As the table below shows, just 290 healthcare providers—only 1.2% of all 340B covered entities—account for nearly half of the program's 35,000 contract pharmacy agreements. These providers (mostly hospitals) have built mega-networks seemingly designed not to help needy and uninsured patients, but to enrich hospitals and pharmacies.
Simple math suggests that any contract pharmacy abuses are concentrated with the top 1% of 340B providers. How long will the program’s defenders (and the other 99%) ignore the facts? My questions below highlight the challenges facing manufacturers, managed care, and policy makers.
For background on 340B contract pharmacies, I again recommend the new AIR340B report The Impact of Growth in 340B Contract Pharmacy Arrangements. (Free download.)
To profile the 340B contract pharmacy market, Pembroke Consulting examined the Health Resources and Services Administration’s (HRSA) Contract Pharmacy Daily Report, as published on July 1, 2014. We screened out all contracts that were terminated earlier than 6/30/14 (n=10,466).
The program’s defenders correctly argue that a small minority of 340B covered entities use contract pharmacies. While technically true, this statement ignores the small proportion of hospitals that are aggressively expanding 340B pharmacy networks.
Apexus, 340B’s prime vendor, counts 24,768 total covered entities. Our analysis reveals that 19,967 (80.6%) do not utilize contract pharmacies. (See table below.) An additional 3,505 (14.2%) have small networks, with fewer than five pharmacies. About 1,000 providers have networks with 6 to 25 pharmacies, accounting for one-third of contract pharmacy arrangements.
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Thus, a mere 290 healthcare providers (1.2% of total covered entities) account for nearly half of all contract pharmacy relationships. Of the 290, 140 are disproportionate share hospitals and 120 are children’s hospitals. This small group has built networks averaging 59 pharmacies, but are as large as 276 pharmacies.
Our new analyses suggest key questions that need to be answered:
- Do covered entities need such large networks to reach vulnerable patient populations? Covered entities are not required to justify such large networks on the basis of access needs for uninsured populations. A BRG analysis found that just 16% of contract pharmacies were located in low-income areas.
- To what extent are these providers creating broad networks to generate revenue from as many fully-insured prescriptions as possible? I describe the process in Hospitals Twist Prescription Assistance Program For Their Own Benefit. The new AIR340B report sensibly recommends: "Contract pharmacies should be located where vulnerable patients qualifying for assistance live, rather than in distant communities selected on the basis of how many people have insurance that can be billed at the largest margin above 340B-acquisition cost."
- How much of the 340B savings are shared with uninsured and needy patients? Covered entities are not obligated to share any 340B savings with financially needy or uninsured patents, nor are they required to disclose how they use profits from the 340B contract pharmacy programs. According to February’s Office of Inspector General (OIG) study, two-thirds of hospitals’ contract pharmacies required uninsured patients to pay the full, non-340B price, even though hospitals were purchasing the drugs at the deeply discounted 340B price. See New OIG Report Confirms Our Worst Fears About 340B Contract Pharmacy Abuses.
- How are 340B entities monitoring these large networks? How (if at all) do they monitor out-of-state mail pharmacies? Walgreens’ Tempe, Arizona, mail pharmacy is a contract pharmacy for 505 different 340B entities.
Meanwhile, will the 99% of 340B entities with no contract pharmacies or smaller networks allow the 1% to continue creating controversy and questions?