
Pharmacy Startup PillPack to Be Terminated by Express Scripts - chermanowicz
http://www.forbes.com/sites/sarahhedgecock/2016/04/14/express-scrips-drops-pillpack-but-pillpack-is-fighting-back/
======
koolba
From the article (emphasis mine):

> “We have historically been contracted with Express Scripts as a retail
> pharmacy, which is what we’re licensed as in the state of New
> Hampshire”–where the physical pharmacy is located–”and they want us to
> contract as a mail-order pharmacy,” he explains. Though the retail-vs.-mail
> order question isn’t a legal one, traditionally pharmacies that dispense
> 30-day prescriptions with typical copays are considered retail, and those
> with 90-day prescriptions and discounted copays are mail-order. _Although
> PillPack does mail its medications to patients (that’s a major selling
> point), everything else about the business model hews closer to the
> definition of a retail pharmacy_.

I would think mailing the meds to the customer is _the_ defining
characteristic of a mail order pharmacy.

~~~
URSpider94
For almost any medical plan, "mail order pharmacy" specifically refers to a
company that provides a 90-day supply of a prescription for a chronic
condition at a special reduced co-pay.

Most health plans let you go to the pharmacy of your choice for regular 30-day
scripts, but require you to use a single provider (typically either Express
Scripts or CVS) to get the 90-day discount.

Insurance companies love these services for the same reason we love Amazon --
high volume drives price efficiency, as does eliminating the need for a retail
storefront with lights and chairs and Muzak and the like.

The retail pharmacy business is a race to the bottom these days. Most small
players have been pushed out by declining reimbursement rates, and the big
guys barely disguise how little they care about customer service. It's clear
that the benefits companies don't want to see another name brand come onto the
scene and demand to take some of their profits,especially one with the
possibility to gain a loyal national customer base by providing an innovative
service.

~~~
hga
_and the big guys barely disguise how little they care about customer service_

That sure seemed to be my experience with all the little CVS stores I used in
the D.C. area in the '90s, but it's not what I see with Wal-Mart in the last
decade in the heartland. Of course, Wal-Mart goes for fewer, much bigger
stores, and benefits from higher volumes than a small CVS which is often only
staffed with one overworked pharmacist (I was always extra careful to check
for dispensing errors when using them).

As for "race to the bottom", well, it sure looks tough. For example, Target
offered upscale pharmacy service, but has given up on doing it themselves in
favor of farming that out to CVS.

 _high volume drives price efficiency, as does eliminating the need for a
retail storefront with lights and chairs and Muzak and the like._

And putting yourself in the likely presence of infectious people or the air
they just exhaled is another reason to avoid the retail pharmacy experience if
you can.

------
joeskyyy
Pillpack user here, and (unfortunately) an express scripts user.

I take 18 pills a day to manage some kidney issues I have, and Express Scripts
doesn't have a good track record with getting your meds to you on time. If I
don't have some of my medications, I could die. Not to mention, it's going to
be a big pain in the ass to count out all those pills, AND take up a
ridiculous amount of space with all the pill bottles, and pill trays.

Incredibly pissed off about all this...

Edit: forgot to mention my amazing feelings towards Pillpack. TJ (the CEO) has
contacted me directly multiple times to make sure everything has been great,
and every interaction I've had with them is __phenomenal __. If your insurance
supports it, I highly recommend it.

------
lbhnact
Just chiming in here to help bring attention to the Express Scripts near-
monopoly. Their market position and it's implications are surprisingly under-
reported.

Surprised the HN crowd doesn't get more riled up about this, given the
implications for science, opiate abuse, and other opportunities missed for
improving the health system.

~~~
ck2
Isn't the lack of ability to negotiate better prices under obamacare a much
much bigger abuse of health care?

The lack of ability to (legally) import from Canada too?

And the fact all prices are becoming geared only for people with insurance to
milk the system.

I don't have insurance and my script went from $4 to $80 when Target cancelled
support for people without insurance. Walmart is the last place now and how
long will that last when they figure out there is no competition.

~~~
lbhnact
I agree the non-negotiation was a major compromise. However it was, as I am
told, basically required to get the ACA passed at all.

The drug companies were represented by Billy Tauzin [1] who, as I am told by
insiders that worked directly with him, was able to get the Pharmacos to not
fight the ACA. Their support was not just critical, but a necessary factor in
getting anything done.

It was a trade-off, whether or not is was worth it is hard to know.

As for your own care, I am sorry to hear about the lack of insurance. Some
states (for often historical market reasons) make it hard for providers to
sell or even give medications to their patients, which is also part of this
problem.

If you look around, there are occasionally 'Direct Primary Care' providers or
community clinics that stock generics for their own patients and will provide
them at no or low-cost. Many organizations and states have processes for the
uninsured to obtain medications at low cost as well. If you find a clinic with
PCPs who are mission-driven, and they are out there, they perhaps can help you
enroll.

[1]
[https://en.wikipedia.org/wiki/Billy_Tauzin](https://en.wikipedia.org/wiki/Billy_Tauzin)

~~~
hga
_It was a trade-off, whether or not is was worth it is hard to know._

It depends on whether you care about there being any new drugs developed in
the future or not. ck2 is having trouble paying his current drug costs and
would seem to be in one camp.

I can pay mine---granted, they've all gone generic---but with a barely, maybe,
kinda treatable genetic in my case but generally common condition for which
nobody has come up with a cure including an effective drug, I'm in another
camp (heck, if new drug discovery had been shut down before the mid-90s or so,
I might well be dead, or suffering enough you wouldn't be blessed with my
contributions to HN). And as more and more people die due to antibiotic
resistance infections I suspect more people will shift into mine.

Ditto importing from Canada, with their small market the easiest thing for
drug companies to do is simply cease exporting brand name drugs to them so
they don't suffer from re-importation and still have something of a new drug
development budget.

~~~
Retric
New drug development is mostly paid for by other party's. The major drug
company's spend money on acquisitions, advertising, and minor tweaks to get
around patents.

ex: Viagra> Uprima and Cialis

Sure, Pfizer for example does spend billions on R&D. But, far more of this is
Development than Research. They also call a lot of dubious spending R&D.

~~~
hga
Then I guess it's just my imagination that in the same decade Pfizer brought
Viagra to market, AstraZeneca developed and brought to market the drug that
just barely manages to keep me functional.

Try again.

ADDED: Side note, apomorphine AKA Uprima is so old a drug Wikipedia tells us
Agatha Christie featured it in a story in 1940.

~~~
Retric
First Viagra was actually an accident. Initial human trials failed, but there
was a useful side effect.

Second, if we want to spend money on research then we can just fund that
directly. Which we do. Subsidizing company's that spend more on advertising
than research is stupid.

US government, Foundations, University's, Pharm all play a roll, but Parma's
role in novel cures is actually the smallest. Granted, still vital as the
others rarely pay for clinical trials.

~~~
refurb
Your comment on Viagra is entirely wrong. It was first tested in pulmonary
hypertension and they noticed the ED effect. It was approved for both
conditions.

Second, the only reason why a pharma company spends on advertising is because
they get a return on it. That is, they spend $10M and get $10M + X in sales
from it. Why else would you spend money?

And finally, most drugs are discovered by private companies, not by the gov't.
It's about a 2/3rd private company and 1/3rd gov't split.

~~~
Retric
Effective != successful. It's considered an Off Label use for very good
reasons.

Second, people take a lot of unnecessary drugs with bad side effects. Sure,
that's profitable for drug companies, but so is flat out robbing people.
Considering how useless many widely prescribed drugs are robbing people may
actually be better for society.

Finally, your flat out wrong on the drug numbers. Drug discovery is very
different from bringing drugs to market. We get ~50 drugs per year, but we
discover vastly more than that.

~~~
hga
Then I suppose this web site is also a figment of our imagination:
[http://www.revatio.com/](http://www.revatio.com/)

Is there any point at which the number of things you claim to be true that we
can trivially point out to be false might cause you to reconsider your
apparent total disdain for the ethical drug industry? The same one that keeps
people like me functional, and joeskyyy alive?

~~~
Retric
Pulmonary hypertension

While sildenafil improves some markers of disease in people with pulmonary
arterial hypertension, _it does not appear to affect the risk of death or
serious side effects as of 2014.[5]_
[https://en.wikipedia.org/wiki/Sildenafil#Pulmonary_hypertens...](https://en.wikipedia.org/wiki/Sildenafil#Pulmonary_hypertension)

I am going to call that a failure, you may disagree.

~~~
hga
So is the study cited by Wikipedia in the half or greater of biomedicine
studies that are just plain wrong, or the half that might be right? And is
that true for all patients prescribed it?

Down in the trenches, doctors don't pay so much attention to studies, as a new
resident who's taken over the primary care of my condition noted. Instead, he
depends on what his experienced supervising doctor has figured out over time,
and of course what he's learning in the world of real patients and ... well,
we really don't know how real the drugs are once they go generic, not when,
for example, Indian companies, even when operating plants in the US, cargo
cult their HPLC tests of batch purity and correctness. The supervising doctor
I mentioned was always interested in my reports of apparent real world bio-
equivalence as the two drugs he prescribed me went generic.

~~~
Retric
It's a meta study of the available literature, so I would put more weight
behind it than a normal study. However I am not a MD.

As to doctors listening to studies, IMO the good ones listen to meta studies.
And specialists I have spoken with try and keep up with their area. Granted,
there are only so many hours in the day, but there is also a fairly limited
number of new drugs every year.

PS: The FDA has only approved ~1,500 novel drugs in it's history. That's a lot
but many of them are fairly irrelevant to most doctors.

------
ThePhysicist
It seems that Express Scripts is simply reluctant to continue their business
relationship with PillPack since they got too big and now pose a serious
threat to their own business model (which probably relies on mail orders as
well). It's of course understandable that they don't want to let a startup
take away a profitable market segment from them, but it seems that they do
this by making use of their market-controlling position, which is probably
illegal (IMHO).

Reading the article it's really hard to say what is really going on though as
the journalist makes very little effort to uncover the real motivations behind
the actions of the two companies.

~~~
refurb
From what I know about Express Scripts, it's probably more about money than
market share. ESI has over 1/3rd of the market and is a huge player. They are
notorious for driving down costs in a very aggressive way. I would imagine
they wanted to cut way back on how much they paid PillPack and PillPack said
"no".

------
wsh91
If you like what PillPack is doing and you take meds, consider switching to
them. :) I've had nothing but great service and, as someone on about eight
pills a day, it's made part of my life much easier.

------
Cypher
I can't see the content & the link asks me to turn off my anti virus.

~~~
nissehulth
They won't let me in even with a fresh Chrome without any plugins at all. They
still tell me to disable adblock.

Their adblock-checking seems very broken.

~~~
quotha
me too, forbes is against privacy badger

