[Congressional Record (Bound Edition), Volume 161 (2015), Part 12]
[House]
[Pages 16183-16191]
[From the U.S. 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 with us. He has got to run off on some other events, but 
we wanted to get you

[[Page 16184]]

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.

[[Page 16185]]

  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 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

[[Page 16186]]

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 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.

[[Page 16187]]

  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 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.

[[Page 16188]]

  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 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

[[Page 16189]]

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 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

[[Page 16190]]

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.
  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

[[Page 16191]]

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.

                          ____________________