Your intrepid blogger is on a GLP-1. It was with great reluctance that I went on one. I have been a diabetic for about 17 years now. I tell everyone it runs in the family, which is indeed truthful. But I admit privately (and I guess publicly as of now) that a lot of my diabetes is tied to my poor eating habits and lack of exercise. I have tried a great deal over the years to keep my HbA1C below 7.0. It worked for a while with generic meds and then with one brand drug. But as I close in on my sixties, I began inching up and went above 7.0.
I am a new drug skeptic. I don’t believe the Food and Drug Administration (FDA) or brand drug makers have the best interests of Americans at heart – the FDA because it is inept, the drug makers because they are greedy, and there is a revolving door between drug makers and regulators that creates a huge conflict of interest that compromises safety. But after consulting with my doctor, I decided to take the GLP-1 plunge. The results have been dramatic. While I have not yet had my first HbA1C test under a GLP-1, I have lost more than twenty pounds and have no doubt that I am now on the right path.
The battle for consistent supply
My biggest issue, however, has been availability. Given my obstinance, I set out to discover what this was all about. To be fair to all, I am leaving out pharmacy names and the drug names themselves – except for the pharmacy to which I am now devoted. But what I found was a familiar pattern in how drug pricing, supply, and availability generally works.
As you may know, you must begin slowly on a GLP-1 and increase your dosage over time. In my case, I had multiple months of increasing dosages. I have used one big pharmacy chain for most of my life. My initial dose through them was late by about two to three weeks and I only received it due to my badgering the pharmacy. I have to say they were unhelpful throughout and refused to really give me firm updates or information along the way. I thought this was just about the shortage of the drug. It was not.
With my first dose finally filled, I quickly set out to ensure my next higher dose would be available early so there was no interruption of my treatment. I dutifully called my pharmacy benefits manager (PBM) to ensure that every dose I needed for the next several months was pre-approved and the appropriate edits were in the claims system. That took me a good two weeks of fighting to get this done. During this time, I worked with the pharmacy for the next month and again received the same lack of transparency and poor treatment. Pharmacists dodged my questions. Less than a week before my next dosage was due, it still had not been obtained by them.
At this point, I began calling other large drug chains (free-standing drug stores, those associated with larger retail establishments, and those associated with grocery stores) and independent pharmacies around my home in Florida and in Georgia where we go each summer for several months. I heard the same things from both independent and chain pharmacies.
- I asked my long-time pharmacy whether they stocked GLP-1s. They answered no.
- I asked the same pharmacy to order or call around to other stores a week to ten days before my refill was needed to ensure no interruption. They were unwilling to do so.
- The pharmacy stated that they order within a few days of refill and if it is not available in the coming week, I am out of luck. Great customer service from one of the leading pharmacy chains in the nation, huh?
- Other chains followed the same policy. They were not willing to work with me to gain my business.
- Independents were far more transparent. They explained that they had no leverage given shortages in the market. More important, they told me that they lose money on every GLP-1 filled and simply couldn’t afford it. They apologized profusely.
How could this be? Losing money on every GLP-1 drug they fill? Could this be the case too for the retail chains?
Success from one drug store chain
I finally found a retail chain that would work with me and quietly explained to me why I was getting the treatment I was getting. They, too, may lose money on every GLP-1 they fill, but have a corporate policy to try to “stock” the drugs their patients need to ensure consistent therapy. This is in part due to their customer service philosophy. But it also is because I transferred all my drugs to this retail chain (they make money on my other drugs), and I walk the aisles of their larger retail store and make other purchases.
This is what the retail drug chain (with locations in Florida and Georgia) did for me. They reminded me to get my doctor to call in the next dosage early. The drug stores in Florida and Georgia worked with each other to coordinate my scripts at different months of the year. The pharmacies have a policy of looking up availability on behalf of their patients and ordering the relevant GLP-1 drug if that dosage would be needed by a patient soon. Yes, sometimes this means too many of the expensive drugs if a patient does not stay on their therapy (a big issues with GLP-1s), but it is a critical service this retail chain does for those who need their drugs. It is not technically “stocking” the drug I guess, but it is very close to it.
The drug chain is Walmart Pharmacy. Thanks Walmart! You are the best!
The skinny
So here is the skinny:
- Several major retail chains are unwilling to work with customers to find their GLP-1s. This was the case regardless of whether the retail chain was associated with a PBM or not. More on this later. These chains were less than transparent, were unhelpful, and deliberately obfuscated the issues. (I am aware that “deliberately” is redundant when used with “obfuscated,” but I am still upset about my treatment.)
- Independents and some grocery chains had some very nice and knowledgeable people and told me the way it is. “We don’t have leverage and can’t take the losses,” they told me. I appreciated the sincerity. We are losing these independent pharamcies due to market forces and the consolidation occurring both in the pharmacy and PBM industries. This is very sad.
So how does the drug supply chain stack up on GLP-1s and perhaps many other brand drugs
- Brand drug makers – they make the most. They have obscenely high prices and have little incentive to grant any major discounts to wholesalers.
- Wholesaler middlemen – they do not get large discounts from drug makers on GLP-1s, but it is hard to feel sorry for these mammoth guys as they make money both on the supply-side and buying side overall.
- Pharmacies – On GLP-1s, wholesalers are not granting favorable pricing. When PBMs are ready to reimburse pharmacies for dispensing drugs to a member of a health plan or employer group, the PBM often under-reimburses for the brand drugs. Thus, pharmacies can lose money or barely break even on GLP-1s and other brands. Losses on GLP-1s can be in the tens of dollars or even more depending on a pharmacy’s buying power.
- PBMs – They not only squish the reimbursement to pharmacies but charge employer groups and health plans much greater prices for these drugs. They also enter deals with brand drug makers and gain a handsome rebate on GLP-1s in return for favorable treatment on a formulary. This rebate usually is not shared with pharmacies to reduce their costs, with the consumer at the point of sale, or with employer groups on the back end. A retail pharmacy associated with a PBM would not even help on the “stock” issue as there is a distinct line between the pharmacy operation and the PBM. But there very likely are favorable payments from the PBM to a sister company pharmacy to keep dollars within the family – but that is a story for another day.
Conclusion
So, what I found is that pharmacies losing money or barely making money is not unusual for GLP-1s and some other brand drugs, especially for smaller, independent pharmacies. Some larger chains may have this problem, too. And the more expensive the drugs are, the more probability of losses. The losses they suffer is a result of the opaque drug channel and the perverse rebate system we have with brand drugs.
For GLP-1s specifically, a recent survey by the National Community Pharmacists Association (NCPA), which is the lobby for independent pharmacies, found:
- 90% of pharmacies would stock GLP-1s if they could.
- 96% said they experienced shortages or backorders.
- Just 37% said they were keeping stock on hand.
- 63% said they are ordering the products based on paid claims because of the drugs’ high prices and because the reimbursement from PBMs is often below the pharmacy’s cost.
So, my journey on a GLP-1 was initially rocky. The drug shortage has admittedly settled down a bit for my specific GLP-1 and I have Walmart watching my back each month so I have no interruption. My nice public-sector retirement plan covers the entire cost of my drug as well.
But access to GLP-1s and costs are very different for most Americans. My journey was easy compared with what many Americans go through finding and paying for their expensive drugs each month. I am among the lucky few.
#weightlossdrugs #glp1 #drugpricing
— Marc S. Ryan
