Two major trends are driving decreasing reimbursement to pharmacies: DIR fees and copay clawbacks. Direct and indirect remuneration (DIR) fees imposed on community pharmacies, sometimes weeks or months after a medication is dispensed, can eat up the pharmacy's profit on a prescription transaction, and sometimes even lead to a loss. According to a survey by the National Community Pharmacists Association (NCPA), 53 percent of pharmacists said DIR fees are assessed quarterly; 67 percent of those surveyed said no information is given as to how much and when DIR fees will be collected or assessed. DIR fees began when Medicare Part D was established, but they now appear in many commercial health insurance plans as well.