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Welcome to today's edition of Waypoint Unscripted. This is Ben Coakley with Waypoint RX. I am so glad you're here. Today's topic is going to be the high cost of convenience. This was inspired by the story of my grandfather, and his switch to mail order many many years ago, which ultimately cost him his life, and cost my family many years without him being present with us.

Welcome to the May 31st edition of Waypoint RX Unscripted. Today's topic is going to be PBM doublespeak. Before I get started I want to just give you one little caveat here. There are plenty of really good people who work for PBMs and I'm not really sure that they truly understand what PBMs actually are doing to pharmacy owners.  One of my good friends said recently, PBM employees really drink the PBM Koolaid. This blog is not an indictment on specific people in the PBM industry, this is just an indictment on how PBMs try to position themselves.

We have a saying in the South when someone uses double speak. We say they are "speaking out of both sides of their mouth." Keep this in mind when I share a recent story with a PBM rep. I was at a conference recently and met a PBM rep there. In our conversation, she kept referring to PBMs as friends to pharmacy owners. She actually said, "We can be the best friend to pharmacy owners." I started thinking, "What does being a best friend mean?" My best friends, I have two of them, would drop anything or almost anything to be with me when I'm in need. One of my best friends currently lives in Atlanta. My wife and I were moving out of our house (so she could be closer to her Pharmacy School) and we were forced to move out of our house a little bit earlier than we anticipated. He actually got in his car, drove down from Atlanta to Greenville, about two hour drive, and rented a U-Haul, showed up at my door, knocked on my door and had a U-Haul truck sitting outside. He helped me load up all my stuff, take it. My wife was about eight months pregnant at the time so she wasn't going to be as much help as she would have liked to be, but that's what a best friend does. He didn't ask. He didn't call. He just showed up when I needed him. I wonder sometimes, are PBMs really best friends to pharmacy owners? I wonder why people who work for PBMs think they're friends to pharmacy owners.

I then started asking questions like, "Why would PBMs assess DIR fees and not let pharmacy owners what they are 'til six months down the road? If you truly are friends to pharmacy owners, why wouldn't you try to help them with DIR fees?" She said, "Well, we don't make any money on DIR fees." I responded, "Well, when you collect them what happens to them?" She said, "We give a bunch back to CMS, and then we keep certain amount to put programs together for our customers." I said, "So you technically are making money. You're actually building brand value by using DIR fees." Of course she responded, "Well, no we don't profit from DIR fees. We just break even on that." I'm not really sure that she understood that you can actually profit in other ways than what's on your financial statements.

Then I asked her, "Do you think it's unethical that your PBM owns a mail-order pharmacy?" She said, "Absolutely not." I said, "So do you feel like your PBM is treating that mail-order pharmacy consistently with the way you're treating independents?" She said, "Absolutely." Well, at this point one of my friends decided to come over and I asked him the question. I said, "Do you feel you get treated the same way as this particular mail-order pharmacy?" He said, "Well, I'm not really sure how anybody could actually say that with a straight face." I said, "Well, what's your opinion of the PBM industry?" He politely said, "I wouldn't hose them off if they were on fire." That's the PG version of what he said. I'm not going to get into what he actually said here. I looked over at this representative of the PBM and I said, "That's what independent pharmacy owners think of you." She of course was perplexed and said, "I don't understand why."

We then started talking about a few other issues and one of my other friends from the state of Arkansas came over. He started asking questions about compounding and why PBMs don't reimburse for compounds. Through that process, this particular PBM rep said, "Well, you know, you're in a really good state for independents."  He said, "Yeah, we are." He said, "I'm very thankful to be in that state." She said, "Well, you know, we've been trying to work with Blue Cross Blue Shield of Arkansas to get them to move down the continuum of reimbursement." This of course piqued my interest because that is a very intersting statement for her to make. So, I asked her "What the heck does that mean? What is moving down the continuum?" She said, "Well, this particular insurance company overpays pharmacies in Arkansas." I said, "So moving down the continuum ..." She interrupted me and said, "Yeah, that's just trying to get them in line with what market rates are." I said, "So you're actively soliciting this particular insurance company in Arkansas to reimburse community pharmacies less." She said, "Well, no no. No no no." Then I said, "I have witnesses who heard that." I then said, "And how are you the best friend to pharmacy owners again?"

That's PBM doublespeak. That's, "Oh, you need us over here, but on the other hand we're actually going to admit that we're trying to get you lower reimbursements." There's something really seriously wrong when somebody who represents that company actually doesn't understand what is going on.

Finally the last thing we talked about was something really outlanding. She said, "Well, you know, I run this up the chain. I float these ideas by one of the major associations in the independent pharmacy community, and they pretty give us the thumbs up on  a lot of the stuff that we do." I looked at her and I said, "So you're telling me one of the leading associations in this industry gives you the thumbs up to basically take advantage of their members?" I said, "I just don't believe that." She said, "Well, I run it by certain people at this association." I said, "I absolutely refuse to believe that this association is rubber stamping these things. I said, "There would be a mutiny worse than The Bounty, if you ever have heard that story.

These are the things that PBMs and PBM reps are telling people. They're saying, "You need me. We're great for you," and then on the back end they're also telling us the things that they're doing to hurt us. Whether that's intentional or unintentional, I'm not sure, but this particular case I believe it was completely unintentional. But the idea is that if we actually dig deep enough, we can actually find out their motives. It all starts with asking the right questions. If we get a chance to meet with PBM reps, we need to do that. As much disdain as we have for them, we need to take the time to learn what they're doing, learn what their people understand about them, because I'm not really sure that we're ever going to change the PBM industry without changing the people who work for the PBMs. We need to help them (the ones who care) understand truly what is going on behind the scenes and how that negatively impacts community pharmacies.

Thank you for your time today, and I hope you have a wonderful rest of the week. Happy Memorial Day out there to all the veterans and we are very thankful for all the people who made the ultimate sacrifice (1.8 million). Finally, I want to give one more shout out to my mom. She is 64 years young today. Happy Birthday.

Visit our website:www.fightbackmovement.com

Did you know that revenue goes up the happier your patients are? In our never ending journey to help pharmacy owners have more personal, financial, and ownership success, we have only come across a few ideas that we feel should be a part of all pharmacies. This idea we will discuss today is tracking patient satisfaction.

This is more important now than ever because PBMs are trying to coerce your patients to use their preferred pharmacies or their mail order pharmacy. One bad experience for any patient may result in them making the switch. You know better than we do that you cannot afford to lose any patients in today's pharmacy environment.

We have known that this is an issue in the retail pharmacy world for some time. We even created a survey concept that many owners used for some time. However, like most surveys, we experienced the typical problems associated with surveys: cumbersome to administer, low response rate, etc.

Pharmacy owners are no stranger to crazy, outlandish stories from insurance companies and their representatives. That is why the story I am about to share most likely will not come as a shocker to any of you who read this.

I was in meeting with a large insurance company in my state this week. When they were reviewing the benefits of their new policies, I noticed there was a significant amount of love for CVS and Caremark. I just so happened to know that Caremark is the PBM this insurance company uses for their prescription benefit management. So, it wasn't a surprise to me that they chose to use them in their examples.

They also mentioned at some point their pharmacy network. I decided to look up their network to see which pharmacies are currently in it. I noticed that there are many independents in the network. At that point I was a little curious why the independents were not mentioned anywhere in the presentation, especially when they were going through the prescription benefits and in network pharmacies.

Understanding what I know about community pharmacy, I informed the gentleman sitting next to me that they didn't even mention the independents. He agreed that this was a little curious especially after I mentioned that almost half the prescriptions filled in the US are filled at independents. I told him that I was going to ask the presenters why they didn't mention the independents and he agreed to join me to hear the answer.

I walked up after the presentation and asked the presenter (she just happened to be a high ranking executive of the company) why there was no mention of the independents. She actually said to me, "I don't know." I then asked her if she knew what percentage of scripts in America are filled by independents. She said she did not know. I informed her and she was very surprised.

This is where the story gets good. I then set my sights on their relationship with Caremark. I asked her if Caremark pressured them to recommend mail order to their agents. She said that she would not comment on that. I then asked her if she ever gets concerned about what Caremark bills her company for the management of the drug plan. She asked me to elaborate. I told her of a story I once read where Express Scripts billed an insurance plan $485 for a drug and reimbursed the independent $20. And to top it all off, I said it cost the pharmacy $40 to purchase the drug. The first thing she said is that it is big pharma that is wreaking all the havoc on drug prices. She then said that the pharmacy needs to negotiate a better contract with the PBM. Once she finished, I acknowledged the issues she brought up are legitimate but they didn't answer my questions. I repeated my question, "Are you concerned about what Caremark charges your company for prescription drug management?" I will never forget her words. She said "Sir, I really appreciate your time and concerns, but there are other people who I need to speak with."

She essentially told me to take a hike in a very nice way. My immediate thought was, "I hope you are joking." This is a legitimate expense that all insurance companies need to look at because most of them aren't doing so well in our current environment. It makes me wonder what her motives were for moving on from our conversation. Maybe one day we will know the full truth.

We hear all the time that you must find balance in your life. The more and more I think about this, the more and more I don't like the word balance. I do not think it accurately reflects what is possible in the real world. The reason for this is because someone asked me the other day what I would do if I found out someone in my immediately family had a terminal illness. I then asked myself would I work as much as I do now? Would I dedicate as much time to my social life as I do now? Or, would I want to spend as much time as possible with my loved one? We all know what the answer should be in this series of questions.

What this person was asking me meant is would family be more important than work or social at that point in your life? The answer for most people would be yes. This means that your family life would be weighted more than the other areas of your life. This is the exact opposite of balance. Balance insinuates that everything is equally weighted in your life all the time. There is no way this is possible. Not only is the above situation plausible, there are an infinite number of scenarios that can cause one area to be more important than another.

So let's all agree to stop using the word balance and start using the word harmony. Harmony means that as things ebb and flow, we consistently keep the right perspective. It means that we know things are out of whack sometimes and we need to work diligently to get them back to "Homeostasis."

There used to be a program called the Wide World of Sports that came on when I was a child. We would all gather around the television to watch it because it had some of the most fascinating things we have ever seen. Then one day the producers took it to a whole new level: they released a bloopers edition.

These bloopers were designed to highlight the lighter/funnier side of sports. The premise was that sports are often too serious and competitive. They wanted to provide some humor in this serious world.

I think pharmacy is often like that. It is a world full of serious issues and complications, serious people, and sometimes serious insanity. A little humor every now and then can help us get through the long, hard days we experience in the pharmacy world.