from Medicare Part D networks maintained by drug benefits have become much more likely to exist over the past decade, according to new research from USCHealth Matters.

Independent pharmacies and those located in low-income, Black or Latino communities were more likely to be excluded from "preferred" pharmacy networks, which also put them at higher risk of closure, researchers also found.

The study is the first to examine how significant growth in preferred pharmacy networks in the Medicare prescription drug benefit may have contributed to the struggles of retail pharmacies, which researchers in a previous study closed at unprecedented rates. Pharmacy Benefit Managers (PBMS), who control drug benefits on behalf of employers and insurers, control the beneficiaries of non-preferred pharmacies by shocking higher costs at those locations.

Use of preferred pharmacy networks tripled over the past decade to 44% in Medicare Advantage drug plans and grew from 70% to 98% in standalone Medicare drug plans, the researchers found. This shift coincided with a wave of mergers involving the nation's largest PBM and retail pharmacy chains, which may have encouraged PBMs to nudge patients toward pharmacies with which they are affiliated and away from competitors. The Federal Trade Commission alleged in a preliminary report last year that PBMs "routinely create narrow and preferential pharmacy networks" to favor their own pharmacies and exclude rivals, and Arkansas recently passed an initial law barring PBMs from owning or operating pharmacies.

“Our study shows that pharmacy networks in Medicare Part D designed by PBMS are contributing to the growing problem of pharmacy closures, particularly in communities that already have convenient access to pharmacies,” said the study's lead author, Dima Mazen QO, a senior chair of the USC Schaeffer Center for Health and Economics and the Pharmacy and Pharmacy Centers.

Differences in network participation

The researchers analyzed the pharmaceutical closures between 2014 and 2023 to find their most important findings:

• Apotheken, die mit weniger als der Hälfte der Pläne bevorzugt wurden, war 1,7 -mal häufiger als diejenigen, die in den letzten zehn Jahren von den meisten Plänen bevorzugt wurden, nachdem Faktoren wie Eigentümer und Demografie nach der Nachbarschaft berücksichtigt wurden.
• Apotheken, die nicht als bevorzugte Apotheken für einen Teil -D -Plan teilnahmen, schlossen sich um 3,1 -fache, und Apotheken, die sich ausschließlich aus dem Netzwerk befanden, schließen sich 4,5 -mal häufiger.
• Während 4 von 10 Apotheken im Jahr 2023 ein unabhängiges Eigentum hatten, wurden nur 0,8% der meisten Pläne bevorzugt. Inzwischen wurden 70% der Kettenapotheken durch die meisten Pläne bevorzugt.
• Etwa 3 von 10 Apotheken in schwarzen, lateinamerikanischen oder einkommensschwachen Stadtteilen wurden durch die meisten Pläne in diesem Jahr bevorzugt, verglichen mit fast der Hälfte der Apotheken in höheren oder weißen Stadtteilen.
• Die Netzwerkbeteiligung variiert im ganzen Land erheblich. In einer vielfältigen Gruppe von 13 Staaten, zu denen New York und North Dakota gehören, wurden weniger als ein Drittel der Apotheken durch die meisten Pläne bevorzugt.

Political implications

“Our results show that federal PBM reform is necessary for expanding preferred pharmacy networks,” said study lead author Jenny Guadamuz, associate professor of health policy and management at the University of California Berkeley School of Public Health. “New laws may prove elusive, but there may be room for regulatory action.”

The researchers point to actions the Centers for Medicare and Medicaid Services could take, including considering provisions that ensure Part D plans meet preferred pharmacy access standards and mandate preferred status. Regulators and policymakers could also mandate increases in pharmacy reimbursement, particularly for critical access pharmacies that are at risk for closures and if they serve “pharmacy deserts.”

Sources: