The Express Scripts discussion is broader for Canadian pharmacy

In this, the fourth blog I have recently written on Pharmacy Benefit Managers (PBMs) activity in Canada, it strikes me that much of the commentary I’m hearing from industry insiders is losing sight of the forest from the trees. It’s not just about Express Scripts Canada (ESC). Their recently announced changes serve as a flashpoint for a much broader policy discussion that needs to be tackled in Canada.

My comments are my own and not necessarily shared by any organization with which I am professionally affiliated.

My concerns about PBMs in Canada are larger than just the coming changes from ESC. The introduction of a new service fee imposed by ESC, with their rationale that the fee will be used for the development of new services, not yet been developed (and in my opinion not being asked for by pharmacy), represents the tree in the forest. ESC is not alone in Canada as a PBM, but it is recognized as a major player in the Canadian PBM sector. That is why my first blog asked the question: “Is it possible Express Scripts Canada will break the camel’s back?” I feel like Canadians have an opportunity, still, to prevent insurers and PBMs from devastating the traditional pharmacy landscape through their unilateral imposition of fees, or through restricting patient choice of pharmacy provider.

In early 2022, I had the privilege of moderating a panel discussion hosted by the Canadian Foundation for Pharmacy. While the major theme of the discussion was to highlight the key role pharmacists were playing in the United States with respect to testing and vaccination during Covid, I also wanted to speak to them about the effects of Direct and Indirect Remuneration (DIR) Fees on pharmacies. The panel consisted of an independent owner from Wisconsin, an independent owner from Florida, and a pharmacist with the National Community Pharmacists Association. 

In our prep for the panel, the two pharmacist owners shared with me that after accounting for DIR fees, they were actually losing money on 50% of the prescriptions they filled. That’s a pretty tough way to run a business! On top of the unpredictable DIR fees that can be clawed back months following the prescription fill date, the PBMs and insurers create Health Maintenance Organization (HMO) networks, limiting a patient’s choice of healthcare provider. Patients must see a network doctor and visit a network pharmacy or they won’t be covered. 

In Canada, we have already seen the rapid expansion of insurer and PBM-directed care through Preferred Provider Networks (PPNs). PPNs fragment patient care and limit patient choice. In my opinion, that is not the type of access to healthcare that Canadians want.

So, what can we do north of the border to push back on future unsustainable fees to pharmacies and the expansion of PPNs that limit patient choice to where they can access healthcare?

In my second blog in this series, “It’s time to follow the money,” I suggested that what I and other Canadian employees could do is challenge their employers to ensure their own benefits plans do not support PPNs and other American-style PBM initiatives. Another action that can be taken for those who care about the Canadian pharmacy sector is to support the Canadian Pharmacists Association and the provincial pharmacy advocacy associations in shedding light on this issue. CPhA has developed key messages on this topic and is advocating reaching out to elected officials to assist them in their understanding of the seriousness of this complicated issue.

Finally, I think it is worth repeating the question I asked in a previous blog. “Do we want to retain our red and white healthcare system, or do we want a red, white, and blue HMO system of pharmacy similar to what exists today south of the border, where insurance companies and PBMs have crippled pharmacy by imposing DIR fees on them?” Even though it is more than two years since I sold the group of pharmacies I co-founded and led, I am firm in my belief that community pharmacy in Canada is part of the solution to the challenges that Canadians are facing in accessing primary care. Crippling pharmacy through the imposition of fees and limiting patient choice of healthcare provider through PPNs is something I am prepared to invest my energy and time to prevent.