Tuesday, August 8, 2017

Florida Legislature Mandates Patient Convenience

Most Floridians will not have heard of Senate Bill 800 (SB800), which passed last spring (2017). But it is an important bill and potentially provides us important lessons. 

I have heard complaints about the frustration in obtaining medication through various workers' compensation systems. About a year ago, I wrote Pharmacy Frustration, in which a story about recurrent prescription frustration was highlighted. I have written about drug formularies and Prescription Cost Control. And this post is focused on pharmacy and an improvement brought to Floridians in the 2017 legislative session (without much publicity or hoopla). 

Much of the world we live in is about economics. Most people I talk to are oblivious that they are making economic choices in their daily lives. Oh, they get the money part, and whether they do or do not have enough money to do what they want. But economics is so much broader. When we decide we do not have enough time to watch a particular television show, because we "need" to clean the living room, that is an economic choice. It is supply and demand, too little time and therefore economic choices. 

Several years ago, I lectured a high school class on economics and value. I showed them pictures from my local grocery, paired together. One was of a pre-packaged steak, the other of some specially-prepared steak kebabs with the same meat, some vegetables, on skewers and re-packaged. One was of some sliced meat and condiments, next to another of pre-made sandwiches in the deli case. There were several other examples. My question for the students: "what are you buying in the kebabs and sandwich that you are not buying in the (less expensive)  composite ingredients?

It was a little frustrating. The class did not grasp the answer either easily or quickly. But they eventually came around. The answer is simply "convenience." You can buy ingredients and make food (using your time), or you can buy the food in a more convenient form and save yourself time. The downside is that this option will likely cost more money. An economic choice in which you decide whether you value your time or your money more highly in that particular instant. 

Multiple similar examples could be described, but space is limited. In short, every retail experience is offers a combination of product and service. Arguably, some retailers are majority service or majority product, but all contains some of each. Notably, service is a difficult sector of the economy. I have worked in the service sector for most of my life, and can vouch for the many challenges it includes. 

Returning to pharmacy, there is certainly a product element in medication. The patient is prescribed medication and we need to purchase it in our local community. They travel to a pharmacy. In Florida workers' compensation, the patient travels to their own choice of pharmacy. In other states, workers' compensation patients may be more limited, as recently described in a WorkCompCentral article about Louisiana. 

In this regard of pharmacy choice, Florida workers' compensation is perhaps becoming an exception, as pharmacy benefit management has come into vogue, and many group health carriers are limiting or specifically directing pharmacy care. So, when you purchase coverage from a particular health insurer, you may be forced by that contract to use a particular pharmacy. This kind of agreement delivers the pharmacy company a large and dedicated clientele, in exchange for which it delivers a lower-cost service to the insurance carrier. It is an economic decision about the patient, if perhaps not a decision of the patient. 

Of course, the patient retains some decision-making authority also. You decide from whom you purchase an insurance policy. Sure, purchasing an individual policy yourself, instead of buying the plan offered by your employer or organization, may costs hundreds  of dollars more. However, through such a policy you may have more physician selection, more access to various pharmacy, or other benefits. In deciding which coverage to purchase, you are making a cost-benefit decision, just as the carriers are making cost-benefit decisions in structuring their plans and setting prices. 

A complaint I hear about pharmacy comes from people who take multiple medications. I know one person who takes a daily pill that is filled in 30 day supplies, another that is filled in 90 day supplies, and yet another that is also filled in 30 day supplies. This patient has taken all three medications for years. And here is the rub, you might think that this results in one monthly trip to the pharmacy. No, in this instance, this results in at least two monthly trips to the pharmacy, sometimes three. 

You see, the prescriptions were not all instigated at the same appointment. None of us ever scheduled a doctor's appointment with the thought of making the appointment coincide with the monthly anniversary date of some existing medication. So, we visit the doctor, receive a script, and go pick it up at the pharmacy. Thus, patients end up, over time, with various prescription dates and therefore re-fill dates. 

Pharmacy managers will remind us that most scripts can be scheduled for home delivery and they tout the convenience. I have a friend that has been through many hoops with that, and has utterly failed to connect the Pharmacy Benefit Manager (PBM) and doctors on the "same page." Hours of phone work have resulted in success with mail delivery of one of several medications. Why not keep trying regarding mail delivery of the others, I asked. The response is simple, how many hours will be devoted, and will there be results. This is another example of consideration of your time, a cost-benefit analysis. This friend has given up and finds it less time-consuming (or time wasting) to drive by the pharmacy than waste hours on the phone setting up mail service options that have not born fruit. 

In a world in which customers have freedom to choose, customer service might reign. I know an elderly friend who consumes many meals at a local fast food provider, but persistently complains about the food quality. I asked one day, why do you keep going there. He answered, "they have great service and I enjoy the people." Service rules his decision to persistently eat food with which he is not impressed. The quality of the service drives his consumption choice (another economic decision). 

But in a world of PBMs and decisions made by others (such as your employer selecting health insurance to offer at an economically advantageous price), we may have less consumer choice. In that instance, the providers or pharmacy may feel they have less motivation for us to be satisfied. Let's face it, if your insurance carrier only allows you to use ABCXYZ pharmacy, you are going back there, and they know it. They may have little incentive for customer service or satisfaction. 

Into this mix stepped the Florida Legislature with 2017's SB800. This bill will:
require health insurers and health maintenance organizations, respectively, which issue or deliver certain policies or contracts to offer medication synchronization to allow insureds and subscribers to align refill dates for certain drugs at least once in a plan year.
See, the patient can now force the insurance company or PBM in Florida to make those refill dates line up. The patient described above with the two 30 day and one 90 day refills, will now be able to go to the pharmacy once month for refills, instead of two to three times. The patient will get some convenience from legislation. Convenience that competition might have brought, but which has required legislation due to the structure of our health insurance system. 

On the surface, this will likely seem a pleasant surprise from our legislature. Certainly, it will be a benefit for those who require multiple medications, particularly those for whom driving may be a challenge. In time, there is certainly the chance that PBMs and pharmacies will raise their price to accommodate for this mandated shift; more patient/customer convenience may mean less pharmacist convenience. As convenience shifts, the price point may also. 

Some will argue that the pharmacy suffers no inconvenience in this, but synchronizing will require personnel time. Time is money. That time invested in synchronization may be recouped by the pharmacy, as the result should be less customers to wait on (with the customer coming only once per month to be served, rung-up and bagged) instead of thrice. In the end, it may be that pharmacies will gain efficiency and save money through the legislative mandate. 

Time will tell whether this legislative mandate affects price. But, in the short-run at least, it appears likely to increase patient convenience. 

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