[Congressional Record Volume 161, Number 153 (Tuesday, October 20, 2015)]
[House]
[Pages H7016-H7023]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
HONORING AMERICA'S PHARMACISTS
The SPEAKER pro tempore. Under the Speaker's announced policy of
January 6, 2015, the gentleman from Georgia (Mr. Collins) is recognized
for 60 minutes as the designee of the majority leader.
Mr. COLLINS of Georgia. Mr. Speaker, I appreciate the opportunity to
be here this evening. It is a good time to be back here on the floor
tonight, especially after coming back from a week, I am always very
pleased to go see home, be a part of folks who get outside this
beltway, get outside where they get up in morning, they go to work,
they do the things that families do and communities do, and they do so
with a sense of purpose and work.
I think tonight we are going to bring to light, during our time
together, we are going to talk about some of the great folks, our
American pharmacists and the battle that they carry on every day. They
are true champions on the front lines of health care.
Tonight we are going to be joined by several people. My good
colleague from Georgia, Buddy Carter, is going to be here. Dave
Loebsack from Iowa is going to be here as well. We will have many
people come in and out.
Over the next 60 minutes, I hope the words that we speak will
encourage and inspire those who care for our constituents in their time
of need.
Back in 1925, the first celebration of National Pharmaceutical Week
was held October 11-17. In 2004, American Pharmacists Month was
launched to bring greater awareness to the expanding role of
pharmacists in the healthcare system and recognize their unwavering
commitment to patient care.
On October 1, we celebrated Pharmacist Appreciation Day and
participated in the third annual tweet-a-thon. This year, there were
7,214 tweets from 1,285 tweeters, and I wanted to share some of my
favorite ones at this time.
They say:
Can you give me a flu shot through the drive-through?
We do more than count pills. We ensure medication safety
for our patients in a variety of settings. We save lives.
We filled insulin for a patient after she was refused by
the big box pharmacies.
What does Batman have in common with your pharmacist? They
save lives.
I wanted to be a pharmacist because in my small town,
doctors rotated in and out, but the pharmacist knew my
community.
Every year, the American Pharmacists Association Academy of Student
Pharmacists creates a national theme to encourage and advocate for the
profession of pharmacy, and this year the theme is: Live your ``why.''
We are going to come back to that a lot tonight, Live your ``why.''
It is incredible to read the outpouring of stories from student
pharmacists around the country.
Hannah Holbrook is a pharmacy student at ULM, one of the most active
and committed student pharmacist chapters in the Nation. She told a
local paper: ``Even as students, we can be leaders and have impact on
patients.''
I believe the next generation of pharmacists is going to do truly
remarkable things that could radically transform patient care, but it
won't happen unless Congress acts. We must act to level the playing
field so independent and community pharmacists can not only compete,
all they are asking for is a chance, and we need to make sure that we
step up and do that.
Tonight, like I said, we are going to share from many as we go
tonight, but I want to start off with Representative Blum, who has come
down to speak
[[Page H7017]]
with us. He has got to run off on some other events, but we wanted to
get you here tonight. We are glad that you are here to speak on this
important issue for your community and others.
I yield to the gentleman from Iowa (Mr. Blum).
{time} 2000
Mr. BLUM. Mr. Speaker, I rise today in support of pharmacies across
the country, especially the independent community pharmacies who
operate in a tough business climate to serve rural areas and provide
patients with convenient, affordable, and personal care.
In my home State of Iowa, 72 of our 99 counties are considered
medically underserved; and of these, 27 are served by only one
pharmacy. Many of these areas are rural, and a large number of citizens
in these sparsely populated areas rely on their community pharmacy for
access to lifesaving drugs and treatments.
Unfortunately, the implementation of Federal policy to address the
rising costs of drugs has left independent community pharmacists at a
disadvantage. Often unable to cover the costs of maintaining and
managing a storefront, community pharmacies are closing their doors at
an alarming rate. This leaves many Americans without access to the
timely, efficient, and personal patient services they provide.
To that end, I am most happy to cosponsor H.R. 592, to ensure that
pharmacists are recognized as providers under Medicare part B so that
my constituents can have access to local healthcare services instead of
traveling long distances to seek out care.
Additionally, I am also proud to work with the gentleman from Georgia
(Mr. Collins) as well as my colleagues across the aisle, such as
Congressman Dave Loebsack from the Second District of Iowa, to lower
the cost of drugs and promote fair competition and choice, which will
ultimately benefit patients.
I will continue to work to pass legislation, such as H.R. 244, to
increase the transparency of drug payment rates under Medicare part D
and TRICARE, while ensuring a fair, competitive market for generic
drugs.
Finally, I wish to highlight the work of Hartig Drug Stores, the
second-oldest family-owned independent drugstore company in America,
which has locations throughout my district, including my hometown of
Dubuque, Iowa. Hartig's pharmacies operate in three States, employing
437 people.
I believe we should be enacting policies that allow these kinds of
local pharmacies to thrive instead of shut down. My hope is that
through the continued hard work of their dedicated employees and the
implementation of better policies at the Federal level, these family
businesses will continue to serve patients in and around my district
for many years to come.
Mr. COLLINS of Georgia. Thank you, Mr. Blum.
I think what you have recognized are the struggles that are going on
right now. And what I have found--I was speaking with a Member tonight
from one of our Midwestern districts. It was on the floor as we were
voting earlier. I started explaining what was going on in our
independent pharmacies. This Member did not know. They had not had a
chance to interact. They didn't know what was going on and the changes
that were going on. So you being here tonight helps highlight that.
I think as we educate Members, this is just an inequity that is in
our healthcare system that needs to be fixed.
I appreciate the gentleman from Iowa (Mr. Blum) being here.
There are many things that are talked about in our time up here. Many
times, we talk about not being able to work together. This is an issue
that draws us together.
Mr. Loebsack and I have worked through two Congresses now on this
issue. We are going to work on more together. It is my honor to yield
to the gentleman from Iowa (Mr. Loebsack) to expound on this because we
have been working on this for a while, and it is good to have you here
tonight.
Mr. LOEBSACK. Thank you, Mr. Collins. It is great to be here. I know
that you folks have a lot of things going on on your side of the aisle,
and it is a testament to your commitment to this issue that you have
gotten a number of your colleagues here tonight to speak to this issue,
to speak to the importance of independent and community pharmacists.
It is really, really important for America that we talk about this.
And as Mr. Collins said--and Mr. Carter, I appreciate your invitation
as well--it is really important that we speak to how important these
folks are for our communities, for health care, for their patients.
Mr. Blum, thank you for being here tonight as well.
Mr. Blum represents the district that borders me to the north, and he
mentioned the Hartig pharmacy. They have a pharmacy in Iowa City, and I
took a little bit of time out of my schedule a couple years ago to
visit there and to hear the problems that they have when it comes to
all kinds of issues.
This month, of course, is American Pharmacists Month. It is a month
during which we recognize the important role that pharmacies play in
our communities. Pharmacists are, in fact, frontline healthcare
providers, and they are counselors for many patients who consistently
depend on their training and expertise to stay informed, to stay
healthy, and to stay out of the hospital. They also play an incredibly
important role in strengthening the economies of the areas they serve,
particularly in rural counties like so many of those that I represent
of the 24 counties I have.
It is also crucial that these pharmacies have a level playing field,
as was already mentioned by the gentleman from Iowa (Mr. Blum), when
trying to run a successful business in a challenging and complex
environment. Like most small-business owners, community pharmacists
face many challenges to compete and negotiate on a day-to-day basis
with large entities on their business transactions.
I have personally visited, as I have said, many of these pharmacies
in my district, the Second District. I have learned firsthand how they
often struggle to compete.
One problem I have heard, for example, from many pharmacists is that
the reimbursement system--and I am sure we are going to hear more from
folks about that tonight--for generic drugs is largely unregulated;
and it is, in fact, a mystery to many folks. Generic prescription drugs
account for the vast majority of drugs dispensed, so it is critical for
pharmacists' bottom line that their reimbursement is transparent.
However, pharmacists are reimbursed for generics via the maximum
allowable cost, or MAC, lists created by pharmacy benefits managers,
PBMs--the drug plan middleman, something we have heard so much about.
But the methodology used to create these lists is not disclosed. It is
a secret. It shouldn't be a secret. It should be open. We need to have
transparency on this front. Also, the lists aren't updated on a regular
basis, resulting in pharmacists often being reimbursed below what it
costs them to actually acquire the drugs. That makes no sense
whatsoever.
So to address the problem, I partnered with the gentleman from
Georgia (Mr. Collins) to introduce H.R. 244, the MAC Transparency Act.
We have a lot of folks onboard on this. It is a bipartisan bill at a
time when, as Mr. Collins said, there is not a lot of bipartisanship in
this body at the moment.
Basically, what this bill would do is it would ensure that Federal
health plan reimbursements to pharmacies keep pace with generic drug
prices, which can skyrocket overnight, as we know.
I am not going to go into great detail at the moment. We have got
time to talk about this a little bit more. There are other things we
can talk about tonight. But I just wanted to say a few things at the
outset and to just thank you again, Mr. Collins and Mr. Carter, for
setting this particular time aside so we can really educate our
colleagues, as much as anything, about the problems facing independent
community pharmacists.
Mr. COLLINS of Georgia. I thank my colleague. I do appreciate that.
And that is the issue here: education. People can look in on this.
They can hear what we are talking about. They can see this education
part of it.
This is found in every district. It is almost like veterans. There is
no Member of Congress that doesn't have veterans' issues, because they
come from
[[Page H7018]]
every area. Every one of our districts has independent pharmacists. And
as one told me just the other day, he said, if the condition doesn't
change, they will be gone in a year and a half.
I have had, even in my area, county governments who believe that they
can cut their healthcare costs by going and taking the pharmacies and
putting them with a PBM and centralizing it for county employees. They
said that they would save X amount of dollars. And when I called my
county commissioner and asked him about this, I said: You save this
amount of money. But, I said: If you realize, if you take county
employees out of the system, government operating this--and this is
someone on my side of the aisle. I told him: You take government and
put this in control, you are going to put pharmacies out of business.
And I said: How much do you save when they have to lay off employees?
They shutter their businesses, and you lose sales tax, property tax,
and the peripheral income that comes with that.
We have got to address it, and that is why we are here tonight. This
educational process is important.
When you come up through the legislative ranks--whether it is here in
Congress or the State house, where I started, you meet folks who you
learn to have a great deal of respect for, especially from the places
that they have come and what they have done in the past.
Buddy Carter, the Congressman from the southeast coastline of
Georgia, is one of those who actually is a pharmacist.
I think one of the things I want to emphasize tonight is--and some
people might be saying: Why are you bashing pharmacists? We are not
bashing pharmacists. Pharmacists are great. I love them. No matter
where they work, it is the system that they are trapped in that is
broken, that is hurting the individuals who need that care.
So tonight we are going to have a great perspective from one in the
profession who understands this firsthand, from owning those
pharmacies, but also dispensing and taking care of patients.
With that, I yield to the gentleman from Georgia (Mr. Carter) for his
comments.
Mr. CARTER of Georgia. Thank you, Representative Collins, and thank
you for hosting this tonight. This is certainly a very important
subject. It is very important to me, personally, yes, but it is more
important to our healthcare system.
Mr. Speaker, for over 2,000 years, the practice of pharmacies has
existed to help people with their ailments. Today, the most common
pharmacy position is that of the community pharmacist. Community
pharmacists are the front lines of medication, instructing and
counseling on the proper use and adverse effects of medically
prescribed drugs.
However, over the past decade, there have been several issues that
have threatened the role of community pharmacists. Being a community
pharmacist myself, I know these issues all too well. I believe that
there are three main issues that we can address in Congress that will
allow the community pharmacists to continue to fill the invaluable role
of counseling Americans on the proper use and dangers of prescription
medications.
First of all, MAC pricing transparency.
When I became a Member of the United States Congress and I got
involved in government, I jokingly said that if I could learn 10
percent of all the acronyms in the Federal Government, I think I would
have been a success. Then I got to thinking about it, and I feel a
little silly now because there are a lot of acronyms in pharmacy as
well. One of those is MAC, M-A-C, maximum allowable cost. Another is
PBM, pharmacy benefits manager.
Now let's talk about MAC pricing transparency. This is a bill that is
being offered, and this is a situation that needs to be taken care of.
It needs to be addressed. It is perhaps one of the most pressing--if
not the most pressing--issues facing community pharmacists right now.
MAC is a price list. The maximum allowable cost is a price list that
lists the upper limit or the maximum amount that an insurance plan will
pay for a generic drug. In other words, if you have a generic drug and
it is on that MAC list, they are going to tell you what the maximum
allowable cost is. That maximum allowable cost may be $10. Now, if you
can buy it for $9, more power to you; but if you have to buy it for
$11, you are only going to get paid $10. That is why they call it the
maximum allowable cost.
Each insurance plan sets the maximum allowable cost for the plan.
Some States require them to follow a certain policy, if you will, a
certain procedure when they set those plans, those prices. Most States
don't. In a lot of States that don't, the insurance companies can set
it wherever they want to, whatever they want to set it at. They may
choose a drug that is only available in a certain area for a certain
price.
For instance, if I am in southeast Georgia, I may not be able to get
that drug at that price that they set it at because they used the price
that it is available in the northeast and is not available to us in the
southeast. That is why we have got to have transparency. That is why we
have got to have maximum allowable cost transparency.
PBMs are supposed to ensure that the cost of the drugs do not rise to
unaffordable price levels, which is supposed to allow continued access
to medications to Americans and maintain low costs for employers who
provide coverage for those employees, and that is very important. They
are supposed to set those prices so that their plan's recipients, the
ones that are covered, are able to get those medications.
Therein lies a couple of problems. One is what I just explained, that
it is not always available at the price that they set. A second is that
sometimes the price goes up. We know that the price of generics have
been going up significantly and rapidly. When that happens, sometimes
the insurance companies, the PBMs, are slow to raise their MAC prices,
which means that if I have got a MAC price of $10 and, overnight, the
price of that drug went up to $20, until the insurance company raises
the MAC price, I am still going to get paid $10 even though it is
costing me $20. That cannot be sustainable for community pharmacists.
Community pharmacy is somewhat different from other healthcare
providers in that we have a product. We actually have a product that we
have to pay for. We have that product.
Now, granted, doctors' offices have injectables they have to pay for
and so and so, and we understand that. But in community pharmacy, we
actually have that product on our shelf, and we have got to pay for it,
regardless of how much we get paid for it. The wholesaler doesn't say:
Well, how much did you get paid for it? That is how much we are going
to charge you.
We wish it worked that way, but it doesn't work that way.
The way it works is they have got a set price. If it is $20 and I am
only getting paid $10 for it, I am losing that $10.
Now, some of you may think: Well, you can make up that $10, can't
you, and charge the patient? No. You can't do that.
If they have got a copay, that copay is $5, that is what they pay. I
can't charge them $15 to make up for that difference. That is not
allowed. That is one of the things that is leading to the detriment of
the community pharmacy.
But perhaps an even more important point there is what happens with
the patient. Because, keep in mind, ultimately what we are talking
about here, when we are talking about keeping community pharmacies
open, when we are talking about making certain that this provider is
available, we are talking about the patients.
{time} 2015
We are talking about the patient and patient care. If I am not able
to pay for that medication because I am not getting reimbursed enough,
that patient is not going to get the medication, and that is going to
lead to even more medical costs. That is why this is so vitally
important. In the end, what it comes to is patient care.
What is the problem? What is the problem with PBMs, with the pharmacy
benefits managers? First of all, there is no transparency. There is no
transparency in the contracts with the PBMs. For example, several years
ago Meridian Health Systems, a nonprofit that owns and operates six
hospitals in southern New Jersey, hired a PBM to help reduce their
surging medication
[[Page H7019]]
costs for its 12,000 employees and their families.
This PBM projected it would slice at least $763,000 from Meridian's
$12 million in annual medication spending. Just 3 months into the
contract Meridian was on pace to balloon by $1.3 million. This PBM
insisted that it was actually saving Meridian money. It was not.
After some investigation by Meridian, Meridian discovered that this
PBM was making huge gross profits ranging from $5 per prescription to
multiple times that amount. In one example, Meridian was charged $92.53
on a generic bottle of antibiotics while the PBM only paid $26.91 to
get the prescription filled. That is a profit spread of $65.62.
Therein lies the problem in what is referred to as the spread, the
difference between what the PBM actually charged the company and the
difference in what they actually paid for. That is the spread that the
PBMs work on.
The amount that PBMs charge the small businesses, the customer, or
the government under part D of Medicare can be significantly more than
what it actually costs for them to fill the prescription. As I
mentioned, PBMs don't always update their price list in a reasonable
amount of time. This hurts pharmacies, and more than that, again, it
hurts patients.
There has been evidence to suggest that some PBMs wait until 4 to 6
months to update that reimbursement rates after a drug price rises.
There has been evidence of that.
I have experienced that while I was still working. Ten months ago,
before I entered Congress, before I became a Member of Congress, when I
was still running my drugstore, I experienced this. I experienced where
a product would go up in cost, yet the PBM would not adjust their
price, their cost, their MAC.
We would have months, literally months, where we were getting paid
less than what we were having to pay for the drug. Obviously, that is
not sustainable. That business model doesn't work for anyone regardless
of who it is.
This leaves pharmacists getting reimbursed for drug prices that could
be extremely out of date. Any small business in the country can't
sustain operability when they don't know how much it costs to provide
the customer with their service. You are basically asking a business
owner to operate with no understanding of revenue. No one in the
country can operate a business like this.
We need as much transparency as possible to make sure that PBMs are
doing what they were created to do. My colleague from Georgia (Mr.
Collins) has introduced H.R. 244, the MAC Transparency Act, which would
provide much-needed transparency to the operations of PBMs and provide
pharmacies, businesses, and Americans a better understanding of their
insurance coverage and the true drug costs. This is a very important
piece of legislation.
Another issue that is very important and extremely important to
pharmacists is provider status. Now, Mr. Speaker, I graduated from
pharmacy school in 1980. I have what is known as a bachelor of pharmacy
degree. Back then it was a 5-year degree. The pharmacists that are
graduating now are graduating with a doctor of pharmacy degree, a 4-
year professional degree that usually comes after a bachelor's degree.
In most cases, they have at least 6 and, in most cases, 8 years of
education. Their clinical expertise is so impressive right now. The
practice of pharmacy has changed so much during the years that I have
been practicing. I have seen it go from where we did nothing more than
fill prescriptions to where now the pharmacist is a vital member of the
healthcare team.
Mr. Collins mentioned a little while ago about someone asking if they
could get a flu shot in a drive-through. We have actually seen that
done sometimes. But the point that I want to make is pharmacists now
are actually administering vaccines.
How does that help us? How does that help Americans? How does that
help our healthcare system? Obviously, our vaccination rate improves.
Keep in mind, in south Georgia, where I represent, rural health care is
a concern. We quite often say that, in Georgia, there are two Georgias.
There is north Georgia and the Atlanta metro area and then there is the
rest of Georgia.
Access to health care is very important in south Georgia,
particularly in the rural area of south Georgia, where you find that
pharmacists are some of the most accessible healthcare professionals
out there. If it were not for our pharmacists, many of these patients
would not get those vaccinations, and that is very important. It is
very important that we have provider status for pharmacists.
The U.S. healthcare system has come into an era of integrated care
delivery systems that provide all-encompassing care to Americans. This
new structure of care will provide Americans with the type of care that
allows constant collaboration with all sectors of health care to
provide the highest level of care.
As all of us know, the majority of Americans that rely on healthcare
professionals are the elderly. However, under part B of Medicare,
pharmacists are excluded from the list of providers under Medicare part
B.
This is something that is going to have to change. Regardless of how
you might feel about the Affordable Care Act, regardless of how you
might feel about what is our state of health care here in America now,
one thing is for certain. We are going to have to utilize all
disciplines in health care to improve our system. We are going to have
to utilize pharmacists. We are going to have to utilize nurses and
physician's assistants. We are going to have to make use of all of
those.
Now, to my physician friends, make no mistake about it. Doctors
remain the quarterback. They remain the captains of the team. We have
to have them. They are essential. But these services that have been
provided in the old model where doctors did everything and the other
healthcare professionals didn't participate has got to change in order
for health care to sustain here in America.
We have got to utilize these. My wife is a physical therapist. The
physical therapists who are graduating now, again, are so clinically
oriented and they can do so much more. We find that in all different
aspects in allied health care.
That is something that we have to do. That is why it is vitally
important that we have provider status for pharmacists, physicians,
physician's assistants, certified nurse practitioners, qualified
psychologists, clinical social workers, certified nurse midwives, and
certified registered nurse anesthetists.
All of those are reimbursable and covered under Medicare part B, but
pharmacists are not. Pharmacists need to be included in that. These
professionals make up a healthcare team that provides an integrated
healthcare plan for the treatment of a patient. However, I have never
experienced a patient that required this level of care without being
prescribed medications. It is a vital part of it.
If we don't get the medications to them, the whole process fails. Why
does the patient go to the doctor and spend all this time being
diagnosed and this doctor use all of his expertise in diagnosing this
patient if they are not going to get the medications? It is a vital
part.
We refer to it as a three-legged stool where you have got the
physician, you have got the pharmacist, and you have got the patient.
All of them have to work together to make the system work.
If we really want to provide a fully integrated healthcare system,
pharmacists' services should be included under Medicare. This is why my
friend from Kentucky (Mr. Guthrie) has introduced H.R. 592, the
Pharmacy in Medically Underserved Areas Enhancement Act. This
legislation would include pharmacists under the list of providers under
Medicare part B and provide a true integrated healthcare team for
Medicare patients.
Finally, the third thing that we need to do and that Congress can
do--some health plans, particularly Medicare prescription plans, have
selected certain pharmacies to be the plan's preferred provider. We
must have any willing provider, pharmacy legislation, rather than allow
insurance plans to pick and choose a preferred pharmacy.
Now, this is something I have, unfortunately, a lot of experience
with. I have been practicing for over 34 years
[[Page H7020]]
now. Let me tell you, I have had patients who have been with me that
long. They are a part of my family.
I have provided services to them. They have come to my store. I have
provided generations of services to them, to their parents, to their
grandparents, and now to them and to their children. Yet, they at the
first of the year come to me, some of them in tears, and tell me, ``I
have got to change pharmacies. I don't want to. But my insurance plan
is telling me that this is the only pharmacy I can use.''
Sometimes the PBMs will mask it by saying, ``Well, that is not true.
They can use you. They can go ahead and pay for the medications and
submit us the receipts and we will see if we can reimburse them or they
can go to our preferred pharmacy and pay the $5 copay.'' That is not a
choice. That is not a choice at all.
Other plans will tell you, ``Okay. You can use this pharmacy outside
of our preferred network if you want to. The copay is going to be $45.
But if you use our preferred pharmacy, the copay is going be to $5.''
Well, let me tell you, if you have 10 prescriptions, as a lot of
elderly patients do, are you going to pay $450 as opposed to $50? That
is not a choice. That is not something that is going to lead patients
to stay with their pharmacy.
They are going to have to change, and they don't want to do that. Mr.
Speaker, having a choice makes a difference. These relationships that
patients have with their healthcare providers are very, very important.
So my colleague from Virginia (Mr. Griffith) has offered legislation
to remedy this problem. The Ensuring Seniors Access to Local Pharmacies
Act of 2015 would allow Medicare enrollees to keep their longtime
pharmacist if that pharmacist agrees to the terms and conditions of the
Medicare prescription drug plan.
In providing this reform, we will be able to provide a free market
system for prescription drug plans that will lower cost while also
providing comfort to Americans. This is win-win.
Now, before you say, ``Oh, Buddy, all you are saying is that you want
to force people to have to do this,'' no, not at all. I am a free
market guy. You will not meet more of a free market person than me. All
we are asking to do is to have the ability to compete. That is all we
are asking to do, to participate in the free market.
If the insurance company--if the PBM, sets the reimbursement, if I
see, okay, this is the reimbursement they are going to pay me, if I am
willing to accept that reimbursement, I should be able to participate.
That is all we are saying.
Give us the opportunity, if we are a willing provider, to
participate. Select Networks are hurting us. But, more importantly--
more importantly--they are hurting the patients.
Why is that? Because now the patient, instead of going to my pharmacy
where it is convenient, where they have been going for 34 years, where
their parents went, where their grandparents went, are having to go and
travel long distances, particularly in south Georgia, to get to the
pharmacy that is a Select pharmacy, the Select provider. A lot of times
they just do without. Then what happens? Then all of a sudden medical
costs rise, and we don't see adherence. That is a problem.
So those three things, Mr. Speaker, are three things that are very
important to community pharmacies.
I want to thank again my colleague from Georgia (Mr. Collins) for
bringing this up and let you know that I have been honored to serve as
a pharmacist. I think it is a noble profession.
But, most importantly, I want to make sure you understand this is
about the patients. If community pharmacies don't survive, this is
going to mean that health care in this country suffers.
Mr. COLLINS of Georgia. Mr. Speaker, I appreciate my friend from
Georgia and his passionate defense of what we are doing here tonight.
Earlier this month many of my colleagues and I sent a letter to CMS
in support of proposed guidance to ensure part D plan cosponsors
consistently report pharmacy price concessions. That letter was led by
fellow Georgian and a good champion of pharmacists, Austin Scott, and
it is my pleasure to yield some time to him now.
Mr. AUSTIN SCOTT of Georgia. Thank you, Mr. Collins and Mr. Loebsack.
I appreciate your being here. This is certainly a bipartisan issue and
gets to the heart of some of the challenges in health care in our
country right now. I certainly rise today in support of our Nation's
community pharmacists and our pharmacies which play a critical role in
our healthcare system.
Many of these independent businesses operate in underserved areas
like the ones that I represent in rural Georgia, 24 counties. In areas
where a doctor may be many miles away, local pharmacists deliver flu
shots, give advice on over-the-counter drugs, and help with late-night
drugstore runs for sick kids.
Many people see their pharmacists much more often than their doctor,
and there is a very personal relationship between these community
pharmacists, patients, and the physician. They are community pillars,
and they contribute greatly to the economies. It is crucial that these
pharmacies have a level playing field when trying to run a successful
business in a challenging and complex environment.
As you know, Mr. Collins, I was an insurance broker for many years. I
thought I might tell a very personal story about one of my clients who,
shortly after their contract was issued, the gentleman's child got sick
and they needed a prescription filled. So they went to the local big
box pharmacist or pharmacy, and they wouldn't fill it for them.
{time} 2030
Even when I, as the agent, could provide evidence that the person was
insured without the card, they simply would not fill the gentleman's
prescription. The local community pharmacist was the one that filled
the script.
Now, the irony of it and what we are talking about here and where the
real problem comes in is that, when the person got their insurance card
because of the PBMs, they could no longer use that community pharmacist
that was the only one that would provide the service that they needed
when they actually needed it.
So it is extremely important that, when we have these business
models, we keep those local community pharmacists where they are able
to run a successful business and stay in business.
During the August district work period, I stopped by another
drugstore, a small drug store in Quitman that had been there many, many
years. Generations of people have continued to rely on them for their
services.
While I was there, I watched one of our senior citizens, a lovely
lady, come in. The owner called her by name. They caught up on family
and friends and what was going on in life, and she had some questions
about the medications.
And let me tell you that pharmacist knew the answer to every single
one. He knew her history with those medications and was able to answer
those questions that she asked. She left there with a smile on her face
knowing that she knew what she needed to take, when she needed to take
it, and what she needed to take it with.
As I stopped at these local community pharmacies like the ones I
visited in August, I continued to hear concerns from them about what is
happening in the pricing structure and that, if the price on a drug
goes up, the insurance company has the ability and takes several months
to change the rate when the price goes up. But if the price comes down,
as happens in free market sometimes, they immediately reduce the price
that they reimburse to the pharmacist.
There should be no excuse for the difference in the timeframe in
which the reimbursement occurs. If it can be done when the price is
changing to the downside, it can certainly be done in the same time
limit when the price is changing to the upside.
A lot of things we have seen lately in pharmacy. We saw where a
venture capitalist purchased a drug and raised the price of that drug
several thousandfold overnight. That has been happening, and local
community pharmacists have expressed concerns with this issue for many
years.
It has happened with nitroglycerine tablets, for example, that has
been around for decades and decades. They
[[Page H7021]]
have gone from 8 cents apiece to $8 apiece. Digoxin for a heart
condition, doxycycline, the same thing has happened with these drugs.
How is this happening? And who is going to help us fix this if not
for the ability to get the information from their local community
pharmacist?
They are the ones that care the most, and they are the ones that are
willing to help resolve the challenges with the higher drug costs in
this country.
So one would ask: How is it that, in many cases, our local
pharmacists are kept from being able to participate in the networks?
Well, in many cases, the networks that are blocking out the local
community pharmacists are actually owned by the big box pharmacies.
If you want to talk about a conflict of interest, that is about as
conflicted as it gets when your big box pharmacists own the network
that actually can determine who you can get your drugs from and they
box out their own competition.
Quite honestly, I think it would be a wonderful issue for the Federal
Trade Commission to get involved in and to bring competition back into
that area.
One of the things that I think would help is H.R. 793, the Ensuring
Seniors Access to Local Pharmacies Act of 2015. I want to thank my
colleagues that are here that are also cosponsors for it.
This bill allows community pharmacies that are located in medically
underserved areas or areas that have health professional shortages the
ability to participate in Medicare part D in the preferred pharmacy
networks so long as they are willing to accept the contract terms and
conditions that other in-network providers operate under.
This is reasonable. This is patient choice. This keeps the small
business owner out there. Let me ask you to make no mistake about it.
This is big business versus small business.
One of the other things that I want to talk about is MAC, the maximum
allowable cost. Pharmacists are often reimbursed for generics by this
MAC list. You have heard Buddy Carter talk about this earlier. He
certainly knows more about it than I do. This list is created by the
PBMs, but nobody knows how they create this list.
As patients, we have a right to determine how the costs are derived
for the drugs that we are going to take. And understand this. It is not
a manufacturer's cost. It is not a manufacturer's cost. It is a maximum
allowable cost. When the lists are updated, certainly it should be done
in a timely manner.
I am happy to have cosponsored H.R. 244, and I certainly hope to see
that bipartisan bill pass.
With that, Mr. Collins, thank you for taking the lead on this issue.
Our local community pharmacists are extremely important to our
healthcare system. There is a way to create a scenario under which the
patients have more choice and that requires keeping that local
community pharmacist in business.
Mr. COLLINS of Georgia. Well, Mr. Scott, I don't disagree with you. I
thank you for being here. You have been a great champion to this cause
as well.
I think the interesting thing here--I want to repeat--basically, what
we are going back to is some simple fixes. We are not asking for one to
be preferred over another one.
I think exactly what the PBMs actually want is they want to prefer
and they want to run you into their network and control you.
And, by the way, most people don't realize that a lot of our
community pharmacists have to buy from PBM, who operate other big box
stores, who, in turn, then audit them and can fine them if they don't
follow the plan exactly.
These are the kind of crazy things that just obviously----
Mr. AUSTIN SCOTT of Georgia. Can I repeat one thing you just said
right there?
Mr. COLLINS of Georgia. Go right ahead.
Mr. AUSTIN SCOTT of Georgia. They get to audit their competitors.
Now, in what other scenario in the world could you say it is a free
market when your competitor, who is the big box multi-billion-dollar
operation, gets to audit their small business competitor?
Mr. COLLINS of Georgia. It is baffling. That is why H.R. 244 simply
says you have 7 days to update the list, number one. Number two, it
says that patients will not be forced by PBMs to use a PBM-owned
pharmacy, an obvious conflict of interest.
And according to Medicare data, PBM on mail order pharmacies may
charge plans more, as much as 83 percent more, to fill prescriptions
than community pharmacies.
Mr. Loebsack, you have been with us on this from day one. Tell me
some more about what you are hearing out there.
Mr. LOEBSACK. Oh, my gosh. First of all, I want to thank Mr. Carter.
It is testimonials like his that I have been hearing for the last 10
years, since I have been in Congress, since I first went to an
independent community pharmacist, and you spoke with such great
passion.
You are not alone, as you know. Every single person like you in my
district can tell me the same things that you have told me. That is why
I am on these bills. That is why I am talking tonight about these
issues.
I don't have the firsthand experience that you have as a pharmacist.
The closest I ever got to a pharmacy, other than picking up my
prescription drugs, before I got into Congress was when I was 16 and 17
years old. I was a delivery boy for Greenville Pharmacy in Sioux City,
Iowa, which, by the way, still exists, since 1969. Actually, longer ago
than that it was established. But I would deliver prescription drugs to
folks, especially to the elderly who couldn't get out of their home,
who couldn't get to the pharmacy.
That is what this is about, as you said. It is about making sure
ultimately. And as a Member of Congress, my job is to make sure that
folks have access to affordable quality health care.
And that is where pharmacists play such an important role, whether it
is with medication therapy management or just simply consulting on an
informal basis with someone who comes in and has a lot of different
prescriptions and is confused by what to take and when to take them.
You folks really do such a wonderful job. And if we lost that
service, as you said, because of unfair business practices, because of
being squeezed by the big guys--and it doesn't make any sense at all
for that to happen--then patients would suffer in the end.
That is why I support both of these pieces of legislation, two of
these that have been mentioned already. 244, which Mr. Collins just
mentioned again, to make sure that everyone understands what it is
about, it is a measure that will increase transparency of generic drug
payment rates in Medicare part D and the Federal Employees Health
Benefits program, which serves a lot of folks, as we know, millions of
folks, and in the TRICARE pharmacy program by requiring those PBMs,
one, to provide pricing updates at least once every 7 days. That
doesn't seem like a lot to ask, to me, and I am sure it doesn't seem
like a lot to ask for you; number two, disclose the sources used to
update that MAC list and to notify pharmacies of any changes in
individual drug prices before these prices can be used as a basis of
reimbursement. This is complete common sense. That is why there are
Republicans and Democrats alike on this bill, and I hope we can move
this bill forward.
In Iowa, the State legislature did pass something not quite this
comprehensive, but something similar to this, because in Iowa folks
understand what these PBMs are doing and what those independent
community pharmacists are up against.
And the second piece of legislation, H.R. 592 that was already
referenced, again, a bipartisan piece of legislation, has got 218
cosponsors. If memory serves me, that is exactly the number we need, if
everybody votes, to pass a piece of legislation in this body. We could
get it done. If we brought it to the floor, we could get it done.
Maybe we ought to do a discharge petition. Sorry. I don't mean to
create too many anxieties there with you folks. But, nonetheless, we
have got to get this thing done. It is about making sure that our
pharmacists are able to continue to deliver the kind of quality health
care.
Look, whatever we decide at the Federal level when it comes to
utilizing pharmacists to their full potential, this legislation does
stipulate that nothing
[[Page H7022]]
will override State scope of practice laws as well.
Because I know that a lot of folks in other professions have concerns
about that, that pharmacists are going to go too far. Well, they are
not going to. If States have laws in place about scope of practice,
this legislation will not override that.
But it is about making sure, as Mr. Carter said and as Mr. Collins
would agree and others who have been so active on these issues would
agree--it is about making sure that folks get the quality care that
they need.
If we close down these pharmacies in these rural areas--95 percent of
the folks in Iowa are within 5 miles of an independent community
pharmacist--if they close down those pharmacies, those folks in my
district who depend upon those pharmacies and those pharmacists are
going to suffer. That is unacceptable to me.
Thanks again for giving me the time to speak on this.
Mr. COLLINS of Georgia. Mr. Loebsack, you hit it right. There are so
many times we get to talking policy and big picture up here. The bottom
line is what we do up here--and when I was in the State legislature,
you could see it because you were a little bit closer--States are
starting to pick up this mantle, as you just said, in Iowa and other
States. But it goes back to that feeling of what I call security.
Now, as I said just a few minutes ago, the pharmacist is not the
issue. The pharmacist is someone who helps in the curing process. They
are part of that.
I don't want to ever have anyone who happened to watch this to say,
``Why are you bashing pharmacists?'' We are not bashing pharmacists.
What we are taking shots at and what we are trying to find solutions
for is an abusive practice that has been set up in the name of saving
money at the expense of the patient. That is unacceptable.
It is time we have a hearing up here on those kind of abuses. I call
for that. I call for the bills to be brought to the floor. Let's do
those kind of things. We have got 26 cosponsors and growing daily on
H.R. 244. They are understanding the issue.
As we go into this thing, one of the things that I talked about
earlier and I said I was going to come back to was: Live your ``why.''
You know, think about this. I want everybody to have a choice. If you
like going to the big box and getting your bananas, your shotgun
shells, and your aspirin at the same place, go for it. That is great. I
love it.
But if you want to go to there and then go by and see your pharmacist
who opened up, hung a shingle, so to speak, had that American Dream, he
sells other things--and in my pharmacy I can get a scoop of ice cream
and I sit there and talk and I see people and see life. That is what it
is about. It is not about forcing us in.
That is one of the problems that on our side we have had about health
care in general. The government, that is not the place. This is an area
where we have got our thumb sort of on the scale, and we have got to
stop that. I think this is what does that, and your help has been
tremendous in that regard.
Congressman Carter, one of the things we see in Georgia and I know we
have seen it in Iowa--in short, you have a story--I have got stories I
am going to probably share a little bit later--just where this is has
affected a patient.
Several of my pharmacists talk about how they have had customers that
have been coming to them for years and then get a disease that they
can't keep the medicine because it is too expensive. Do you have some
examples like that where this kind of legislation would help?
Mr. CARTER of Georgia. Well, there is no question about it. As I said
earlier, I am a free market guy. All I want to do is compete, and I
want to compete on a level playing field. Let me compete.
You know, when I first entered pharmacy before PBMs became so vogue
and became such a big part of this, it was pretty easy in the sense of
being in business in pharmacy because all you had to do was be nice to
the people.
{time} 2045
I mean, it was about customer service. It was about taking care of
the patient, and that is what we are talking about--taking care of the
patient.
I told you earlier I have had generations of families who trade with
me--grandparents, parents.
Mr. COLLINS of Georgia. I want to jump in right here on this, and if
you have a story, we will talk about it.
My own family member had an issue, and we were discussing medication.
I knew the doctor--I could call--but my first call was to my pharmacist
because I said I knew I could get him; I knew he would answer; and at
the time--and what was amazing was--my parents didn't buy their drugs
from him, but, yet, he picked up the phone, and he heard my complaint.
Is that sort of what you see and what you have seen as well?
Mr. CARTER of Georgia. Oh, there is no question about it. In fact, I
have experienced it.
Look, I have been a community pharmacist, as I said earlier, for 34
years. I have been in business for myself for almost 28 years now. I
live near where my pharmacy is. I live less than 5 miles away from it.
I am a member of that community. I was the mayor of that community for
9 years. For 9 years, I was mayor. I served in the State legislature. I
represent them now in Congress, and I have gotten calls in the middle
of the night.
What is interesting and what has been very rewarding for me
professionally is when I ran for office and when I would be knocking on
doors, and I would introduce myself. ``I know you. I know you. You
helped my mother when she was under hospice care. You got up and went
to the store and met me there one night and got her medication.'' Now,
let me tell you that that makes you feel good.
Mr. COLLINS of Georgia. It does. Again, when you get into this, it is
about people.
Mr. CARTER of Georgia. It is.
Mr. COLLINS of Georgia. Politics and drug stores and people. This is
about politics. This is about people. It is those people. It is people.
It is policy.
What kinds of things have you heard, Mr. Loebsack?
Mr. LOEBSACK. I just want to say one thing.
Pharmacists are among the most respected folks in all of America, and
there is a reason for that.
Now, Mr. Carter, I realize you went from being a pharmacist to being
a Congressman.
Mr. COLLINS of Georgia. We do question that.
Mr. LOEBSACK. We might question your judgment about that kind of a
transition, and you are finding out about that; but, nonetheless, every
single time I go to a pharmacist, it is the same thing--they care. They
care about their patients.
Again, I have so many stories, but it would take forever for me to
recount all the stories of all of the pharmacies I have gone to in my
congressional district over the last 9 years. I have 24 counties. I
have a lot of local pharmacies, as you might imagine, and those
pharmacists are among the most respected folks in the community. They
are right up there with the clergymen; so that tells you something
about them and about their profession and about how folks look up to
them and about how folks depend upon them.
As you just said, they are the folks who get called when they are
worried about their prescriptions. They are the folks who can be
reached the most easily. Other professionals can be reached, but
pharmacists are right there at the ready, and that is very important.
Mr. COLLINS of Georgia. It is.
If you are following and tracking, we can talk bills, and we can talk
regulations, and those are great things; but the bottom line is what is
best in the health care arena from the whole perspective.
You did a great job, Representative Carter, about talking about the
doctor and all the different agencies coming in together.
I will never forget, when growing up, the story, for me, of, when you
got to the pharmacist, you were getting better. One, I had gotten
through the doctor's office--I had gotten my shot, or I had gotten
whatever--but I had gotten to the pharmacist's. Just give me some
medicine. Let me go home. Back then, there was some tasting bad stuff--
I don't know where that came from--but I remember going in, and they
would take time, and they would care.
[[Page H7023]]
Still, in my district and in many of your districts, you can go in
and look at the community pharmacist who was on the square. A lot of
them had lunch counters. A lot of them had other things. They sold
cards and trinkets. What is amazing to me today is I do not want to see
through consolidation and corporate work a system that has a
fingerprint on the scale, where government has basically allowed this
to happen--to start taking away the centerpieces of American squares.
When you start taking away the centerpieces of squares and of lots and
of communities, both big and small--when you start doing that--then we
are part of the problem. It is time we started educating everybody we
can.
Do you see that?
Mr. CARTER of Georgia. I do see that.
I want to mention just two things.
First of all, as an American taxpayer, you can imagine my being in
business and having what we call ``taxation without participation.''
Here we have Medicare part D plans that are paid for and supplemented
through the government, which I pay taxes to, but my business is not
allowed to participate. I am being taxed. I am paying my taxes and am
doing what I am supposed to do. It is being used for a plan that
excludes my business. How fair is that? I am not asking for anything
special. All I am asking for is an even playing field.
Another thing that I want to mention is that I have intentionally not
mentioned the names of PBMs. There are some good PBMs, and it is not
the company that I have the problem with as much as it is the process
and the model. I mean, that is very important to understand--we are
talking about the model here--but I will tell you this. There have been
numerous instances where companies think they are going to be saving
money, and the PBMs have misled them into thinking they are going to
save money. Let me tell you that these are some of the most profitable
businesses around.
Mr. COLLINS of Georgia. May I jump in right here?
Mr. CARTER of Georgia. Sure.
Mr. COLLINS of Georgia. You may have heard this.
I agree with you in that there are some great PBMs out there that do
work. We are not just saying PBMs in general.
The other thing that bothers me is--and I have heard this from my
pharmacist, and you, I know, have experienced this, and we have talked
about it, and Mr. Loebsack has as well--my pharmacists, my community
pharmacists, are scared to say something. They are scared to talk about
what is actually going on because they are scared their contracts will
get canceled. They are scared that they will get another audit.
I am sorry. I am not a pharmacist. You can't audit me, and I am going
to stand here and talk about it for the pharmacists because they can't.
That is wrong. Anybody who wants to say that that is right, I do not
understand that; but when you have got pharmacists who are just honest,
hardworking people who are trying to run independent businesses and
when they are scared to talk about their vendors to work a workable
plan, what are we doing here? This should be easy.
Mr. LOEBSACK. It doesn't serve any of us. It certainly doesn't serve
any of us in the end, because those folks are the ones who are serving
us, and if they are suppressed--if their voices cannot be heard--that
stifles competition. It goes back to the market. It stifles
competition, and that is not good for any of us in the end.
Mr. COLLINS of Georgia. When things change and when they say that we
can't give input because we are scared, that is just a problem.
We are coming up on our time of closing.
Any last comments, Mr. Loebsack?
Mr. LOEBSACK. Yes.
Thank you, Mr. Collins. Thanks again for inviting me and Mr. Carter.
I really do appreciate this.
As always, Mr. Carter, I have learned something tonight from a
pharmacist--I always do--and I really appreciate your comments.
I just want to touch upon sort of the issue of the city square. That
is so important for so many of our rural districts, as you folks know
all too well. It is kind of hard to explain that to our more urban
colleagues, but we have to do the best that we can. A pharmacy is so
absolutely critical for the economy of a small community. Yes, it is
absolutely critical and necessary to serve the population in the area,
but it is important for the economy as well.
We have a pharmacy--Mahaska Drug in Oskaloosa, Iowa. It is off the
square a little bit, but it is such an important institution in its own
right. Every Christmas, they have wonderful decorations, and they have
things to sell for Christmas. I mean, people come to depend upon them
to do the kinds of things they have done in providing not just the
pharmacy services but other things as well. If they were to go under as
a pharmacy, I am not at all sure that they would survive, and that
community would suffer as a result. Folks' choices would be lessened.
Their tradition would be hurt. It would be a disaster in many ways for
so many of our local communities if those pharmacies were to close
down.
I, for one, am with you. I am not willing to accept that. I am going
to fight as hard as I possibly can with you, and we are going to do it
together, holding hands across the aisle, which, as you know, doesn't
get done a lot around here; but when we can come together, I think it
is important for us to do that. So thanks again for organizing this
tonight. I appreciate it.
Mr. COLLINS of Georgia. Mr. Carter, would you like to add just a
couple of things?
Mr. CARTER of Georgia. I will very quickly.
First of all, again, I want to thank you, Representative Collins and
my colleagues--all of you--for participating in this. This has been a
great exercise.
Among my proudest possessions are the plaques that the baseball teams
give you every year whenever you sponsor a team, and I have got a wall
that is just filled with them. Patients come in all the time. ``There I
am. I played ball. That was the team I was on,'' and they point toward
it. It was the Carter's Pharmacy team.
I want to ask you: How many PBMs have you seen sponsoring Little
League Baseball teams? I mean, seriously.
Folks, we are talking about something that is essential to our
communities, and this is a dire situation. I am telling you. If this is
not fixed soon, you are going to see a whole profession of community
pharmacies going by the wayside. This is a matter of survival here.
Again, we are not asking for a government handout. All we are asking
for is to be able to compete. It is to be able to compete in a fair
market, in a free market, on a level playing field. Ultimately, the
loser here is going to be the patient. If we allow this to happen and
community pharmacies go away, the ones who are going to suffer are
going to be the patients.
Thank you again for this. I can't tell you how proud I am of my
profession, a profession that I chose years ago when I was in high
school and when I was a delivery driver. After I realized I was not
going to be the athlete that I wanted to be, I decided it was time to
get serious and decide on a profession. I did, and I could not be any
prouder than the profession I chose of professional pharmacy. Thank
you.
Mr. COLLINS of Georgia. I thank all of my colleagues for coming here
tonight.
I am going to go back to where we started: Live your ``why.'' Live
your ``why.'' That is all we are asking. Our independent pharmacists
and our community pharmacists are just simply saying: Let us have an
even playing field. We will play with the big boys. We don't care. Just
let us have our ``why.'' When we do that, our benefits come to our
communities.
Mr. Speaker, I yield back the balance of my time.
____________________