In today’s health care market, consumers generally access prescription drug coverage through their managed care plan. Recently these health plans have begun to use limited and restricted networks of providers to hold down costs. In all cases these “narrow networks” reduce consumer choice in lieu of lowest cost services by limited providers willing to take lower reimbursement in favor of increased volume. In pharmacy, this often results in limited access to prescription benefits to large box stores or mail-order facilities.
Thanks to extremely important advances in drug research, pharmaceutical therapy is the single most affordable and effective treatment of today’s routine and most complex health conditions. Independent pharmacies offer extremely generous access to a number of health care services in the retail setting, including medication, counseling, as well as medication adherence and disease management programs.
To ensure patient access to care, many states – including Texas, have adopted “Any Willing Provider” laws that require managed care companies to allow health care providers to become network providers based on geography or other characteristics, so long as a provider is willing and able to meet the conditions of network membership set by the carrier – including, but not limited to reduced reimbursement.
Independent community pharmacists, considered the backbone of health care infrastructure in towns across the state, are often not offered contracts with managed care companies to serve consumers in their communities, which may result in deterioration of chronic conditions, more physician visits, higher utilization of emergency rooms, and extended hospital visits.
The Alliance of Independent Pharmacists (Alliance)
has worked tirelessly with the legislature and the Texas Department of Insurance (TDI) to enforce the intent, spirit, and specific wording of Any Willing Provider laws as written in Texas statutes. Those efforts have been mitigated by legal arguments offered by managed care companies, specifically stating that federal laws regarding self-funded or ERISA plans fall outside of the jurisdiction of state insurance laws.
Policy advocates, insurers, providers, and consumers rank access to health care as a priority with regard to health and well-being. Pharmacists in underserved areas are witness to patients seeking additional choices and more competition when it comes to their health, including but not limited to drug therapy management services, wellness clinics, disease management services, preventive screening programs, and direct communication with pharmacists about specific concerns with their prescription drug therapy. As a result, many other health costs are often overlooked when considering the effect of limited access to care.
Current state “any willing provider” laws are designed to enhance free market principles, access to competition and choice, yet remain unenforced. Simply put, exclusive networks designed by managed care companies limit consumer choice and diminish innovation and quality of care for all Texans. Further, a true free market and competitive environment allows for bidding of contracts from all interested and able participants. Today’s restrictive networks do not solicit competitive rates, they serve to restrict pharmacy participation as a means of controlling costs, limiting formularies, and managing utilization of pharmacy benefits – all of which negatively impact consumer access to appropriate pharmaceutical care.
The Texas Legislature through legislative action, amendments, and interim studies has acted on behalf of enhancing access to pharmacy competition and benefits for several years, dating as far back as 1991. As of today, the Texas Attorney General has been requested to give opinion as to the standing and status of Texas laws in light of federal preemption laws. A favorable opinion of the standing of Texas laws will provide the guidance the legislature is requesting. In light of Texas’ legislative intentions and recent federal court decisions, independent pharmacists look forward to enforcement of current “any willing provider laws” or will again seek further clarification from the legislature in 2017. Stay tuned.
The Alliance of Independent Pharmacists of Texas (Alliance) is a not-for-profit 501 (c)(6) corporation dedicated to the advancement of independent community and compounding pharmacy interests at the state and federal level. The Alliance represents more than 600 independent pharmacy owners to ensure the economic viability and security of independent community and compounding pharmacy in Texas. The Alliance provides a forum for those practicing in community pharmacy to exchange information, develop strategies, goals, and objectives that promote community health and wellness, in addition to the advancement of the profession.
The Alliance began in 2004 as a strong group of independent pharmacy investors within the Texas Pharmacy Association Academy of Independent Pharmacists. Pharmacists responded to concerns of independent community pharmacy by uniting to ensure the future of the practice.