Through the lens of rural patients and pharmacies: A content analysis of state level pharmacy benefit manager regulations and policies

Abstract

Background: Pharmacy Benefit Managers (PBMs) are responsible for establishing community pharmacy reimbursement practices and prices to varying degrees. Understanding PBMs' reimbursement practices is necessary for the continued viability of community pharmacies located in underserved and rural patient communities. Currently, there is a gap in literature exploring PBM reform and the impact this legislation has on rural pharmacy practice.

Objectives: This content analysis reviews the legislation complied by the National Community Pharmacists Association (NCPA) and determines its benefits to pharmacies and patients in rural areas.

Methods: The NCPA PBM Reform legislation document included bills from 48 states and the District of Columbia, that were introduced between November 30, 2018, through December 7, 2021. Bills were classified as enacted (n = 81), in debate (n = 186), or as having failed to be enacted (n = 120). Eighty-one enacted bills were reviewed to assess if it benefited patients, pharmacies, or both. Bills not benefiting either pharmacies or patients were excluded.

Results: Fifty-seven bills were included in the content analysis, where six categories were identified using thematic analysis and classified as: PBM Operations, Drug Pricing, Transparency, Reimbursements, Cost Sharing, and Prior Authorization. Only twenty-two bills were identified as potentially benefitting both rural pharmacies and rural patients through inclusion of legislation managing PBM practices involving patient steering, network adequacy, pricing transparency, reforming cost-sharing structures, and streamlining prior authorization processes.

Conclusions: This study identifies multiple PBM legislation categories having the potential to impact rural pharmacy operations and patient outcomes. However, further research is needed to understand the specific financial and clinical impact of these PBM legislation categories on rural communities and rural pharmacy practice, as well as their alignment with enabling pharmacists to combat unique health disparities and challenges facing rural communities.

Keywords: Pharmacy benefit manager; Rural health; Rural pharmacy.

Fig. 1

Selection process.