PHARMACY ACCESS TO PAYER NETWORKS

To oppose pharmacy access criteria that impose discriminatory requirements or qualifications on participation in insurance payer networks that interfere with patient continuity of care or patient site-of-care options; further, 

To advocate for laws and regulations that require healthcare payers to disclose to pharmacies applying to participate in payer networks the criteria and the clinical and operational outcome data reporting requirements used to include, retain, or exclude pharmacies; further, 

To encourage healthcare payers to standardize network access criteria and eliminate those reporting requirements already imposed by accrediting bodies or regulatory agencies. 

Rationale

As hospitals and health systems have become more engaged in developing ambulatory care services, pharmacies (e.g., health-system specialty pharmacy, outpatient infusion, community pharmacy) in those settings increasingly find themselves excluded from healthcare payer networks and, a related concept, drug manufacturer networks (see ASHP policy 1714, Restricted Drug Distribution). Vertical integration in healthcare has led to many discriminatory practices by pharmacy benefit managers (PBMs) to carve out care from hospitals and health systems providing patient care, which may include infusion services and specialty medications. Vertically integrated systems allow payers to steer patients toward lower cost-of-care options and carve out health-system pharmacies from joining their networks. ASHP acknowledges that healthcare payers, PBMs, and drug manufacturers may develop and use criteria to determine pharmacy access to their networks to ensure the quality of services and the financial viability of pharmacies (i.e., ensuring sufficient patient volume to profitably operate). However, when creating pharmacy networks, payers, and manufacturers should also consider the potential impacts on a patient’s care and choice. Patients generally choose pharmacies that are most convenient for them. When pharmacies are locked out of a payer network, patients may face barriers (e.g., physical access) to therapy, which can delay or otherwise frustrate treatment.

Pharmacies within health systems have an advantage when it comes to electronic health record integration, proximity and relationship to providers, and, in some cases, onsite clinical pharmacy specialists. Significant research has been conducted demonstrating the positive impact of utilizing a health-system-based pharmacy. Specifically, integrated health-system-based specialty pharmacies have been shown to lead to improved patient outcomes, superior patient and provider satisfaction, and reduced overall healthcare costs. This is achieved through reduced primary and secondary non-adherence, decreased time to specialty therapy initiation, real-time patient safety initiatives, proactive patient monitoring and outreach, reduced polypharmacy, and enhanced care coordination with internal health-system providers. This clinically superior environment, coupled with health systems’ ability to measure and meet outcome-based metrics, allows them to easily compare their performance against other pharmacies. Therefore, inclusion of health-system pharmacies in payer and manufacturer networks could improve care coordination and quality-based care and reduce overall healthcare costs. Exclusion of health-system pharmacies from these networks, coupled with rising drug costs, infrastructure costs, and reduced reimbursement due to site of care challenges have had a severe impact on the financial margins of many hospitals and health systems.

Within contracting for both access to payer networks and manufacturer limited distribution drug agreements, there are sometimes terms requiring health-system pharmacies to provide substantial amounts of data in exchange for inclusion in these networks. These data reporting requirements are variable depending on the negotiating parties and are often duplicative with reporting requirements imposed by accrediting bodies or regulatory agencies. Since there is not a standardized reporting approach to payers, pharmacies are faced with having to create different reports to different payers that meet contractual obligations to ensure proper reimbursement (ASHP policy 2232, Revenue Cycle Management and Reimbursement and Pharmacy Compensation for Drug Product Dispensing). Similarly, specialty pharmacies that are accredited must demonstrate compliance with required metrics. These requirements often call into question the ownership and privacy of certain patient-related data, but compliance is often required to successfully gain access to the necessary networks to provide patient care. The lack of transparency of PBM practices throughout the entire process introduces significant barriers to health systems’ ability to provide optimal, effective, and timely care to patients. Hospitals and health systems may choose to enter a dispute resolution process (e.g., arbitration) if a pharmacy is excluded from participation in a network, but this process is costly and time-consuming. Furthermore, the health systems may struggle to negotiate better deals and write more effective contracts to establish a more satisfying pharmacy-payer relationship (ASHP policies 1809, Health Insurance Policy Design and 2028, Pharmacist’s Role in Health Insurance Benefit Design.) Obstacles to preserving continuity of care for patients include increasing complexity of navigating the vertically integrated pharmacy marketplace, contracting for inclusion in payer networks, and scope of data reporting requirements imposed on pharmacies to maintain access to these networks.