Specialty patients in Los Angeles could be forced to use mail-order, advocates say

NEW YORK — Thousands of patients in Los Angeles with serious, chronic diseases could soon find themselves unable to get their drugs from community pharmacies, advocates for the pharmacies said.

Over the past several weeks, specialty pharmacy patients — most of them HIV patients, as well as those with cancer, autoimmune conditions and other disease states — covered by Anthem Blue Cross have received letters from the health insurer stating that starting Jan. 1, 2013, their drugs will only be covered if they obtain them through mail order from CuraScript, a mail-order pharmacy owned by pharmacy benefit manager Express Scripts, while those who continue to use retail pharmacies will have to shoulder the full cost of their drugs, antitrust lawyer David Balto told Drug Store News. Balto, who was a policy director of the Federal Trade Commission during the Clinton administration and brought some of the first cases against PBMs and often represents community pharmacies, began advocating for the Los Angeles pharmacies after several of them contacted him when their patients began receiving the letters.

"As part of  our efforts to enhance healthcare affordability, Anthem Blue Cross has contracted with a vendor to purchase certain high-cost specialty drugs in bulk and provide them via home delivery to our members," Anthem spokesman Darrel Ng told Drug Store News. "This action, among many others undertaken by our company, helps moderate healthcare costs.  We think this is important at a time when businesses and individuals are deciding whether they can afford to continue to maintain health benefits coverage. In addition, studies suggest that home delivery of prescription drugs can improve medication compliance and a recent study has even shown enhanced health outcomes."

Express Scripts declined to comment further.

While no lawsuit has been filed, and Balto said he and the pharmacies for which he is advocating were exploring options and examining whether Anthem's decision violates any anti-trust laws, the dispute is an example of the often testy relationship between pharmacy retailers — particularly independents — and PBMs. PBMs say mail-order represents a more cost-effective and efficient way of getting drugs to patients and say mail-order saves customers money on prescriptions compared with brick-and-mortar retailers. For pharmacy retailers, however, not only does use of mail-order cut into their business, it also means that patients don't have access to the kind of face-to-face interaction that the retailers say many of them need and tout as their key advantage. PBMs have also emphasized that they offer 24-hour access by phone to pharmacists and nurses, including pharmacists whose entire focus is on a specific condition such as HIV and who know all the drugs, interactions and other issues involved. But Balto said a "disinterested voice at the end of a 1-800 number" isn't enough.

"This is far more than just dispensing drugs," Balto told Drug Store News. "People will lose those services, and that will threaten the continuity of care they receive."

Balto said that while mail-order may be appropriate for some patients, it's not for patients with complex, chronic conditions like HIV. Specialty pharmacists themselves also say their role goes far beyond dispensing.

"Putting a label on the bottle — that's the least of what we do," Marva Brannum, a clinical pharmacist at Edwin's Prescription Pharmacy, one of the pharmacy's Balto is representing, told Drug Store News. "The care is actually part of the prescription."

Brannum, who has worked with HIV and AIDS patients for nearly 30 years, said working with patients also included knowing the psychological and social issues involved with their disease states, fitting medications into their lives and being able to alter their therapies quickly when needed. For example, some patients are homeless or transient and don't have the option of receiving three-month supplies of drugs through the mail or are living in a situation where other people don't know about their status. Working with patients directly also allows pharmacists to know about drug interactions. "We are an extension of the patient's clinical team," Brannum said.

For Brannum, it's not just knowing the drugs the patient uses, but knowing the patient. "The most intricate part that leads to quality outcomes and leads to decreased costs for us is knowing the patient in total," Brannum said.

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