Are Specialty Pharmacies Unfairly Charged DIR Fees?

With the Community Oncology Alliance and the Centers for Medicare and Medicaid publishing reports about direct and indirect remuneration (DIR) fees, pharmacy benefit mangers (PBMs) are being condemned by many health care professionals and advocacy groups.
 
PBMs justify these fees as a way to ensure that pharmacies are meeting their standards, and providing patients with optimal care. However, according to the recently published reports and testimonial from different providers, these fees may threaten the viability of retail, independent, and specialty pharmacies.
In particular, specialty pharmacies have a lot at stake in terms of DIR fees. These pharmacies treat patients with serious illnesses, such as HIV and cancer, who require complex treatments for survival.
 
Since these pharmacies dispense medication that can cost thousands of dollars per patient per month, retroactive DIR fees can become overwhelming, and may eventually impact patient access to medication.
 
“When a DIR is calculated in such a way that it’s a percentage, it’s even more harmful since specialty pharmacies’ average dispense rate is a lot higher per transaction dollar amount than the average pharmacy in the community setting,” said Mike Agostino, RPh, vice president, Pharmacy Innovation and Business Development, Hy-Vee, president-elect of the National Association of Specialty Pharmacy (NASP).
 
Additionally, the parameters that DIR fees are calculated on do not always translate to specialty pharmacies. Many PBMs charge the fees based on meeting certain quality benchmarks regarding disease states that specialty pharmacies do not typically treat, Agostino told Specialty Pharmacy Times. Clearly, there is a lack of knowledge regarding specialty pharmacies and the patients they treat.  
 
“Right now, specialty pharmacies are most adversely impacted by DIR fees, just because these fees do not incentivize specialty pharmacies to perform based on utilization. These are fees that are applied for all claims across the board,” Agostino said. “They are typically performance metrics that are assigned to categories that are not found within a specialty pharmacy, such as generic efficiency, 90 day fills, cholesterol management, diabetes management, and hypertension management.”
 
If a pharmacy does not meet these parameters, the clawback will likely be greater, compared with a pharmacy that meets PBM standards. Independent specialty pharmacies may be at risk of closing their doors due to high, nontransparent fees, which may cause a disruption in treatment for patients.
 


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