In this Money Tree Series Episode, Coach JPMD talks about the role played by pharmacies and their influence on the Money Tree. The Money Tree Series episodes are geared to helping physicians and other healthcare providers learn the ins and outs of running a successful Medicare Advantage practice. You can download the money tree diagram at www.coachjpmd.com/moneytree.
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Coach JPMD 0:05
So if you hear that sound, you know that we're going to be talking about money in the money tree series. And actually we're completing with this series or completing the series with this episode on pharmacies. And, you know, why am I doing all this? Why am I doing the monetary series? Why am I creating this podcast? And I think one of the things that has intrigued me as, as far as the business of medicine is concerned is how much physicians and health care providers, nurse practitioners, physician assistants don't really understand the business of medicine. You know, my wife loves Hallmark, and she watched a Hallmark Channel, especially during the Christmas season. And you cannot watch a show or a movie without seeing tons of Medicare Advantage Commercials, we're in the middle of open enrollment. And patients are signing up. And we need to understand what they're signing up for. And I think one of the things that I've done is created a series. And I'll kind of summarize that when we get back after the intro.
Welcome to the practice impossible podcast, we're your host, Jude Pierre MD, also known as Coach JPMD discusses medical practice topics that will guide you through the maze that is the business of medicine, and teach you how to increase profits and help populations live long. Your mission should you choose to accept it is to listen and be transformed. Now, here's your host, Coach JPMD.
Coach JPMD 1:40
So welcome back. So you know, today's series, or today's episode is going to be on the pharmacy, and how it affects the payment tree and the costs associated with it. This is a difficult topic. So I'm going to try to summarize things as best as I can. And some of the details of of the, the aspects of the pharmacy payment and how it works in the Medicare Advantage realm is in my course on Medicare Advantage. And you can always sign up at www.learnaboutmedicareadvantage.com and sign up for the free course. And there you will find some more in depth details about the pharmacy expenses and how that affects your reimbursement and your revenue. So pharmacy expenses. So how does this all work? You know, pharmacies are everywhere. You got CVS, Walmart, Walmart, Walgreens, Publix, they all have pharmacies, and they're all competing for the business of your patients. And one of the things that you have to understand is that Medicare Advantage plans, receive monies from CMS to purchase drugs or to reimburse patients or pharmacies for drugs that are dispensed by physicians. And so, CMS gives a set amount of money per pay per patient, depending on the acuity of the patient or the disease processes that the patient has.
And that's the monies given as part of the Part D payment to the health plans. So, CMS gives us Part D amount based on actuarial data from people that are much smarter than I am, who come up with these numbers to to reimburse, or to distribute monies to Health Maintenance Organizations HMOs, Medicare Advantage plans, right. And these monies are then distributed based on the contracted rates, that the pharmacy benefit managers, negotiate with wholesalers with retail pharmacies with manufacturers, and it's a whole complicated reimbursement system that's so complicated that I had to find a diagram that actually details all of these things. And I'll, I'll share that in the show notes. But one of the the resources that I used to understand how this all works is through the drug channels Institute.
And they came up with a US distribution reimbursement system that kind of organizes the whole patient administered outpatient drug, product flow, financial flow and contract flow. And I'll share that in the show notes. I don't want to get into the weeds in this podcast, but I basically want to detail how we as physicians can save monies when we are taking care of our patients. In the Medicare world, one of the things that you have to understand is that brand names, medications are going to cost the health plans more. And of course, as a patient needs these brand name medications, then do prescribe them. I'm looking at a screenshot here of Eliquis on good RX. And some of the pharmacies are charging retail price $635, discounted Co Op costs are $553. So if you have a member that's on Eliquis, and they're needing this every month, that expense is going to go towards that patients benefits that are given to them by the Medicare Advantage plan. So if let's say the benefits for that member, is, let's say $5,000 a year, well, within how many months, 5-10 months, 10 months, then that patient would have used up all of their benefits in their rehab, their costs are going to go up unless they reach a catastrophic phase.
And that's, that's another thing we can talk about. And we do talk about that in the course. That's called the coverage gap or the doughnut hole they used to call it. And so what if we prescribe a generic medication? Well, if you prescribe generics, let's say you have a patient that can't take Eliquis, doesn't want to take Eliquis can't afford to take Eliquis, because of the copays, then you can prescribe warfarin, we have our Warfarin clinic in the office, and patients really don't have to pay anything to to get their labs drawn. And we're able to manage their PTO and ours in the office and with no co pays for the checks. And they're usually don't they usually don't have a copay for generic medications, which allows the patient to not have to spend as much money. Now, you know, sometimes you may wonder you may say, well, it's Eliquis may be a better drug Pradaxa may be a better drug or whatever the anticoagulant is. But if the patient is not taking that drug, because they can't afford it, then what's the point? Right. So another way to help save the patient money, which will in turn save you money, is to prescribe generic medications like we just talked about, but also to have patients pick up those medications from a Walmart.
Walmart has a $4 prescription drug plan that includes some generic medications that patients may already be on. And some of those medicines includes gemfibrozil, fenofibrate towards statin. Some of the diabetes medicines, I'm looking at this website here, glimepiride, glipizide, metformin. All these afford all the drugs that are available. And if the patient pays $4, then that won't go towards their pharmacy benefit from the health plan, which will in turn help you save money. In other ways sample, so let's say a patient has to be at Eliquis and you want to support them, because they don't don't have the ability to come to the office or get the INRs checked. Then what you can do is give them samples of medications, which we sometimes do in the office, which will offset the costs. And if you give patients samples of medications, then that does not go towards the patient's a Part D plan and thus saves money. So that's just another way.
I was looking at Publix I didn't know know this, but I just in doing research for this course. Publix used to actually give free medications, free antibiotics, free Metformin, I have a family member that that lives in Haiti, and she would come and visit us and she's on Metformin. We used to get Metformin for her from the Navy bases, 90 prescriptions, but they did away with that program. So as of June 2022, it looks like so Publix no longer has the free list of medications. But there are some other pharmacies that might have that. So again, it's about doing some research for your patients and, and allowing them to get generic medications if they can't afford or can't take the brand name medications. So that's another way.
So depending on the health plan, different health plans may provide different benefits for the members and for the patients. So sometimes patients may be may switch medication or switch health plans to get better drug benefits. But with that, that may decrease other services or other other things that they may be getting from that one plan that they're switching to so this is a time that patients enroll in different health plans. Looking for better benefits. And the goal is to understand this process and to kind of understand what patients are going through on a yearly basis. Because if we understand it better than we can serve our patients better, and we can understand and have empathy for them and in terms of the medications that they may be wanting to be on or be off of, based on a different reasons.
So I hope this monetary series helps you in understanding what we do in managed care and how monies are distributed. And if you want to see the full diagram, you can go to www.coachjpmd.com/moneytree and you can get a download of that. And we're winding down this year. And we've got some exciting things coming down the pipe. Great interview of for my first video interview podcast is coming. So stay tuned for more and we hope to see you in two weeks.