CVS Health controlling dispensing of opiods through Caremark PBM, Part 2

control of medication falls under the lens in this week's Your Life, Your Health

Part 2 of our examination of CVS Health’s use of its PBM to limit the dispensing of opioids begins with one of two transmittal letters used to send this material to over 500 healthcare leaders and to 105 pharmacies in the Southeast Texas area.

During the Primary Care Week at UT Health Long School of Medicine from Oct. 4-6, there were presentations by the UT Health Center for Medical Humanities and Ethics with several presentations by Anna Lembke, MD, medical director, Addiction Medicine, chief, Addiction Medicine Dual Diagnosis Clinic, and program director, Addiction Medicine Fellowship, associate professor, Department of Psychiatry and Behavioral Sciences, courtesy faculty appointment, Department of Anesthesiology and Pain Medicine, Stanford University School of Medicine.

This and the following exchanges took place by electronic mail, which places Dr. Lembke’s comments at the end of the link and my response at the beginning.

Dr. Lembke asks what I think is the proper role for pharmacists in healthcare. I answer that question. In part, my answer states: “It does not include a provision for pharmacists, pharmacy benefit managers (PBM), and/or primary care providers, employed by retail pharmacies, to counsel patients and or to limit access to medications when they do not have medical records of the patient, and do not have a HIPAA-compliant right to review the records that are available. For pharmacists who are filling a medication to contact the provider and to question the prescription, in my judgment, is excellent. This is what happens when the staff pharmacist in a nursing home recommends a change in a medicine. A verbal or written communication takes place and an agreed upon change or continuation takes place.”

I responded to this exchange with Dr. Lembke in part: “Your analysis was very helpful. I totally agree that physicians are unwittingly one of the major causes of the opioid abuse crisis and that if physicians and physician organizations were better at policing themselves, pharmacists would not need to. Thank you for your insight. It is helpful. I do agree that our intents and our commitments to finding a solution are the same As a result of this discussion about CVS Health, the CDC Primary Guideline’s for Opioid Use and your lectures, I met with our IT staff yesterday and we are deploying a support tool which automatically calculates the Morphine Milligrams Equivalent and prominently display it in several places in our EMR. All records which exceed 50 MME will be reviewed; all which exceed 90 MME will be referred to a SETMA specialist with special interest in this concern, and those unresponsive will be referred to a Pain Management Specialist.”

I added a section introducing the processes and ideas that have led SETMA to the point it is today. This note of Oct. 8 to Dr. Lembke resulted from further thoughts about CVS Health’s plan to limit the dispensing of opioids to a one-week supply. In part I state:

“In conjunction with your last note, which expressed the value of only one week’s supply of drug being dispensed, I realized that you and I are both right.

1. If a PBM mail-order prescription, which limits dispensing to a one-week supply of an opioid at a time, can assure an uninterrupted delivery of medicine, the benefits you noted would be achieved, i.e., preventing patients ‘borrowing’ drugs from next week’s supply. The discipline would contribute to the decreasing of this method of abuse.

2. The problem will be that mail and other delivery methods are not dependable enough to make sure that the medication will predictably arrive every seven days. How many of us have paid significant additional fees to get next-day, or two-day delivery only to get delivery five or six days later? The additional anxiety and stress this will add to the life of people already living under great stress, will be accompanied with significant additional cost added to the obtaining of these medications. Who will pay that cost?

3. While CVS Health and their PBM, Caremark, assure us that hospice and cancer patients will be excluded from their plan, how will CVS determine that the patient is on hospice or that they remain on hospice?

4. As my son’s pharmacist friend affirms, our worst nightmare is real. If the patient is not receiving their medications by mail, with the problems that creates as detailed above, CVS Health’s PBM plan will require the patient, the patient’s family, or the patient’s care giver to go to the pharmacy weekly. If that is a block away, it is problematical enough, but what if it is 25 miles away? Of course, CVS Health can provide an exemption, but who will administer that and how?”