It’s All About The Money: How Mandatory Mail Order Pharmacy Puts The Lives of People Living With HIV and Hepatitis C At Risk

By: Michelle J. Sherman, RPh, FASCP, AAHIVP, MichRx Pharmacist Consulting Services, Inc.

Over the past couple of years health insurance companies have added HIV antiretroviral medications to their “Specialty Drug Lists.” This results in the drugs being placed on the highest copay tiers with the highest copay structure. In many cases, it is unaffordable for people living with HIV/AIDS. In addition, health insurers have forced clients to utilize mail order “Specialty Pharmacies” picked by the health insurance plan.

What is Specialty Drug?
In defining specialty drugs there are two main factors: cost and complexity. Using a cost-based approach, CMS [Centers for Medicare & Medicaid Services] categorizes a specialty drug as one with a minimum monthly cost of $600 with respect to the Medicare Part D drug benefit. Other organizations utilize a higher cost threshold for specialty classification that may be as much as double that of CMS. Complexity can encompass a number of factors and affect various groups, including patients, payers, manufacturers, and the pharmacy itself.[1]

About 25% of people infected with HIV/AIDS in United States are co-infected with Hepatitis C (HCV). Intravenous drug users (IDUs) are co-infected with HIV/HCV at rates between 50%-90%. Additionally, medications used to treat HCV are extremely expensive and are also classified as specialty drugs.[2]

Many of these mail order pharmacies are owned and operated by the insurance company themselves. There are so many conflicts of interest in this behavior you would think the FTC [Federal Trade Commission] would put a stop to it, but instead they seem to turn a blind eye and is encouraged. In recent weeks, we have seen major insurance company mergers. Aetna spent $37 billion to buy its rival Humana; Centene spent $6.3 billion to buy Health Net and Anthem is close to a $47 billion deal to buy Cigna.

As Robert Reich so eloquently put it “We’re rapidly on the way to having a handful of giant health insurers. The only difference between this outcome and a government-run single payer, such as Medicare for all, is that revenues will go into executive salaries, dividends, and advertising and marketing rather than into lower premiums and health care.”

The insurance companies dupe employers, CMS, ADAP’s [AIDS Drug Assistance Programs], State Medicaid’s and Insurance Exchanges when they are told that they will “get a better deal” and cost them less if they make their employees and members utilize mail order pharmacies instead of local community pharmacies. This is just not true. The interest for the insurance companies and their relationship with their specialty pharmacies is one thing…Making Money! When Cigna forced their members into mandatory mail-order, Cigna profits grew 29% in the 4th quarter of 2014. Cigna’s mail-order pharmacy revenues increased 23% from 2013 to 2014.

Furthermore, mail order pharmacies send out medication to patients without ever contacting the patients and providing care to see if the patient is even taking the medications. According to the National Community Pharmacists Association (NCPA), it results in billions of dollars of wasted medications that drain the healthcare system.

Photo Credit:
National Community Pharmacists Association (NCPA)

So how are these mail order mandates putting the lives of people living with HIV at risk?

Community HIV pharmacies have been providing excellent care to people living with HIV/AIDS for over 30 years, managing the patients' drug therapies to avoid potentially fatal drug-drug interactions. Pharmacists help clients with adherence, ensuring that clients take their medication every day so they do not develop resistance to HIV medications, and also provide education on an array of other issues critical for an HIV-positive client's quality of life and well being, such as linkage to other services within their community. Clients have forged relationships with their HIV pharmacists, whom they know, like and trust, and who have become crucial health care providers on the care teams of people living with HIV/AIDS.

Several lawsuits have been filed against these insurance companies for discriminating against people living with HIV/AIDS by forcing them into mail order pharmacies. Consumer Watchdog has been successful in settling lawsuits with Anthem Blue Cross and United Healthcare. At this time there are active lawsuits against Aetna and Cigna. Will CVS Caremark and Express Scripts be next? We can only hope so.

The HIV Continuum of Care shows that of the 86% of people diagnosed with HIV, only 40% are engaged in care; 37% are prescribed antiretroviral therapy and only 30% are virally suppressed.[3]  I believe that mail order pharmacies would never improve the number of people virally suppressed, in fact this practice could make the number of people virally suppressed even worse…and here is why:

• Choice. People living with HIV/AIDS are denied choice and are forced to abandon their local community HIV pharmacists that they have established relationships. 

• Discrimination. People living with HIV/AIDS (and HCV) are discriminated against. All the lawsuits that have been filed demonstrate this clearly.

• Privacy. These plans threaten patient privacy. Confidentiality is paramount for people living with HIV/AIDS. Receiving prescriptions via mail where they live or work often breaches patient confidentiality. 

• Sensitivity. This is a major issue and many people living with HIV/AIDS feel uncomfortable discussing their situation over the phone with people they do not know or understand them. It is usually very difficult to get in touch with the pharmacies. Clients call and are shuttled from person to person in the phone tree, causing further stress and there is no continuity of ever speaking to the same person. The responsibility is on the patient to contact the pharmacy not the other way around. People working the phones are usually not trained in the HIV Continuum of Care and are usually not sensitive to people living with HIV/AIDS and related issues. With some insurance companies their call centers are outsourced to other countries, where the callers have no idea how to deal with clients and solve their issues. One client was told by the mail-order pharmacy that they could not mail to a PO Box but could deliver it to his work or to a neighbor.

• Drug Interactions. Disjointed pharmacy services result in life threatening consequences. Mail order pharmacies are only interested in filling the “specialty” prescriptions for clients, and therefore only supply HIV antiretrovirals or HCV medications. They encourage clients to get the rest of their medications from their local pharmacies (the pharmacies they know, like and trust and have established relationships). This tactic is catastrophic and can result in major drug-drug interactions and negative clinical outcomes. The mail-order pharmacy has no idea (nor do they care) what other medications including over the counter medications, vitamins, supplements and even street drugs the client is using. As a pharmacist and healthcare provider this a major cause for concern and proof that the mail-order hype that they provide better care is just plain wrong. 

• Coordination. There is no coordination of care. The HIV Continuum of Care is not about filling and billing the medications, throwing it in the mail and hoping it arrives on time. People living with HIV/AIDS, as well as HCV, need coordination of care such as referrals to physicians, mental health providers, ASO’s, support groups, legal aid, community resources just to name a few; and their local trusted HIV pharmacist can provide this coordination of care….the mail order pharmacy cannot provide it.

• Timeliness. Prescriptions arriving late. Mail-order pharmacies are notorious for poor service and having prescriptions arrive late. Adherence is paramount with antiretroviral medications. We know that adherence must be 95% or better. When clients don’t receive their medications on time, the pharmacy is promoting non-adherence, which is completely unacceptable. In my experience, it happens more often than not, clients become even further stressed out and they reach out to their local HIV pharmacist….yes the one they have a relationship with, who they know, like and trust. The local pharmacy then has to try to solve the problem caused by the mail-order pharmacy.

• Billing. Mail order pharmacies do not bill ADAP. Many clients that are forced to use mail-order pharmacies also qualify for ADAP. In these cases ADAP will pay the copay for the antiretrovirals resulting in a zero copayment for the client. This is a critical part of HIV care, as copays can often be high and unaffordable to the client. Mail-order pharmacies don’t bill ADAP therefore clients are caught between a rock and a hard place. They are forced to use these pharmacies, which actually cost them more money, where using their local trusted HIV pharmacy would cost them nothing.

• Patient Assistance. Mail order pharmacies do not utilize manufacturer copay cards. For clients who don’t qualify for ADAP, manufacturer copay cards, which save clients huge out of pocket expenses every month. In many cases the copays are unaffordable. If clients could use their local HIV pharmacies, copay cards can be utilized costing the client very little and in most cases nothing.

• Stress. Stress related negative outcomes are common.[4] The resulting stress caused by the mail order pharmacy mandates on people living with HIV/AIDS is detrimental to the immune system and can further compromise the immune system.[5]   

From everything you have read in this article, you can clearly see that forcing people living with HIV/AIDS and/or HCV to use mail-order pharmacies can greatly compromise care and to the behemoth insurance companies it’s about one thing…..IT’S ALL ABOUT THE MONEY…..Do the lives really matter?

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Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates. 

[1] American Pharmacists Association: http://www.pharmacist.com/specialty-pharmacy-unique-and-growing-industry 
[2] CDC: http://www.cdc.gov/hepatitis/populations/hiv.htm
[3] HIV Continuum of Care: https://www.aids.gov/federal-resources/policies/care-continuum/
[4] Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry. Suzanne C. Segerstrom and Gregory E. Miller. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361287/
[5] Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk. PNAS, April 2, 2012 DOI: 10.1073/pnas.1118355109