Barriers to medication access, misused taxpayer money among Oregon Health audit findings
The Oregon Health Authority’s (OHA) delivery of Medicaid services is limiting medication access, misusing taxpayer dollars, causing independent pharmacies to lose money, and not ensuring transparency within the industry, according to a 55-page audit released Monday by the Secretary of State's office.
The audit was focused on Oregon’s delivery of Medicaid, known as Oregon Health Plan, and the role of Pharmacy Benefit Managers (PBMs), third-party companies that act as go-betweens for insurance companies, drug manufacturers, pharmacies, and government.
“Pharmacy benefit managers play an important role in delivering pharmacy benefits to millions of Oregonians, but as the audit shows, they operate in a complex structure that lacks transparency,” said Oregon Secretary of State LaVonne Griffin-Valade.
PBMs have a large influence in the pharmaceutical industry and can impact which drugs are covered by insurance and where prescriptions can be filled, and according to the audit, the three largest PBMs in the United States control 80% of the market share.
Oregon’s regulation of PBMs is limited and does not require their work to be shared, the audit said.
More than 1 million Oregonians rely on Oregon Health Plan for insurance coverage, and Oregon taxpayer dollars fund the delivery of this insurance.
Without transparency within the industry, it is difficult to know whether taxpayer dollars are being put to their best use, said Kip Memmott, Audits Director.
“It’s always important we make sure taxpayer funds are being spent as effectively as possible, and Medicaid is a prime example,” said Memmott.
The audit also showed that Coordinated Care Organizations (CCOs) in Oregon do not all have access to the same prescriptions, meaning switching to a different CCO could pose issues in accessing needed medication.
The audit explained that the current process for Medicaid medication delivery is too complex, involving 16 CCOs, six PBMs, hundreds of pharmacies, multiple drug manufacturers, wholesalers, pharmacy administrative organizations, the Oregon Health Authority, and the Department of Consumer and Business Services.
Independent pharmacies are losing money because of the complex system, as pharmacy reimbursements vary depending on the drug, pharmacy type, and PBM.
National pharmacies, like CVS, are reimbursed twice the amount of independent pharmacies for certain prescriptions, the audit showed.
Rep. Rob Nosse, D-Portland, and Rep. Nancy Nathanson, D-North Eugene, said they will prioritize regulating PBMs in the 2024 legislative session.
"Put simply, the behavior we have seen from PBMs towards both national and community pharmacists and their businesses is harmful,” said Nosse.
Auditors provided recommendations for the OHA and lawmakers for improving the system of Medicaid delivery and PBM regulation, including:
Pass laws requiring PBMs to report information about the work they are doing
Implement a fee-for-service model, in which prescription drug benefits would be administered by OHA
Ensure fair pharmacy reimbursement
Have a consistent preferred drug list for all CCOs
Require CCOs to obtain a yearly independent audit of their PBM
“Other states have enacted legislation targeted at patient protections, pharmacy protections, and transparency. Oregon has taken some initial steps but can do more to protect Oregonians,” Griffin-Valade said.
Sydney Wyatt covers healthcare inequities in the Mid-Willamette Valley for the Statesman Journal. Send comments, questions, and tips to her at SWyatt@gannett.com, (503) 399-6613, or on Twitter @sydney_elise44
The Statesman Journal’s coverage of healthcare inequities is funded in part by the M.J. Murdock Charitable Trust, which seeks to strengthen the cultural, social, educational, and spiritual base of the Pacific Northwest through capacity-building investments in the nonprofit sector.
This article originally appeared on Salem Statesman Journal: Misused taxpayer dollars, medication access limited, OHA audit finds
