Anyone involved in the pharmacy channel – pharmacies, pharmacy benefit managers (PBMs), insurers, payers, drug wholesalers – should be paying attention to the Wal-Mart/Caterpillar arrangement. Pharmacy channel margins on generic drugs will be increasingly seen as a mechanism to control total drug spending. As a result, I expect even more adoption of cost-plus reimbursement models as Wal-Mart continues to challenge the pharmacy industry's traditional economic model.
This arrangement can best be described as a “preferred network” versus an explicitly “restricted network.” Members have a zero-dollar co-pay at Wal-Mart, but can choose to fill their prescriptions at other retail pharmacies for the normal $5 generic copay. See my original analysis of the deal (WMT + CAT: Pharmacy's Future?) for a summary of implications for the pharmacies and PBMs.
AWP is an endangered benchmark. Todd Bisping, pharmacy benefit manager at Caterpillar, describes AWP as a “flawed methodology.” I agree. See my June overview AWP: Dead Parrot or Just Resting? for more.
Wal-Mart’s reimbursement is explicitly cost-plus versus the more traditional list price-minus. The new pricing methodology is “based on Wal-Mart’s actual invoice prices on drugs.” Note that Wal-Mart’s invoice price for generics should generally be below a generic manufacturer’s Average Manufacturer Price (AMP) because of Wal-Mart’s buying power.
Payers recognize that retail pharmacies need to make a profit. Mr. Bisping notes Wal-Mart’s reimbursement includes “some money for their overhead and any margin they have to make.” It’s not clear from the article whether the margin is expressed as a percentage (basis point) mark-up, a fixed dispensing fee per script, or some combination. We also don’t know the magnitude of these profits, although Wal-Mart has been willing to accept lower margins on generic drugs than traditional chain and independent pharmacies. See Wal-Mart Redux.
This program incorporates a new benefit design strategy. Mr. Bisping states: “We felt that by negotiating directly with the pharmacy, that we could make price matter as well as choosing the pharmacy that we think will provide the best service for our employees.” This deal turns traditional benefit design on its head. Normally, those of us with third-party coverage generally pay an identical co-payment regardless of our pharmacy’s efficiency or cost structure. In contrast, the members share in the cost-savings associated with using a lower-cost channel. I explained these economics in January’s post Wal-Mart's PBM Game Plan.
PBMs get disintermediated from an important financial flow. Wal-Mart’s strategy explicitly cuts outs the PBM rather than making Wal-Mart into a PBM. Caterpillar’s PBM (RESTAT) apparently has a fairly transparent pricing model, so there were fewer business issues compared to a traditional PBM.
GET READY FOR THE COST-PLUS REVOLUTION
When generic dispensing rates (GDR) were 20%, payers did not pay much attention to the costs or margins associated with generic drugs. But GDRs are now 70% and rising, which means that pharmacy channel costs and margins will be increasingly seen as a mechanism to control drug spending. The coming wave of generics will focus even more attention on hidden economics of the channel (retail pharmacy, drug wholesalers, and PBM mail order).
Nonetheless, there are some tricky policy and benefit design issues associated with tightening generic margins. You may want to re-read Generic Drug Profits: Too High or Appropriate Incentive?, in which I highlight the powerful economic incentives for rapid generic substitution that are created when the pharmacy channel earns higher profits.
My really tough question remains unanswered: At what level of drug channel profits could payors still encourage rapid generic substitution while not “overpaying” for generics? Wal-Mart seems intent on challenging the pharmacy industry to answer this question in a new way.
We also recently blogged about this over at Prescription Access Litigation.ReplyDelete
A few thoughts/questions come to mind here:
1. If Walmart is willing to accept lower margins on generics under a cost-plus reimbursement scheme, there are several non-mutually exclusive possible reasons why: (a) They expect that volume will make up for lost margins on each scrip. (b) It's part of a quasi-loss-leader strategy. I think both of these are arguably what were behind WalMart's original $4 generics push. It's safe to say that for those $4 generics, Walmart isn't giving them away or selling them at a loss, but they are foregoing some revenue. But think of how many people it's gotten in the store! There's a reason that the Pharmacy is often waaaay in the back at chains like Walmart -- as you pass all the other aisles, you remember other things that you need (oh, we're out of laundry detergent, let me stop and get some), or see things that catch you eye, and why make another stop?
A zero copayment is an attractive incentive for any Caterpillar employee within a reasonable distance of a Wal-mart, and 70,000 employees is a nice customer segment for Walmart to capture.
2. One can't help but be intensely curious about the details of this deal. How does Walmart disclose the "cost" part of the "cost-plus" equation to Caterpillar? What confidentiality provisions are in place? Can't Caterpillar still use this information to pressure other pharmacies for lower rates, or even seek a better deal from some competitor? Are the cost figures auditable?
interesting times indeed...
Wal-Mart is surely using this as semi-loss leader. Why not. But in all fairness, pharmacies in Wal-Mart are not "way in the back". They put theirs up front to the side of the entrance. Still, when you are in the store, you are likely to consolidate trips and go ahead and shop.ReplyDelete
Given volumes they want, this will likely work for them. I'd be surprised if others don't adopt this strategy as well.
Cost plus pharmacy models have been going on for years, just not at this scale. Physicians often purchase drugs from pharmacies at cost plus along with self-insured health systems that own pharmacies (basically pay themselves vs. an outside retail pharmacy at AWP minus). At any rate, this is pretty scary stuff to the retail pharmacy world. PBMs are already hanging on a thread called 'admin fees' (not that I feel badly for them!).ReplyDelete
Just read the story about Caterpillar & Wal-Mart. Medco just announced record earning. So let's see: the PBMs - for the moment - are enjoying record profits, mostly from mail order generics, which they priceReplyDelete
at a discount off AWP. Wal-Mart offers cost plus pricing to Caterpillar,along with cheap generics. It looks like this will be adverse to the big
PBMs. But wait..what does cost mean? My guess is that it's the 'landed' cost to the store & not Wal-Mart's actual cost. If I'm right we're looking at Wal-MAC pricing, which, while presumably lower than the going rate, will still yield solid profits for Wal-Mart and the approach is no more transparent than Medco's.
"Oh what tangled webs we weave".
Cynical Old Pharmacist
PBMs that own mail order services will be less interested in a cost-plus arrangement than PBMs that do not because of the greater profits on generics at mail than at retail. This cost-plus approach could be a competitive advantage for the latter PBMs. Will they be pressured by their mail order vendors to refrain from offering a cost-plus generic arrangement?ReplyDelete
The problem is that whatever cost-plus arrangement Walmart has devised will over the long term not be substainable. Look at the original reimbursement contracts offered in the 1970's by that upstart PCS. Walmart has established a ceiling on this pharmacy deal as far as reimbursement goes but there is no floor in the long run.The payor always wants it for zero dollars..
interesting post as always, Adam. Just to clarify I worked at Wal-Mart pharmacy for almost a decade and I'd consider their pharmacy locations off to the side of the store, but far from the front. Customers will usually pass the entire clothing department opposite of the registers, about 5rows of health and beauty, 1-2 books and magazine aisles, 5-7 aisles of food (not just the super Wal-Marts) and THEN get to the pharmacy. That's a lot of opportunity for impulsive shopping. -BReplyDelete
You raise an important point about the supply side of the equation -- pharmacies that make a profit on generics are more incentivized to substitute when possible. However, there is a demand-side consideration in this new concept as well: CAT members are heavily steered toward generics through a copay waiver. I suspect that at least some of the savings that this employer expects to reap are driven by members actively switching to generic therapy to take advantage of this waiver.ReplyDelete
Ultimately, we're talking about patient behavior change here -- not pharmacy substitution -- as a driver of utilization shift.