How PBM Mail-Service Pharmacies Help Patients

JC (00:08): To The Pharmacy Benefit, a podcast looking at the PBM industry, I'm JC Scott. Many Americans use mail service pharmacy for convenience and value. During the COVID 19 pandemic, even more people have been using PBM mail service pharmacies as a safe, convenient, and reliable way to get their maintenance medications and other central prescription drugs, without having to leave home. But in the past few weeks, the US postal service has been under greater scrutiny, even as more Americans rely on the mail and other common carriers to deliver all manner of things they need. The political noise around the post office has raised some questions for patients who rely on mail service pharmacy. JC (00:45): Joining me to talk about all of this and help address those questions is PCMAs very own Claire Winiarek. Claire is the vice-president of policy for the association. She previously held roles with CMS, as well as in the private sector with both Magellan Health and with Anthem. Claire is also a member of the board of URAC, the utilization review accreditation commission. Claire, thank you very much for joining me. Claire (01:09): It's great to be here JC. JC (01:11): Claire, you and I are both residents of the great Commonwealth of Virginia. Our family got our mail-in ballots last week. Are you registered to vote and ready for the election? Claire (01:19): I think we must have gotten our ballots on the same day. Yeah, big day in our house. I've actually been an election official previously. It was an election official for 10 years and never at my own precinct. So I don't know if I really know anything about absentee voting. So as soon as we got the ballot, I filled it out in front of my husband, and my four-year-old got to help us drop it off in the mailbox. So we're ready to go. JC (01:43): That is excellent. And are you going to be volunteering at the polls again this year in this unusual year? Claire (01:48): No, 10 years, I've had my fill. So I'm going to take the day to watch the results roll in, which is something you don't usually get to do when you're behind the scenes. JC (01:58): Well, 10 years, it sounds like you've done your public service. Thank you for that. Claire (02:03): Thanks, I think so too. JC (02:04): So Claire, we're going to be talking quite a bit about the mail today and I'm a little bit curious as we start. What's the most unusual thing that you've had to order through the mail during the pandemic? Claire (02:15): Oh, geez. Probably things for my kids, Twizzlers and other unexpected school-related project supplies, that seem completely normal when you're getting them at a store, but when you have to like type that in at Amazon, just a little odd. What about you? JC (02:34): Well, I'll tell you. We've ordered, especially early on, quite a few groceries. And we found a particular company that looked like it had great deals. And so we tried to order some meat in the mail, like a Beef Tenderloin, and didn't understand it was a restaurant supply company. So the Beef Tenderloin was almost larger than our freezer, and we don't have any vision as to when we'll have enough people in our house to actually defrost and cook that. So just be careful which website you're clicking on. Claire (03:03): Good pro tip there. JC (03:04): Well, let's get into the conversation Claire, and talk about the beginning of the pandemic. Thinking back to March, public health officials recommended physical distancing, governors were issuing shelter at home directives. We were all buying our school supplies and frozen food, and we weren't sure we'd never leave our houses again. Since that time, starting in March, what have the trends been? What have the PBMs seen, in terms of customers using some type of home delivery option for their prescription medications? Claire (03:30): So clearly we've got a top line trend and some more specific point in time trends. It's probably easier to start at the top line. Recent data has shown there's been a really meaningful uptake in the use of home delivery of medications, via IQVIA Institute, which is really a great go-to source for prescription drug spending and use data, whether here in the US or globally. They released a report a couple of weeks ago, showing that home delivery was up 20% through July, year over year. That's pretty big for home delivery, which is usually a smaller portion of the pharmacy channel market, right? JC (04:08): Mm-hmm (affirmative). Claire (04:08): And in terms of point in time, clearly as we entered the pandemic here in the US in March, there was a big effort to make sure you have your maintenance medications in hand, you're doing early refill. So a lot of that uptake we saw at the tail end of the first quarter in March and early April, and it's really dropped down significantly since then. Of course, there was another little spike in June and July, as folks reached the end of their 90-day fill and had to do it again. JC (04:37): So, we saw an increase in demand from consumers for this channel, which makes a lot of sense since we were all sheltered at home. Can you talk a little bit about what PBMs did specifically to respond to facilitate that uptake, and make home delivery more widely available? Claire (04:53): Absolutely. So a couple of approaches here, I think the top one, the outside PBMs were making sure that consumers, patients that were then maybe not were familiar with the mail service channel, were not familiar with home delivery, that they were aware of this really great, reliable and convenient option, and then using the tools that PBMs have, to promote access to home delivery. So part of this was working with the retail pharmacy partners to allow local pharmacies that might have an existing relationship with a patient to do home delivery. Claire (05:27): Another of course is that patient education, reaching out to patients that have an upcoming 90-day fill and saying, hey, let's go ahead and get this filled. Let's get you enrolled in a mail service pharmacy auto-ship arrangement. So you don't have to worry about this, for at least the duration of the pandemic. I think it's really important that as essential as home delivery was early on in the pandemic, it remains such a great option. Even now, folks might not be sheltering in place as we were for most of March and April, but physical distancing is something that's very, very essential at really slowing the spread. JC (06:01): Mm-hmm (affirmative). Claire (06:01): And so home delivery has just been a great lasting option for folks. JC (06:05): You mentioned there as part of the answer, Claire, the partnership between PBMs and some of the local pharmacies to facilitate home delivery. PBMs and pharmacies haven't always had the most collaborative of relationships, at least when it comes to the trade associations that represent the industries in Washington, but they actually came together early in the pandemic to focus on increasing the safety of home delivery, both for those who are delivering the medications and those receiving them. Can you talk about that collaboration? Claire (06:33): Absolutely. Really great and positive collaboration on behalf of patients. So to promote home delivery early on, PBMs and their retail pharmacy partners as you noted, worked together to develop a set of industry best practices for proof of delivery signature requirements. For those that maybe not in the weeds on what those are, it's when you go to the pharmacy in person and you are signing for your prescription to confirm that you have received it. And those requirements are also in place when you are receiving a prescription by mail or through home delivery. So those best practices that were worked through with the retail pharmacies allowed for really practical and common sense alternatives to those requirements. They enabled a minimal, or more minimal, patient and mail carrier exposure when patients receive their medication through home delivery. Claire (07:25): And then in addition to this industry effort, I think it's important to note that from a policy perspective, PBMs also work to educate federal agencies, States and other healthcare stakeholders on the importance of really thinking through those signature requirements through the lens of the pandemic, and making sure that pharmacy professionals, mail carriers and patients themselves weren't put at any undue risk. JC (07:47): And when you think about that very necessary policy change that has been put in place during the pandemic, is that something that you see as lasting beyond whenever we get out of this situation or is this a fairly unique safety measure related to COVID? Claire (08:03): That's a really good question. And I think we'll need to give some more thought to that. The importance of those signature requirements is that they are one of the really limited ways that we can ensure, or really verify, that a prescription was picked up by the patient that it was intended for. So there are fraud, waste and abuse implications of just not having any signature requirements, proof of signature, proof of delivery requirements. And so that's something we want to give some more thought to, to kind of balance fraud, waste and abuse concerns as well as ongoing patient access concerns. JC (08:37): So let's get down to the key question and talk a little bit about some of the politics around these issues. I mentioned at the top, that the US postal service has been in the headlines quite a bit lately, as we approach the election. And in light of adjustments, the administration was considering to how the postal service operates. Some of those headlines implied disruption for patients relying on mail service pharmacy. And it's hard to tell if that's a political talking point or if that's a real issue. And it seems to me, that the question here really is, what are PBMs doing to help consumers continue to feel confident in mail service of their prescription drugs, whatever the potential disruption? Claire (09:13): Well, clearly it's most essential that the more than 266 million Americans that PBM serve have access that's reliable, convenient, and safe, whether you're using mail service pharmacy, or any other pharmacy channel. So that has been top of mind for PBMs throughout not only the pandemic, but as you noted JC, discussion around these operational changes and potential changes at the postal service. So as with any opportunity for disruption, any change, a hurricane or natural disaster that might sort of throw a wrench in the process, PBMs are adjusting their approaches. They're adjusting their shipping methods where it makes sense, perhaps using other carriers to ensure that timeliness. They might also be adjusting when refill prescriptions are shipped, allowing emergency refills at a local network pharmacy, in case of any delay, you make sure you've got it in hand. Claire (10:08): They're also allowing overrides for early refills or allowing for transition fills at retail pharmacies. And then further behind the scenes, they have these really incredible proprietary systems that are mapping the journeys of these medications through the mail. So they can fine tune and make adjustments for when packages are going out, to account for whatever direct disruption might be happening on the ground for a patient. JC (10:32): So, Claire, it sounds like this isn't the industry's first rodeo around these kinds of things. They know how to adjust and adapt. Certainly, I know from speaking to our member companies, they are supportive of a well-funded and fully operational postal service, but they're also well-suited to be able to navigate anything that might be coming their way. And patients should feel confident about this avenue for getting their medications. Claire (10:56): Absolutely. And I know my family does, we find home delivery to be such a great option. I don't have to remember, which as with two little kids, there's not enough for me to keep top of mind. And so I know we feel really confident about home delivery. There've been really great course mitigating tactics that PBMs are using. I do think it's important to note, that point you've just made on a well-funded postal service, that is so crucial and the postal service really allows for the continued affordability of home delivery. So absolutely something to keep in mind as we move forward. JC (11:28): And folks who have tuned into our podcast before know that I'm also a long time mail service customer for my cholesterol medication, which I obviously will continue to need, given the amount of red meat that we have in our freezer. Claire (11:41): Yeah. I'm not going to comment on that, JC. JC (11:44): Let's switch gears away from the pandemic a little bit. You, sounds like you, like me, have been a long-time user of PBM mail service pharmacy. It wasn't just invented during the pandemic. Why is home delivery a good option for many Americans generally? What does it offer beyond the obvious sort of simple convenience of not having to go to the pharmacy? Claire (12:04): Oh gosh, well, let me count the ways. There are so many benefits to home delivery and they're really well-established. We've at this point had more than a decade of really great evidence-based, scientifically-based literature showcasing these benefits. Claire (12:19): Clearly improved adherence rates, that's when individuals adhere to the prescription regimen that they are prescribed. Insurance rates are really, really high for a mail service pharmacy, usually around 87%, compared to 77% when you're picking up your prescription in person. The outcomes that come too, that come along with adhering to your prescription regimen, is also a clear benefit. So those are things like avoiding emergency room utilization or rehospitalizations, because you're not having some of those flare ups or other issues that can happen when you're not as adherent to a prescription as maybe you should be. Claire (12:59): Greater safety is another area, right? We talked about the robotic processes that can be tailored behind the scenes. These mail service pharmacies have gotten just so sophisticated and it's really cut down on the number of dispensing errors that we see. So they're able to just ship out massive quantities of prescription drugs with greater safety rates, lower dispensing error rates than we see at local pharmacies. Claire (13:25): And then I think of course the other piece is the cost savings, right? There is a scale here that makes it a much more affordable option for many. Of course, increased use of generics among individuals served from home deliveries is also another way that we are able to really lower costs through home delivery. But of course, convenience is nothing to discount in any way. Convenience is really, really valuable, the growth of online retailers, the use of them during the pandemic showcases that. So convenience, cost savings, adherence, health outcomes. Great benefits to home delivery. JC (14:00): It would seem though that the one thing the mail service pharmacy may lack is the personal touch, that interaction and advice that a consumer can get from talking face to face to a pharmacist. Is that a pretty big downside to mail service? Claire (14:13): I don't know if it's a downside. Because mail service pharmacies and the PBMs that have them, have pharmacists on staff that often are available 24/7, to provide confidential counseling. Everyone has their own approach to how they want to interact with their healthcare provider. For me personally, I don't always feel comfortable asking really detailed questions at the pharmacy counter or the drive-through, in front of my kids, about whatever prescription we're sort of working through. So it's nice to have that option available when I need it to be available, to talk through my confidential questions. JC (14:47): So, I know it's hard to look far into the future, but once we're out of this pandemic, what do you expect the trends to be? Are people going to continue to get their drugs by mail at the rate that they are now? Or are we likely to revert back to the historical norm? Claire (15:02): That's a great question. And clearly I don't have a crystal ball, so we will see what we will see. But IQVIA has released data, that August data I mentioned earlier, suggesting that some of that increased uptake around mail service pharmacy, will be here to stay. I think it will be really interesting to see, not only with the mail service pharmacy, but also the telehealth and telepharmacy, that telephonic pharmacy consultation that we were just talking about. If these collectively are on the rise and remain on the rise after the pandemic, I suggest they will be, but perhaps not quite as high as we saw at the peak of the pandemic. JC (15:41): And Claire one last question while we're talking about mail, a little bit off topic from the prescription question, but I understand that some PBMs are starting to send COVID home testing kits to patients through the mail. Is that going to become more common? Claire (15:56): Yeah, a really interesting question. So we understand one of our members, United Health Group, early on as really everyone's supposed to be sorting through what types of diagnostic testing is coming to market? What is the safety and efficacy of these? They did actually a pilot in sending some of these kits, test kits, home to check for safety efficacy and the reliability of the results. And that experience was really instrumental in some of the early approval of some of these at-home testing kits. Since then, United Health Group has determined that the swab of the lower nose is just as effective as those like near brains tests that I know some of us have had. Well, we should be thankful we had them, but it's not the most pleasant experience. But the lower swab is really effective. And you're able to send a kit containing that, to a patient at their home to do that at home testing. So, really promising practice that we're seeing out of one of our members. And I think we're, it's a really great idea and we're interested to see what others will do. JC (17:01): Yeah, I know, I've read some headlines about work that CVS is doing with home health care kits that they've sent to patients on their plans as well. I have to imagine others are doing, if not the same thing, similar things to try and facilitate that care at home dynamic for so many people. Claire (17:18): Absolutely. JC (17:18): You talked about testing, which leads inevitably to the vaccine that we're all hoping will be innovated and available sooner than later. And I know at PCMA, that you've been leading a stakeholder group that includes manufacturers, payers, pharmacies, PBMs, wholesalers, and others. That's been focused a lot of the time this year on drug shortages, and now is starting to have conversations about that eventual vaccine. What is your takeaway from those conversations? What's the outlook and the plan for distributing a vaccine, and where do PBMs come into the equation, if at all? Claire (17:53): Really, really good question. So let's sort of break that down one by one first. Just to take a sidenote, PBMs have been leading this really fruitful and meaningful collaboration with other drug supply chain partners, including pharmacies as we noted earlier, the best practices, but also manufacturers, grocers, hospital pharmacists. So it's a really robust conversation that we've been engaged in since March, on a weekly basis. Great example of collaboration. Claire (18:22): We've been talking about drug shortages. We continue to talk about drug shortages and how we can work together to address those, but clearly vaccine access when we have a COVID-19 vaccine or vaccines approved, is going to be so top of mind for everyone. So we've been thinking through, how are ways that the supply chain can support an evidence-based, scientifically-based process of having these vaccine candidates evaluated and approved? Also, how do we ensure science is at the center of any allocation framework? Claire (18:54): That's really determining who's at the front of the line for these vaccines. We know there won't be enough vaccines in the early days. And so, it's really important to get that allocation framework right, to make sure that the folks that need it, that can help slow the spread, are having access to it until we have enough supply to go around. Claire (19:14): So I think these are really important questions around the safety of the vaccine, the approval process for the vaccine, thoughtful processes on allocation, ensuring preparedness of all of the healthcare stakeholders, when we get ready for distribution. These are all issues that I know our coalition is really interested in working on. And again, top of the mind has been thoughtful, transparent evidence-based processes to inform the entire lot. JC (19:40): Well, that's really important work, Claire, that that coalition is doing. And I'm glad that there is that robust dialogue going on. Anything that will get us there faster is positive. Claire (19:50): Absolutely. Couldn't agree more. JC (19:52): Well, Claire, thank you so much. Not only for your time today, for the work you're doing on behalf of industry and in the name of public health, we really appreciate your work. And I enjoyed this conversation. Claire (20:01): I did too. We should do it again sometime. JC (20:04): That sounds great. And I want to thank everyone for listening and hope that you found the conversation informative as well. If you haven't done so yet, please subscribe to The Pharmacy Benefit on Google, Apple, Spotify, or any of your favorite podcast sites. I'm JC Scott, take care.