You have to go all the way to page 242 of the Centers for Medicare & Medicaid Services' (CMS) fiscal year 2022 budget to find information about direct and indirect renumeration fees (DIR fees), but once there, the information is truly shocking. The document reads, "The data show that pharmacy price concessions, net of all pharmacy incentive payments, grew more than 91,500 percent between 2010 and 2019."
And there you have it. Pharmacies have long known that DIR fees were increasing at an alarming rate, and dramatically affecting their bottom lines, but who knew it was by 91,500 percent?
Not surprisingly, the CMS admission was met with shock by many in the pharmacy profession. "This is absolutely unsustainable," B. Douglas Hoey, chief executive officer of the National Community Pharmacists Association (NCPA), said in a press release. "It's completely out of control," he added, noting that "for context, a $4 gallon of milk increased by that much would cost $3,660."
Hoey also noted that the typical community pharmacy pays roughly $81,000 each year in DIR fees, and that DIR fees have been cited as a reason why hundreds of pharmacies have closed their doors in recent years.
DIR fees are imposed on pharmacies by pharmacy benefit managers (PBMs), ostensibly as a way to reconcile rebates and price concessions that affect the price of a drug. However, these fees are usually collected after the point-of-sale and concern transactions long-settled in the pharmacy's books. Pharmacies have long complained about the seemingly arbitrary way in which fees are "clawed back" and the alarming rate at which they have increased. As a matter of fact, last year as pharmacists were at the front lines of the pandemic, NCPA reported 66 percent of pharmacies were experiencing negative cash flow issues due to DIR fees and decreasing reimbursement rates.
Not surprisingly, pharmacy groups including NCPA, the American Pharmacists Association (APhA), National Alliance of State Pharmacy Associations (NASPA), National Association of Chain Drug Stores (NACDS), National Association of Specialty Pharmacy (NASP), and the American Society of Consultant Pharmacists (ASCP), have put DIR fee reform at the top of their priority lists. In January 2021, NCPA filed a federal lawsuit against the Department of Health and Human Services to address the way DIR fees are assessed. That lawsuit currently awaits action.
In the meantime, pharmacies are left to hope for relief, either from a judicial win or enactment of favorable federal legislation. That doesn't mean though, that pharmacists can't find ways to avoid the "sticker shock" that often accompanies a DIR fee assessment.
PrimeRx™ users in particular have a valuable asset at their disposal, with several capabilities that allow pharmacies to proactively anticipate DIR fee amounts and maximize performance in critical areas upon which fees are assessed. A comprehensive discussion of these capabilities is included in Micro Merchant Systems' white paper, "PBM Fees and the Pharmacy: Using Technology to Document and Analyze Bottom-line Impact." A complimentary copy of the white paper can be accessed by clicking here. An overview of these capabilities includes:
PrimeRx Planning Tool. The system's unique "planning tool" allows pharmacies to anticipate future DIR fees based on historical averages for a particular plan. This information is quite valuable since DIR fees are generally not clawed back until after a transaction has settled and been reconciled in a pharmacy's accounting system. With the planning tool, pharmacies have a basis on which to predict fees, which can help with budgeting and forecasting. Pharmacies also gain visibility into the tremendous impact of these fees on their bottom lines.
Performance Metrics. PBMs assess DIR fees based on a pharmacy's performance in key areas including CMS "Star Ratings" criteria. PrimeRx™ system can help pharmacies improve performance in "Star" categories with capabilities that include:
Although there is no "silver bullet" that will eliminate the impact of DIR fees on a typical pharmacy, capabilities offered within PrimeRx™ can add visibility and help document a pharmacy's performance on the metrics upon which DIR fees are assessed.
News that DIR fees have increased by more than 91,000 percent over the past ten years is simply unconscionable. Perhaps this shocking number will be the jolt lawmakers and regulators need to finally recognize the impact these fees are having on the pharmacy industry. Until then, PrimeRx™ will continue to support pharmacies by helping them to better anticipate, and plan for, fee assessments