FARMINGTON — During a time when corporations loom large and seem to eat up the little guys – as well as each other at times – three pharmacies in Franklin county are bucking the trend.

Spruce Mountain Pharmacy in Jay opened its doors in 2009. Mt. Blue Drug in Farmington and Western Maine Pharmacy in Kingfield both followed in 2011. The last 10 years have been turbulent ones for independent pharmacists as consolidation has continued its creep and the politics and instability of health insurance make it a risky business. But with solid, customer-first missions and individual creativity, these businesses are holding on.

All three stores are focused on making their small size their greatest strength. Their responsibility is to their customers and they do not vary from their mission.

“Our pharmacy is part of the community,” said Steve Maki, owner of Spruce Mountain. “Customers see us here and they see us out and about. We coach little league, we volunteer beside them. We know each other.”

Jason Pratt of Mt. Blue Drug agrees. “We provide our customers with physical access. In a chain store, the pharmacy is located in the back. It’s often raised up, behind barriers. When a customer comes in here they don’t have to go find us, we’re right at the counter, and it’s key to our service.”

From left, Jill Savage, Heidi Richards and Paula Smith at work at Mt. Blue Drug. Franklin Journal photo by Nicole Carter

“Being an independent pharmacist gives us the freedom to care for our customers in a personal manner,” said Audrey Parks of Western Maine Pharmacy. “We aren’t expected to fill drug quotas. Our customers know that decisions for their healthcare treatments are made by humans and not computers.”

Maki feels that the flexibility of being small outweighs the power of being large. He is able to rely on his twenty years of experience in the field to counsel customers on their medicines.

“I treat my customers and address their needs the way I think it should be done,” he said. “We aren’t driven by corporate protocol, it’s my protocol and it’s focused on the customer.”

Maki said Spruce Mountain cares for patients through case management. They are able to take the time discussing what the patients require and work with them to manage their health, not transactions. The pharmacy will compound medications on site according to a customer’s individual needs. Spruce Mountain also provides pet prescription compounding services—one more thing that sets it apart from corporate chains.

Spruce Mountain has actually outgrown its space and is renovating a new location down the road on Main Street.

“We are building out a bigger facility,” said Maki. “We don’t need more retail space—we have about 800 square feet at our Tweedie Street store and that won’t change. But we’ve outgrown our ability to serve our customers in this space. We’ll go from one compounding room to two. We’ll have consultation/vaccination rooms to give our customers more privacy. And we’re adding a drive–through for convenience. Our expansion is driven by the demand for our services.”

Up the road in Kingfield, Parks has taken a different route for her customers.

“Our entire building is about 850 square feet, including inventory and work space,” she said. “We do nothing but medical products. No knick knacks or gifts, there is no card section here. We do prescriptions, over the counter medicine, vitamins and other health items. Our role is to serve the health of our community.

“We are different even from other independents in that we fill a specific void in our community. Rangeley’s last pharmacy closed 8-9 years ago. Our customers come from there, from Stratton and Eustis, places where it’s a road trip to fill a prescription. The closest chain pharmacy is about 25 miles away in Farmington. There is no reason for us to stock non-medical goods that we’d have to charge more for.”

Mt. Blue Drug in Farmington has more traditional challenges: close competition. Walmart and Hannaford’s both have pharmacies right around the corner. Walgreen’s (formerly Rite Aid) is on the other side of town.

“We stand out from the big guys just by being ourselves,” said Pratt. “We are able to make decisions for customers that are best for them. Our staff is all trained in pharmacy and are licensed; the chains don’t have that option.”

Mt. Blue Drug has knick knacks on display and maintains a large selection of discount greeting cards. They also feature original art for sale by a local artist.

“We have some non-medical products because it helps. We compete with the other stores with our personalized service,” said Pratt. “I find it very rewarding to be here, I like the challenge of being an underdog and I think our customers like that about us.”

Independent Pharmacy Mt. Blue Drug, in Farmington, Maine. Franklin Journal photo by Nicole Carter

One area of the business that all three pharmacy owners are wary of is the way prescription benefits are managed by insurance companies.

“The prescription volume that drug companies expect to see is not always conducive to what I see as best for the patient,” said Maki. “And the insurance companies follow suit. For example, take a patient who I am treating for diabetes. Generally speaking, diabetics also tend to struggle with high cholesterol, so the payer expects to see statens prescribed along with their diabetes treatment. If that patient has healthy cholesterol levels I am not going to recommend he take statens. They don’t need it. But over time, as the insurance company review his records they will see that as a gap and assume that I am not properly taking care of that patient’s medical needs when that’s exactly what I’m doing.”

Prescription reimbursements are handled by third-party administrators, known as PBMs (prescription benefit managers). The premise of PBMs began to administer Medicare Part D prescriptions—they would act as volume buyers for drugs, and that volume would give them leverage to negotiate better prices with the drug companies.

In recent years, however, drug chains have begun acquiring PBMs, thereby creating their own buying networks. The PBMs are incentivized to give preferred pricing to their corporate parents and leave independent pharmacies out of the process.

“The linear connection between the PBMs and the large chains is about my biggest challenge,” said Maki. “CVS now owns Caremark, one of the biggest PBMs in the country. They have their own preferred network. It’s third-party in name only.”

Direct and indirect remuneration (DIRs) is another trend that has become part of prescription reimbursements. DIRs is a term pertaining to administering Medicare Part D plans. However, PBMs have begun applying the process to commercial health insurance policies as a way to retroactively collect fees from dispensing pharmacies. The fees are often arbitrary and carry different labels, such as service fees, network access fees, administrative fees, and on and on.

“PBMs have found that DIRs are a loophole,” said Maki. “They assign fees for negative reimbursement. They come unannounced, with no accounting. You practically need a PhD in mathematics to figure out the algorithms that go into their billing.”

“DIRs are a huge issue for us,” said Parks. “PBMs use them to inflate the price a customer pays if his drug coverage is part of a deductible. We will collect prescription payment from customers according to what the PBMs dictate. But later, even months later, we’ll get DIR statements that retroactively demand the inflated portion of the money be paid back to them.

“There is no warning or rationale for how it works. As a business owner, it makes managing cash flow difficult. I can’t plan ahead to adjust because I don’t know when or how it will come. The worst part is that it’s pure profit for the insurance companies—they overcharge patients for prescriptions and have no accountability for it. The patients don’t even know because they’ve already overpaid.”

For independent pharmacists, the instability of prescription drug coverage is a constant threat that they meet with caring, personalized service for their customers. It is a political issue that no one without lobbyists is in a position to challenge. With little success Maki, Parks and Pratt (with his partner Robert Holland) regularly reach out to elected officials on the issue, which has grown over the last several years as the line between PBMs and drug chain giants continues to blur.

U.S. Senator Susan Collins is aware of the loopholes that have led to increased profits. Asked for comment, she replied that she has been in touch with some independent pharmacies in Maine struggling with DIRs and hopes to see legislation introduced during the next session. In February, 2019 Congressman Jared Golden introduced a bill for prescription drug price control (co-sponsored by Congresswoman Chellie Pingree, among others), legislation that targets pharmaceutical companies but not payers. Rep. Golden has also cosponsored a bill to allow importation of safe, affordable prescription drugs from Canada, and a bill that would give the federal government the power to negotiate drug prices for the millions of Americans on Medicare.

Introducing legislation is a start but has not brought any relief in the form of law. Franklin county’s independent pharmacists continue to carve their niche, without the clout and influence of big pharma and health insurance lobbies. And as long as their loyal customer base relies on their care, service, and expertise Spruce Mountain, Mt. Blue and Western Maine pharmacies will be mainstays and partners in their communities.