Page 6 - HME Business, March/April 2022

Editor’s Note
Taking a Wrong Turn
Patient steering is becoming a problem for pharmacies. Are HME claims next?
Choice and service go hand-in-hand. You can’t have good service unless you can choose from whom you receive that service. Furthermore, as HME providers know, providing good service to patients results in good care, which improves patient outcomes.
But if we take a moment to look at what is happening in the pharmacy industry (related to ours, particularly when it comes to DME pharmacies), we see a disturbing trend developing: Increasingly, health insurance plans and their pharmacy benefit managers (PBMs) are telling patients which pharmacies to use; the practice known as “patient steering.”
Patient steering is not what those patients want. According to a national survey from the National Community Pharmacists Association (ncpa.org), 84 percent of respondents feel
that PBMs and payers should not be able to tell them which pharmacies to use. The survey, conducted by Public Policy Polling for the NCPA, also showed that 78 percent of those surveyed said insurance plans and PBMs should not require patients to use pharmacies owned by insurance plans and PBMs, or be allowed to require patients to get their medicines through an insurance company’s mail-order pharmacy.
“Being able to choose their pharmacy continues to be a patient priority,” NCPA CEO B. Douglas Hoey, pharmacist, MBA, noted in a public statement when the data was released. “Despite the pandemic having changed other consumer behaviors, they want access to a local health care provider who knows them and will help them find the best, most affordable treatments.”
Now, here’s an interesting kicker: not only do patients feel that payers should not be able to tell them which pharmacies to use, the majority of respondents to the survey said they want insurance payers to pay pharmacies fairly. Nearly 60 percent of those replying said it wasn’t fair that low insurance and PBM reimbursements often means that pharmacies lose money on prescriptions when buying and safely dispensing drugs. Additionally, nearly three-quarters of those replying said that the $1 reimbursements pharmacies sometimes see are “not fair.”
That should sound achingly familiar to HME providers — and doubly for DME pharmacies — who’ve experienced a constantly winnowing away of reimbursement by Medicare, Medicaid and private payer insurance.
So, could patient steering be an issue for HME providers? On the Medicare front, one could argue that competitive bidding has been one gigantic method for CMS to tell Medicare benefi- ciaries which DMEPOS suppliers to use, but for the sake of a simpler discussion, let’s suffice it to say that right now, Medicare beneficiaries are free to choose their provider. This is especially true when we stop and think about the fact that CMS opted not to award contracts for 13 of Round 2021’s bidding categories.
On the Medicaid front, there has been clear evidence of patient steering with some MCOs. Maybe not specifically for DME items, but we do know that MCOs have been reported to have steered patients toward lower-cost care facilities.
On the private payer front, we have seen some health plans pursue arrangements in which they have named “providers of choice” when it comes to HME orders and prescriptions. That indicates a clear willingness to pursue the idea when it comes to HME, which worries me.
With the growing integration of payers and providers and the increasing competitive positioning of major companies such as Amazon and CVS, the dynamic of patient steering poses considerable peril for pharmacies. The HME industry needs to be every bit as vigilant to patient steering as its post-cousins so that we don’t veer off in the wrong direction.
David Kopf
Publisher & Executive Editor HME Business
Volume 29 Number 2 March/April 2022
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