January 5, 2016
The dawning of a new year is a time to look ahead.
It’s easy to focus on setting resolutions and to forget to look into the challenges you’ll face in 2016. But being aware of the challenges that your pharmacy will have to confront in the coming year can help you better prepare to meet and conquer them.
Here’s a look at the top three upcoming challenges that your pharmacy could face in 2016. Are you ready?
Direct and indirect remuneration (DIR) fees, including “network access fees,” “administrative fees,” “technical fees,” “service fees,” “credentialing fees,” and others, are making it difficult for pharmacies to determine how much they’re making or losing on each drug.
The Centers for Medicare & Medicaid Services (CMS) are working to combat these fees, and in 2016, fees that pharmacy benefits managers (PBMs) and Medicare Part D plans charge pharmacies that can be reasonably estimated at point-of-sale should be included in the adjudication process on the Prescription Drug Event (PDE).
While this change won’t stop these fees, it does aim to make it easier to understand how DIR fees affect your overall profit margin.
To truly combat this challenge, you need to be aware of all of the terms and conditions in your pharmacy’s PBM contract, including DIR fees.
PBM consolidations and abusive practices continue to pose a major threat to independent community pharmacies in 2016.
PBMs are consolidating, and the ones that remain are now larger and have added leverage with manufacturers and insurers. CVS, Express Scripts, and UnitedHealth already control somewhere between two-thirds and three-quarters of the market, according to an article from the New York Times. With fewer PBMs to compete with each other, they’re able to make more demands of the pharmacies that they work with.
Many PBMs are still using abusive practices, according to a report requested by the National Community Pharmacists Association (NCPA) called Concerns Regarding the Pharmacy Benefit Management Industry.
Inaccuracy and a lack of transparency in PBM revenue streams, conflicts of interest with PBM-owned mail order and specialty pharmacies, and unclear generic pricing and maximum allowable cost (MAC) payment calculations topped the list of abusive practices used by PBMs, according to the report, and pharmacies can expect to face similar challenges from PBMs in 2016.
In the coming year, independent community pharmacies could face an increase in the number of audits, according to the Work Plan for 2016 released by the U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) Nov. 2, 2015.
The OIG plans to scrutinize Medicare Part D billing and claims more closely to address prescription drug vulnerabilities. As a result, pharmacies should be prepared for more audits and investigations in 2016.
This increase comes after OIG reports that Medicare Part D fraud is growing, and one report even identified 1,400 community pharmacies that had questionable billing practices in 2014.
Combat challenges by setting smart, obtainable and growth-oriented goals for your pharmacy for 2016.