Opinion: The ongoing measles outbreak was 'avoidable.' Now what?

Map by Sarah Milotte, The Rural Index via The Daily Yonder

As measles cases in the U.S. top more than 1,000 diagnosed infections, medical experts Richard Hughes and Anna Larson call the ongoing outbreak "an avoidable public health failure," in their opinion for MedPage Today.

Measles was declared "eliminated" in the United States in 2000, but its status is evolving. The most recent eruption of the highly contagious disease began in rural Texas and "continues to unfold with additional deaths in Texas and New Mexico, an exposure at a major U.S. airport following an identified case in Maryland, and expanding to over half of U.S. states," Hughes and Larson write.

The newly appointed Secretary of Health and Human Services, Robert F. Kennedy Jr., has added to the confusion about the measles, mumps and rubella (MMR) vaccine by endorsing "unproven treatments for measles and emphasizing vaccination as a personal choice rather than a public good," they write. When "he finally recommended measles vaccination to address the snowballing case count, he then ordered the search for new measles treatments instead of promoting vaccination."

Searching for a new measles "cure" won't stop the continuing spread of the disease, but beefing up MMR vaccine rates could. Instead, the administration "has canceled research related to vaccine hesitancy and misinformation," Hughes and Larson add, "and announced a requirement that all new vaccine products undergo placebo-controlled clinical trials prior to licensure."

What is likely to happen? "We can expect vaccination challenges to compound, immunization rates to decline, and vaccine-preventable diseases to rise," Hughes and Larson write. "A comprehensive U.S. approach to shore up our measles defenses and preserve elimination status is imperative, but unlikely."

What can be done to slow the current measles outbreak down? "Consistent application of proven public health measures -- expanded vaccine access, particularly in underserved populations, and improved disease and vaccine surveillance systems," according to Hughes and Larson. "The need to combat misinformation and instill public trust in vaccines is obvious, but bears repeating. . . . Now is not the time for complacency; it's time for action."

Report: Chain drugstores get $23.55 to fill a blood pressure prescription, but a small drugstore gets only $1.51

Adams Family Pharmacy often loses money filling
prescriptions. (Photo by A. Miller, KFF Health News)

Even as independent pharmacists face low or no profits from medication sales, pharmacy middlemen reimbursements favor large drugstore chains. The Federal Trade Commission and several lawmakers are starting to take aim at prescription benefit managers' power and repayment practices.

"On Sept. 20, the FTC sued three of the largest PBMs. . .The lawsuit followed a scathing FTC report that said the 'dominant PBMs can often exercise significant control over which drugs are available, at what price, and which pharmacies patients can use to access their prescribed medications,'" reports Andy Miller of KFF Health News.

How PBMs dominate reimbursement in Georgia is a drastic example of smaller pharmacies being shorted. The American Pharmacy Cooperative, which represents independent pharmacies, "reviewed the price differential paid to a north Georgia pharmacy and nearby chain stores," Miller explains. "The analysis showed chains were paid well beyond the family business. For example, the chains received an average of nearly $54 for the antidepressant bupropion, while Bell’s Family Pharmacy in Tate, Georgia, got $5.54. . . . For a drug used to treat blood pressure, amlodipine, chain pharmacies received an average of $23.55, while Bell’s got $1.51. . . Bell’s Family Pharmacy closed earlier this year."

Nikki Bryant is a pharmacist and co-owner of Adams Family Pharmacy in rural Cuthbert, Georgia, who has worked to find creative ways to bolster the business' income because the pharmacy loses money. "Bryant and other independent pharmacists say they lose money filling certain prescriptions while reimbursements favor chain pharmacies like CVS that have corporate ties to pharmacy benefit managers," Miller adds. "Bryant said she can make more profit on cake and coffee than with many medications."

Some lawmakers are scrutinizing PBMs. "Members of both parties in Congress have tackled PBM reform," Miller reports. "House members recently introduced another proposal, known as the Pharmacists Fight Back Act, which supporters say would add transparency, limit costs for patients, ensure they get the benefit of drugmaker discounts, and protect their pharmacy choices."

Years of underpayments by PBMs to smaller pharmacies have disproportionately harmed rural communities by "accelerating closures of mom-and-pop pharmacies across the country, said the National Community Pharmacists Association," Miller reports. "The U.S. loses almost one such pharmacy a day, said Anne Cassity, a senior vice president of the association."

Powerful pharmacy benefit managers are tasked with cutting costs, but their practices can undercut small pharmacies

PBMs increase profits when independent pharmacies
go out of business. (Adobe Stock photo)

The loss of independent pharmacies across the country has been a concern for rural residents, but who are the fabled PBMs, or pharmacy benefit managers, how do they operate and what do they gain when they force smaller pharmacies to close, ask Reed Abelson and Rebecca Robbins of The New York Times. "A New York Times investigation found PBMs, which employers and government programs hire to oversee prescription drug benefits, have been systematically underpaying small pharmacies, helping to drive hundreds out of business."

PBMs garner the power to underpay smaller pharmacies from "two main sources. First, the three biggest players — CVS Caremark, Express Scripts and Optum Rx — collectively process roughly 80 percent of prescriptions in the United States," Abelson and Robbins explain. "Second, they determine how much drugstores are reimbursed for medications that they provide to patients. . . . When local drugstores fold, the benefit managers often scoop up their customers, according to dozens of patients and pharmacists."

The process of how pharmacists purchase medicines, sell them to patients and receive reimbursements is undermined by PBMs who seek to add to their profits by undercutting smaller drugstores' drug reimbursements. The Times reports, "To take just one example: For a month’s supply of the blood thinner Eliquis, several pharmacists in different states said, the big three PBMs routinely paid them as much as $100 less than what it cost the pharmacies to buy the medication from a wholesaler.

"By contrast, the PBMs sometimes pay their own pharmacies more than what they pay local drugstores for the same medications. Independent pharmacies are powerless to fight back. As the unprofitable transactions pile up, some are unable to stay afloat. . . . [The closures] have disproportionately affected rural and low-income communities, creating so-called pharmacy deserts that make it harder for residents to get prescriptions and medical advice."

There is an inherent tension between PBMs and any pharmacy seeking drug reimbursements. The PBMs' purpose is to cut costs, which is accomplished by paying pharmacies less. Those savings can, "in turn, lower insurance premiums for workers and people covered by government programs like Medicare," Abelson and Robbins write. "But that apparent frugality often benefits the PBMs in ways that have nothing to do with their clients’ interests. . . .At the same time that PBMs are reimbursing pharmacies at rates below their costs, the benefit managers are often charging employers much higher prices and pocketing the difference, according to insurance paperwork reviewed by The Times."