Payer-directed care and closed PPNs ‘pose potential risk of harm’: OCP

The Ontario College of Pharmacists adopted a position against closed preferred-provider networks (PPNs) and payer-directed care in a meeting on July 8. “Closed PPNs (and other payer-directed care models) pose potential risk of harm to patients, contravene established ethical principles guiding the profession and conflict with standards of quality patient care,” the statement said. “As Ontario’s pharmacy regulator, OCP has zero tolerance for any payment or reimbursement models involving pharmacies and pharmacy professionals that put patients at risk, disregard patient autonomy, or that get in the way of a pharmacy professional’s duty to put patient interests first,” it continued. It distinguished between open provider networks, which allow any provider who is willing to meet the contract rules and requirements to join, and closed ones, which have more opaque conditions and are limited to a specific group of pharmacies. The college said it believes that closed payer-directed arrangements “pose a greater risk of harm to patients” because they limit patient choice around pharmacies more than open arrangements do. Read: Alarming growth in ‘patient steering’: CPhA calls on Canada to regulate PPN arrangementsThe statement is the first step in the OCP's plan against PPNs, which includes proposing regulatory changes. The OCP described the position statement as the foundation for further regulatory moves and said policy options will be presented in September. The organization joined the Canadian Pharmacists Association (CPhA), which released a statement saying that “payer-directed care interferes with the established and trusted relationship between pharmacists and their patients, which in turn can compromise patient-centred healthcare,” earlier this year. Vertical integration The OCP said it's been seeing more cases where insurers don't just have a PPN arrangement with an outside pharmacy, but also own those pharmacies. One example is Telus Health, which recently told employees that the company's virtual pharmacy was now the preferred provider and some prescriptions would only be covered if the virtual pharmacy filled them, CBC News reported in March. Amy Miller, a high-school teacher in Waterloo, Ont. spoke out at the OCP meeting to share her story about how she had been affected by a similar shift from the Ontario Teachers Insurance Plan. The plan now has its own pharmacy, MemberRx, which members must use to have their specialty drugs covered. Miller said if she wanted to continue to use her pharmacy, she would have to pay out of pocket. “I have a relationship with my pharmacist. I consider him part of my circle of healthcare providers that I choose, because of my relationship with them, just like one would choose a doctor or a chiropractor,” she said, fighting back tears. She also explained that she had been told that it was more convenient. But since the Humera needed to be refrigerated and she lives in a condo, the solution given to her was to pick it up once it was delivered to a local Michaels arts and crafts store. That doesn’t make sense to her, she said, as her usual pharmacist is only a few minutes from her home. She pointed out that she can pick up her prescription at her convenience from it, and she trusts that her medication has been well managed there. Read: Navigating the challenges of the Manulife-Loblaw PPN arrangementThe Ontario Teachers Insurance Plan argues that the policy ensures that the money saved stays within the plan, a story in the Globe and Mail said.“There is no profit motive or retail element in the MemberRx model—we ensure that all proceeds are returned proportionally to the benefit plans that have partnered with MemberRx,” OTIP spokesperson Patricia Wilkinson-Bizjak said to the paper.Those vertically integrated networks, where insurers own plans, often require members to use their pharmacies. But such plans need not be set up that way—a similar one run by the Alberta Retired Teachers’ Association’s isn’t mandatory for members.American ShadowsIn the U.S., vertical integration is one of the main problems with PBMs, as highlighted in an interim report released by the FTC this week.For example, CVS Health Corporation owns a PBM—CVS Caremark—CVS’ retail, mail order and specialty pharmacies and the health insurer Aetna. The other five largest PBMs in the U.S. don’t own retail pharmacies but have mail-order and specialty ones, and four also own health insurance companies.It also found that the six largest PBMs in the U.S. process more than 90% of prescriptions, with the top three PBMs responsible for nearly 80%. Read: New York Times reporting puts the heat on PBM practices

Payer-directed care and closed PPNs ‘pose potential risk of harm’: OCP

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