Like many other community pharmacies, Murray Drug in Heppner and Condon, is struggling with the reductions in average wholesale prices resulting from the First Data Bank settlement.  The paper quotes Wayne Kradjan, dean of the Oregon State University’s College of Pharmacy, who summed it up well: "Many pharmacies, especially those in rural communities, have razor-thin margins. This could be the tipping point to cause those pharmacies to close their doors. Not only Medicaid patients, but entire communities could then be left without a pharmacist to serve their health needs."

On top of this, the state is considering forcing Medicaid patients to use mail order pharmacies. Murray Drug co-owner Ann Murray explained why that’s a bad idea: mail delivery in their community only comes three times a week; mail order pharmacies routinely send three-month drug supplies and don’t account for changing prescription needs – leading to unused medicine and wasteful health care spending; some drugs must remain frozen or have other special storage requirements; and patients lose face-to-face access to a highly trained medication expert.

“It's getting harder and harder to continue to provide service on what the insurance companies and the government want to pay," Bob Mullay of Hermiston Drug told the paper. But the service he provides remains popular with customers who have other choices such as Wal-Mart. He’s seen many patients lured away by $5 prescription offers only to return for the quality service offered by his independent pharmacy.

Forty miles east of Albuquerque, New Mexico, community pharmacies struggle with declining Medicare and Medicaid reimbursements and mandatory mail order requirements imposed by pharmacy benefit managers (PBMs), the Mountain View Telegraph chronicles.  K.C. West of Mountainair Meds and More says even patients with chronic conditions like diabetes are forced into mail order. Worse, some patients don’t learn of the change until they show up at the community pharmacy for their medication and the claim is rejected. 

Patients get enrolled in mail order unwittingly or against their will, according to Kenneth Romp of May Pharmacy. He then has to call the insurance company to get the denial overridden and the medicine covered. "Why can't [PBMs] offer the same deals to retail pharmacies as mail order?” he said. “A lot of times they're owned by the same company. In my opinion, it's a little underhanded."
In Alaska, Barry Christensen of Island Pharmacy compounds Tamiflu for kids with the H1N1 flu and has strong ties to local families and patients, the Alaska Journal of Commerce reports. His biggest problems? Declining pharmacy payments which may not even cover medication expenses. Insurance red tape. And the cruel, double-whammy of mail order. Long-time patients get diverted to mail order only to return later for an out-of-pocket, emergency fill when mailed shipments don’t arrive in time. 

Bill Altland of Whale Tail Pharmacy says one patient was still waiting for his daily blood pressure medication to arrive by mail 10 days after he ordered it. Altland provided an emergency, 7-day fill, but the insurance company wouldn’t pay for it.  The patient and his community pharmacist were forced to foot the bill for the rival mail-order pharmacy’s incompetence.

The Alaska Pharmacists Association is pushing for PBM transparency legislation in the state, similar to the provisions NCPA and consumer groups are advocating in national health care reform.

These cases highlight the stakes in health care reform. Clearly, economic and budgetary times are tough. That’s why NCPA is working constructively with government officials to replace Medicaid’s average manufacturer price-based reimbursement for generics with a fair payment system.  Getting it wrong could limit patient access, by forcing community pharmacies out of the Medicaid program or to close altogether.