PPNs Strike at the Heart of Community Pharmacy – The Medicine Shoppe Pharmacy

By Janice Harvey, RPh, CDE

A little over three years ago, I opened our pharmacy with the idealistic goal of being able to provide an exceptional, personalized, clinical pharmacy experience within a community pharmacy setting. I am so proud of what we have achieved! We have a great team of pharmacists and staff, and we provide services that we simply could not offer in a high-volume retail pharmacy environment.

There are many challenges in operating an independent pharmacy, some of which affect our very survival. A recent Manulife–Loblaw deal made headlines across the country, as it could threaten the sustainability of independent and rural pharmacies. Some see it as a major step towards a more American-style healthcare system, where there are only a few very large pharmacy chains, insurance companies directing patients to those pharmacies, and pharmacy benefit managers (PBMs) processing the prescription claims.

After significant backlash, the deal has been cancelled as of February 5. Hooray! But let’s look at the deal and why it had us (and other pharmacies) so concerned.

What’s the big deal?

Benefit plans offered by Manulife include a “Specialty Drug Care” program, which allows for coverage of specific specialty medications that are used to treat complex conditions such as Crohn’s disease, rheumatoid arthritis, and multiple sclerosis. (1) According to Manulife, fewer than 1% of their benefit plan members receive these medications. (2) It’s critical that people have access to these specialty medications, but also that they can choose how they receive them. And therein lies the issue.

Manulife had joined forces with Loblaw Companies Ltd. and Shoppers Drug Mart Inc. (Loblaw owns Shoppers). These pharmacies are what are then referred to as a “preferred provider network” (PPN). In these types of agreements, the insurer would agree to pay for the drugs only if they were picked up from a one of the PPN pharmacies. Individuals who did not live near a Shoppers/Loblaw pharmacy could have the medications shipped to their home. As these medications are usually refrigerated, people would need to be home to receive them.

PPNs take away patient choice

PPNs are not new to Canada. Manulife already had a PPN agreement with Bayshore HealthCare, which had very few retail locations, so patients were used to having their specialty medications shipped out and expressed a desire to be able to pick them up from a pharmacy. Manulife felt that this deal would give their patients many options, as they could choose from the roughly 1,800 Shoppers/Loblaw locations across Canada. However, we could just as easily argue that there are many more other pharmacies across Canada, and telling patients that they cannot get their medications from their usual pharmacy actually limits patient choice. This is absolutely the case in Labrador, where there are no Shoppers/Loblaw pharmacies, yet patients have previously been able to go to their local, independent pharmacies for these medications. (3) And in Quebec, PPNs are not legal, so patients there would not have been subject to this agreement.

PPNs limit competition

In a CTV news report on January 30, Stephen Morgan, a UBC professor of health policy, is quoted as saying, “The consolidation of the pharmacy business means less choice for Canadians. It will start looking a lot like our telecom industry where we have less choice and pay high prices. You don’t want to see that in your pharmaceutical sector.” (4) That same day, Don Davies, MP Vancouver-Kingsway and NDP Health Critic, along with Brian Masse, MP Windsor West and NDP Innovation, Science and Economic Development Critic, requested that the Competition Bureau of Canada conduct an investigation into the Manulife–Loblaw arrangement and determine whether PPNs constitute an anti-competitive practice under Canada’s competition laws. (5) As a pharmacy, the loss of one medication out of many isn’t a concern, but if many prescriptions are lost to the PPN pharmacies, it can have a big effect on the bottom line.

PPNs compromise patient care

Looking beyond the competition concerns, many patients have been frustrated by not being able to choose their own pharmacy. Some companies have forced employees to switch to Express Scripts, Canada’s largest mail-order pharmacy. As Express Scripts is both a PPN and a pharmacy benefits manager, it is able to cut costs by reducing dispensing fees. Unfortunately, it can also result in reduced services and safety concerns for patients.

In a CBC investigation, Jamie Mueller, a Labatt employee, talked about missing prescriptions, medication errors, deliveries left outside for hours, and the challenges of trying to resolve problems over the phone. Canadian Pacific Railway employees, many of whom work away from home on production crews, found it difficult to be home to receive deliveries. Other companies such as Home Depot and Canada Post have allowed their employees to use the service on a voluntary basis, recognizing that, “… people are attached to their pharmacy and pharmacist.” (6)

There are many reasons for people to be loyal to their pharmacy. For us, we value the relationships we build with our patients. We know them, their families, and what’s happening in their lives. When they get a new diagnosis or have a health concern, our patients can feel comfortable talking with us and trust that we are looking out for them. It takes time to develop these relationships — we have known some of our patients for decades — and the new pharmacist doesn’t have this history. It’s also unlikely that the new PPN pharmacy will know our patient’s medical history or have access to their health records and lab results, which help to guide our decisions about drug interactions and appropriate treatment. When medication changes need to be made, we can act on them right away. PPN pharmacies simply cannot match the level of service and support that we provide.

“Your health. Our priority.”

As Manulife found out this past week, Canadians feel strongly about changes to the healthcare system, especially when those changes affect their ability to make their own choices about their healthcare needs. We’re not naïve. We know that PPNs and PBMs aren’t going away, that the cost of healthcare will continue to rise, and that insurers will continue to try to cut costs to keep more profits for shareholders. But for now, we are happy that Manulife listened to patients’ concerns and will allow patients to fill ALL of their prescriptions at their pharmacy of choice. (7)

We love what we do. Thank you for choosing us as your pharmacy.

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What’s the big deal?

PPNs take away patient choice

PPNs limit competition

PPNs compromise patient care

“Your health. Our priority.”