Would Canadian pharmacy employees vote for pay and submit?

I believe they would!

There are a couple of points worth highlighting for readers not involved in the Canadian community pharmacy space to help in understanding why the Canadian pharmacy community is pushing back against American style Pharmacy Benefits Manager initiatives in Canada. As always, my views are my own and not necessarily shared by the organizations I am professionally affiliated with.

PBMs created the online claims process in the late 80s or early 90s to make it more efficient for THEM to process claims. Before that, insurers and PBMs required their own employees to evaluate and process millions of paper claims that were being submitted by patients and pharmacies.

I admit that pharmacies received benefits from submitting online claims too. The online system was more efficient for pharmacies than mailing in paper claims, and pharmacies received reimbursement faster than submitting claims manually. What has evolved over the years is something completely different. Today, Express Scripts Canada may be the largest private pharmacy benefits manager in Canada and it appears they may be using their position in the market to impose American style fees on pharmacies north of the border. Further, the systems and policies that have been designed by the insurers and PBMs, like Express Scripts Canada and others, have now become so complex and technical that some of them are virtually impossible for pharmacies to comply with.

I’ll state upfront that I do not condone insurance fraud of any kind. At the same time, the audit processes the PBMs have developed over time are now overly punitive. It is no longer a question of whether there was intent to commit fraud. Even when patients have received the services that were claimed, at the correct pricing, payments are often clawed back by the PBMs over innocent technical errors such as choosing the incorrect office address on a claim for a prescriber who works out of multiple clinics.

Different insurers and PBMs often have completely different rules. Think about today’s two-income families, where households often have more than one benefits policy, The pharmacies must try and coordinate those two policies each time they submit a claim for a prescription. The pharmacy submits a claim and waits for a response to come back from the first PBM, and then they submit the remainder of the claim to the second PBM and wait for a response and so on. Some patients have more than two active plans.

Pharmacies have done their level best to try and help patients navigate their coverage. The result, however, is that in every pharmacy in the land, literally hours of staff time per day are spent on hold with PBMs trying to help the patient with something that pharmacy does not get paid to do.

Now, among other consequential changes that are being imposed by Express Scripts Canada, they are implementing a monthly charge to pharmacies for providing online claims services for THEIR end user clients. That’s ridiculous, and there is no option for pharmacies to opt out, other than to terminate their ESC Provider Agreement.

I recognize that pharmacies are businesses, but pharmacists are frontline healthcare providers. The pharmacists, technicians and support staff who spend countless hours each day helping patients navigate their benefits plans don’t want to put their patients through the inconvenience of having to pay out-of-pocket and submitting. At the same time, pharmacy staff absolutely abhor having to call insurers and PBMs so many times each day (for free). My sense is that if pharmacies polled their staff at the counter for their recommendation, given that ESC is now going to impose a charge on pharmacies for the privilege of providing online claims services for their clients, the resounding response from staff would be to tear up the ESC Provider Agreement. They’ve had enough!

These are some additional thoughts about why ESC may have just broken the camel’s back. I believe that if we were to poll frontline pharmacy employees about what they would recommend as the appropriate course of action, the result would be devastating for the PBMs and insurers.