I ask perplexity.AI:

under trump RX how and where are these Rxs going to be filled, local community pharmacies, mail order or some other way?

TrumpRx is structured so that many of the prescriptions it targets never touch a local pharmacy at all; they are routed to manufacturers’ contracted mail/specialty pharmacies via TrumpRx.gov and the drugmakers’ own DTC portals, with community pharmacies competing only on price for patients who choose not to use the portal.

How TrumpRx fills prescriptions

• Primary channel is DTC mail/specialty: TrumpRx.gov does not itself sell or dispense medications; it directs patients to the manufacturer’s direct‑to‑consumer site, which then uses a contracted fulfillment or specialty pharmacy to ship the drug.

• Valid Rx still required: Patients still need a prescription from a prescriber, but the Rx is sent to the manufacturer’s partner pharmacy rather than the patient’s usual community pharmacy if they choose the TrumpRx route.

• Cash‑pay only at point of sale: The discounted TrumpRx prices are described as cash prices that cannot be combined with insurance at the point of sale, which reinforces channeling fills through the DTC/mail model rather than standard plan‑PBM retail networks.

Role of local community pharmacies

• Indirect participation only: Community pharmacies are not integrated “TrumpRx network” providers; instead, they remain the default channel for patients who stick with their insurance or ask the local pharmacy to match TrumpRx cash prices.

• Competitive pressure, not volume growth: Analyses aimed at pharmacies warn that TrumpRx introduces “channel displacement,” as manufacturers’ DTC programs and mail fulfillment siphon away some prescriptions that would otherwise be filled at community pharmacies.

• Patient choice on each Rx: For a given drug, the patient (and prescriber) can either:

  • Fill through the usual route (local pharmacy, billed to PBM/plan), or

  • Use TrumpRx.gov and shift that prescription to the manufacturer’s mail/specialty partner under a discounted cash arrangement

Where most TrumpRx volume is likely to go

• High‑cost specialty and brand products: The initial deals (Pfizer, Novartis, Sanofi, Eli Lilly, Novo Nordisk, etc.) emphasize big‑ticket brands—GLP‑1s, MS drugs, Hep C therapies, cholesterol biologics—where manufacturers can afford steep “TrumpRx” discounts in exchange for MFN/tariff relief.

• Fulfilled by limited networks: Those products are already heavily specialty/mail‑pharmacy dominated, so TrumpRx volume is expected to concentrate in limited networks or manufacturer‑owned/contracted specialty pharmacies rather than in broad retail community networks.

• Medicaid/Medicare carve‑outs separate: Some Trump administration agreements focus on Medicaid and Medicare MFN‑style pricing within existing plan structures (i.e., still running through PBMs and standard networks); that business would continue to flow through local pharmacies when plans keep retail networks intact, but that’s parallel to, not part of, the TrumpRx DTC cash channel.

Net effect on dispensing channels

• TrumpRx channel: Predominantly mail/specialty fulfillment linked to manufacturer DTC sites; community pharmacies touch those prescriptions only if a given manufacturer allows local pharmacy fulfillment and the patient opts in.

• Traditional insurance channel: Local community and chain pharmacies continue to fill insured prescriptions, but may lose some higher‑margin branded volume when patients or plans migrate to TrumpRx‑linked discounts.

• PBM role weakened but not removed: For the TrumpRx cash‑pay segment, PBMs are largely bypassed, while they remain central for insured fills through existing networks that still include community pharmacies.

so any money paid under Trump Rx will not go toward the pt’s annual Rx deductible and couldn’t Trump Rx accelerate the closing of community pharmacies – especially hitting low income and rural area the hardest. Mail order is hard pressed to provide “need it now ” – acute meds and are notorious for not always maintain proper temperature during shipment – often compromising the potency of Rx medications because of meds getting too hot or too cold during shipment. Doesn’t Trump Rx run the risk of causing few community pharmacies being available, resulting in farther distances for pts to travel and/or poorer services?

Yes. TrumpRx transactions are typically treated as standalone cash purchases, so in most cases they will not accrue toward a patient’s annual deductible or out‑of‑pocket maximum, and the model carries very real risks for community pharmacy viability, especially in low‑income and rural areas.

Deductibles and out‑of‑pocket tracking

• Cash ≠ deductible credit in most plans: Analyses aimed at consumers make clear that TrumpRx is a cash‑price option that sits outside the insurance claim stream, meaning amounts paid usually will not be captured by deductible/OOP tracking unless a plan builds in a specific “file a claim” workaround.

• Plan incentives may conflict: Employer and Medicare commentary frames TrumpRx as “another way” to manage costs, not a replacement for Part D or commercial coverage, and flags that using it can delay reaching the deductible, which can backfire once a patient moves into a higher‑spend phase of care.

Impact on community pharmacies

• Channel displacement, not just margin squeeze: Legal and consulting analyses describe the primary TrumpRx risk to pharmacies as “channel displacement” when manufacturers sell direct through the portal and bypass pharmacies entirely or restrict discounts to DTC/mail‑order fills.

• Greatest vulnerability: independent, rural, low‑income areas: Commentaries from rural owners and trade groups warn that when high‑revenue brand prescriptions move to DTC/mail channels, independents lose both revenue and patient foot traffic that supports broader services, with rural communities hit hardest because those pharmacies often function as the only local health access point.

Likely downstream effects

• Acceleration of closures in already thin‑margin markets, increasing “pharmacy deserts” and forcing longer patient travel distances.

• Erosion of face‑to‑face counseling, immunization, and chronic‑care services bundled around the dispensing function, which are disproportionately important in rural settings.

Mail‑order limitations and temperature risks

• Poor fit for “need it now” meds: TrumpRx’s DTC model is geared to chronic and high‑cost brands, not true acute/urgent fills; even proponents acknowledge that acute antibiotics, short‑course steroids, and post‑op meds are not well suited to multi‑day shipping.

• Documented temperature‑control problems: Multiple investigations and professional society reports have found that mail‑order medications are frequently exposed to temperatures outside the 68–77 °F “room temperature” range, with cargo spaces hitting extremes that can compromise drug stability.

• Regulation lagging practice: Pharmacy boards and researchers have called for tighter regulation and temperature monitoring across mail‑order shipments, noting that current industry practices reserve robust controls for a minority of clearly temperature‑sensitive products, not for the bulk of room‑temperature items that may still be vulnerable to heat/cold excursions.

Net risk to access and quality

• Fewer brick‑and‑mortar options: By shifting profitable brand volume into DTC/mail and cash channels that bypass PBM‑retail networks, TrumpRx increases economic pressure on community pharmacies already battered by DIR clawbacks, low reimbursements, and shrinking front‑end sales, increasing the likelihood of further closures.

• Worse service for vulnerable patients: As rural and low‑income neighborhoods lose pharmacies, patients face longer travel distances, reduced access to acute “need it now” medications, more dependence on mail order with imperfect temperature controls, and less access to pharmacist‑provided clinical services.

Put bluntly, TrumpRx can help certain patients with specific expensive drugs in the short term, but structurally it tends to undermine local pharmacy infrastructure and does little to solve the time‑sensitive and quality‑of‑handling issues that community pharmacies are uniquely positioned to address.

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1. https://www.fdli.org/2018/08/update-the-dea-quota-system/
2. https://usafacts.org/articles/are-fentanyl-overdose-deaths-rising-in-the-us/
3. https://www.kff.org/mental-health/opioid-deaths-fell-in-mid-2023-but-progress-is-uneven-and-future-trends-are-uncertain/
4. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
5. https://www.ecfr.gov/current/title-21/chapter-II/part-1303
6. https://uscode.house.gov/view.xhtml?req=%28title%3A21+section%3A826+edition%3Aprelim%29+OR+%28granuleid%3AUSC-prelim-title21-section826%29&f=treesort&edition=prelim&num=0&jumpTo=true
7. https://www.dea.gov/operational-division/diversion
8. https://museum.dea.gov/sites/default/files/2021-09/Diversion%20Control%2007102019–Accessible.pdf
9. https://www.oregon.gov/oha/ph/preventionwellness/substanceuse/opioids/pages/fentanylfacts.aspx
10. https://www.federalregister.gov/documents/2019/10/23/2019-21989/management-of-quotas-for-controlled-substances-and-list-i-chemicals
11. https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-057)(EO-DEA217)_Researchers_Manual_Final_signed.pdf
12. https://www.congress.gov/crs-product/R45948
13. https://www.dea.gov/press-releases/2020/04/07/dea-takes-additional-steps-allow-increased-production-controlled
14. https://www.ashp.org/Advocacy-and-Issues/Key-Issues/Drug-Shortages/ASHP-and-Healthcare-Groups-Urge-the-DEA-to-Adjust-APQs-to-Mitigate-Ongoing-Drug-Shortages
15. https://www.pharmacytimes.com/view/debunking-the-myths-of-controlled-substance-quotas
16. https://www.federalregister.gov/documents/2024/12/17/2024-30023/established-aggregate-production-quotas-for-schedule-i-and-ii-controlled-substances-and-assessment
17. https://www.deadiversion.usdoj.gov/quotas/quotas.html
18. https://www.federalregister.gov/documents/2025/11/28/2025-21509/proposed-aggregate-production-quotas-for-schedule-i-and-ii-controlled-substances-and-assessment-of
19. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2833721
20. https://www.osc.ny.gov/reports/continuing-crisis-drug-overdose-deaths-new-york

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CMS is cracking down on it in Medicare Advantage while expanding its use in traditional Medicare

https://www.medpagetoday.com/practicemanagement/reimbursement/119157

Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced an agreement with Medicare Advantage plans to lessen the use of prior authorization, but the agency also said it would conduct a demonstration project looking at expanding its use in traditional Medicare. In this story, we look at what has happened so far and what experts are watching for in the future.

As the year comes to a close, the Trump administration seems to be going in two different directions when it comes to the use of prior authorization in Medicare.

On the one hand, there is the effort by CMS to crack down on the use of prior authorization among Medicare Advantage plans and other federal and private insurance programs. In June, HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz, MD, held a roundtable with industry stakeholders.

The participants included America’s Health Insurance Plans, the Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, Cigna, Humana, Kaiser Permanente, and UnitedHealthcare. The participating insurers pledged to, among other things:

• Standardize electronic prior authorization submissions
• Reduce the volume of medical services subject to prior authorization by Jan. 1
• Implement real-time approvals for most requests by 2027
• Ensure medical professionals review all clinical denials

Prior Regulation

That agreement came on top of regulatory changes to prior authorization that were already underway. For example, CMS issued a final rule on interoperability and prior authorization in January 2023, and more regulations later that year as part of the Medicare Advantage and Part D final rule, explained Neil Patil, MPP, policy director at the Medicare Policy Initiative at Georgetown University’s Center on Health Insurance Reform. “Those two rules put a lot of new requirements on plans,” including streamlining the use of electronic prior authorization requests rather than requiring providers to submit requests via phone or fax, Patil said in a phone interview.

In addition, “by law, Medicare Advantage plans have to cover traditional Medicare services,” he said. “A lot of plans were using prior authorization as kind of a way to deny some of the care that beneficiaries are legally entitled to … so CMS put out some new rules saying, ‘You have to follow traditional Medicare laws, regulations, National Coverage Determinations, and Local Coverage Determinations. You can’t just unilaterally deny something that would have been covered under traditional Medicare.'”

But even as CMS is scrutinizing prior authorization in Medicare Advantage, it is also expanding its use — if only a little — in traditional Medicare. In June, CMS announced a new demonstration project in traditional Medicare: the Wasteful and Inappropriate Service Reduction (WISeR) Model. Under the model, “CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process” under traditional Medicare, the agency said in a press release, adding that the model will help “patients and providers avoid unnecessary or inappropriate care and [will safeguard] federal taxpayer dollars.”

The WISeR Model will test new technologies including artificial intelligence (AI) to see whether they can expedite the prior authorization processes for certain items and services “that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use,” the press release noted. “These items and services include, but are not limited to, skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.” Emergency services and inpatient-only services are exempt from the model, which will initially be tested in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

Although the model is “voluntary” for providers, “providers and suppliers in the assigned regions will have the choice of submitting prior authorization requests for selected items and services or their claim will be subject to pre-payment medical review,” the agency noted, so either way the claims for the affected services will be reviewed.

Pushback From Congress

The model came in for some immediate pushback on Capitol Hill. “It’s baffling how in one breath the administration is trying to take a victory lap on insurers streamlining prior authorization in Medicare Advantage, and in the other instituting the same delay tactics in traditional Medicare,” Rep. Suzan DelBene (D-Wash.), whose state is one of those included in the model, said in an email to MedPage Today shortly after WISeR was announced. DelBene is the chief sponsor of H.R. 5940, which would prohibit WISeR’s implementation. The bill has 32 co-sponsors, all Democrats. A Senate companion bill introduced by Sen. Patty Murray (D-Wash.) has 17 co-sponsors, also all Democrats.

This is not actually the first time that prior authorization has been used in traditional Medicare, according to Marsha Simon, PhD, adjunct professor of health policy at George Washington University in Washington. Prior authorization has worked well there when it comes to the purchase of electric scooters and the use of ambulances to transport patients to routine dialysis appointments; both of those items had been involved in allegations of fraud or overuse, she said.

“It’s not prior authorization that’s the problem; it’s the vendors who are conflicted,” said Simon. She was referring to the information technology (IT) vendors that CMS has contracted with to implement the WISeR Model. Under the model, the vendors are paid a share of the savings generated by the claims that they deny.

And that’s not their only conflict, according to Patil. With two of the vendors, “we’ve done some digging into them and they have financial and strategic investors tied to Medicare Advantage plans; that’s where we’re concerned about potential indirect conflict-of-interest concerns,” he said. “They could potentially try to make traditional Medicare less popular” by denying lots of claims. In addition, “a few vendors … do have existing relationships with Medicare Advantage plans…. I think this does raise some concerns about the measures CMS has taken to ensure the WISeR Model isn’t inadvertently endorsing Medicare Advantage markets.”

Little Word to Providers

Meanwhile, WISeR is slated to launch on Jan. 1, but doctors in the affected states have heard very little from the vendors about how the program will work. For example, in Washington State, Virtix Health has been assigned as the IT contractor, said Bindu Nayak, MD, vice president of the Washington State Medical Association. But “there really hasn’t been any information from Virtix Health to the healthcare providers,” she said in a phone interview. “I did look at their website and … I noticed they have job listings for physicians to be the ones who will review the claims to be denied … so they are still setting up shop.”

“With traditional Medicare, prior authorizations are not a big part of the picture,” said Nayak, an endocrinologist in Wenatchee, Washington. “I certainly am concerned about Medicare recipients who may find that it is hard to handle [denied] claims; they are a vulnerable group, so to make things harder for them to navigate … is not fair to the patients.”

Asked about the level of communication between vendors and providers, a CMS spokesperson said in an email that “CMS is actively working with WISeR participants and CMS Medicare Administrative Contractors (MACs) on readiness. WISeR participants, MACs, and CMS have been conducting education and outreach to providers in selected states and will continue to do so as the model begins. CMS will continue to work with providers and participants to ensure any issues are rapidly identified and resolved.”

Prior authorization’s benefits should not be overlooked, according to Michael Lutz, managing director at the consulting firm Avalere Health. “I tend to believe there is a role for prior authorization when it’s done correctly, when it’s executed efficiently based on clinical guidelines and well-documented approaches to delivery of care,” he said in a phone interview. “So it does not surprise me when, in a world where we need to be focused on controlling costs and increasing quality, that folks like Medicare are looking to see what prior authorization can bring to the market.”

“If we get rid of prior authorization completely, we lose a lot of the benefits of managed care,” but it needs to be implemented efficiently and in a way that doesn’t interfere with physicians’ workflow, he said. “What I do see across the board is a desire to use technology … to make the process better, to make it less disruptive to patients and members of the health plans, and I do think we can get there.”

One thing Lutz said he’ll be watching is the use of AI in the WISeR Model. “There’s a lot of drive to use AI to help comb through the clinical information and be an aid to the final reviewer as they look at these cases,” he said. “But there’s also a lot of pushback from regulation about how AI can be deployed…. Is regulation going to interrupt the process? Is regulation going to enhance the process of adoption or guide it in certain ways? I think that’s the big question.”

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Some pharmacists are substituting their judgment for that of ordering physicians. The AMA opposes such actions.

https://www.ama-assn.org/practice-management/scope-practice/investigating-pharmacists-refusal-fill-valid-physician-orders

Wayne, New Jersey, ophthalmologist Donald J. Cinotti, MD, is accustomed to the usual delays with having orders filled promptly at area pharmacies. Those can relate to medication shortages, prior authorization and other insurance restrictions, or the occasional instances in which a pharmacist appropriately warns of a potential drug-patient or drug-drug interaction. 

But Dr. Cinotti was taken aback when he heard from an ophthalmology colleague—a DO—in Central New Jersey that a pharmacist had refused to fill that doctor’s prescription because it was “outside the prescriber’s specialty.” Dr. Cinotti’s colleague had ordered a cream to treat a patient’s rosacea, which can increase the risk of the inflamed-eyelid condition blepharitis.

“Outside the prescriber’s specialty” for an ophthalmologist to order a medication for an eyelid condition? That seemed wrong to Dr. Cinotti.

Did the pharmacist perhaps mistake the ophthalmologist’s doctor of osteopathic medicine (DO) degree for the doctor of optometry (OD) degree—with optometrists of course being valued members of the physician-led team, but not permitted to order such medications? Was there a typographical error that led to some DO/OD confusion? No, and no. 

As Dr. Cinotti and his colleagues in New Jersey investigated the matter, they discovered that other ophthalmologists, anesthesiologists and other doctors were encountering instances in which pharmacists appeared to substitute their judgment for the physician’s in refusing to fill orders for sedatives, anxiolytics or dermatologic agents.

“Such refusals contradict American Medical Association policy opposing pharmacists’ authority to initiate, modify or substitute medications outside a physician’s explicit direction, and amount to inappropriate intrusion into the practice of medicine,” Dr. Cinotti noted in a resolution that the American Academy of Ophthalmology introduced at the 2025 AMA Annual Meeting in Chicago. He serves as an alternate delegate for the organization in the House of Delegates.

“Pharmacists are not trained or licensed to make medical diagnoses and their scope of practice does not include the authority to override a physician’s clinical judgment or determine a patient’s treatment plan,” said the resolution, whose recommendations were adopted by delegates with a minor amendment. 

“These denials disrupt patient care, compromise safety, delay medically necessary treatment and may create liability and access issues, particularly for patients with urgent or chronic conditions,” the resolution added. 

More study needed

At the Annual Meeting, physicians’ testimony on the resolution “universally acknowledged that while pharmacists play an important role as part of a physician-led team, they should not have the authority to unilaterally withhold medication from patients after it has been prescribed by a physician,” a reference-committee summary noted. 

To address the issue, delegates at the 2025 Annual Meeting directed the AMA to study the matter and its impact on patients and work with state medical boards and pharmacy boards on it. A report is likely to be issued at the 2026 AMA Annual Meeting in June.

With its action, the House of Delegates reaffirmed “existing policy opposing unauthorized medication substitution, inappropriate pharmacy inquiries and unauthorized treatment modification by pharmacists.”

The AMA also supports legislation or regulatory actions requiring pharmacists and pharmacy chains to either fill a valid prescription or immediately refer the patient to an alternative dispensing pharmacy, with notification to the prescribing physician.

The AMA is fighting scope creep, defending the practice of medicine against scope of practice expansions that threaten patient safety. Both in Congress and at the state level, the AMA is pushing back on pharmacists’ efforts to inappropriately expand their scope of practice.

Building on AMA advocacy

The delegates’ latest actions build on existing AMA policy and ongoing advocacy efforts. In 2023, the House of Delegates adopted policy that “deems inappropriate inquiries from pharmacies to verify the medical rationale behind prescriptions, diagnoses and treatment plans to be an interference with the practice of medicine and unwarranted.”

Other supportive language on this issue is found in AMA policy on drug formularies and therapeutic interchange, generic drugs and therapeutic and pharmaceutical alternatives by pharmacists.

Meanwhile, the AMA has worked with state medical associations such as those in Illinois and Minnesota to ensure that physicians’ prescribing orders are not impeded. Those states have seen two of the more promising state laws recently enacted help protect patients who rely on opioid therapy. The Illinois law enacted in 2025 includes several important provisions, including:

• “Decisions regarding the treatment of patients experiencing chronic pain shall be made by the prescriber with dispensing by the pharmacist in accordance with the corresponding responsibility as described in 21 CFR 1306.04(a) and 77 Ill. Adm. Code 3100.380(a).”
• “Ordering, prescribing, dispensing, administering, or paying for controlled substances, including opioids, shall not in any way be predetermined by specific morphine milligram equivalent guidelines except as provided under federal law.”

And in 2024, Minnesota enacted a more comprehensive set of provisions that include:

• “No physician, advanced practice registered nurse, or physician assistant, acting in good faith and based on the needs of the patient, shall be subject to disenrollment or termination by the commissioner of health solely for prescribing a dosage that equates to an upward deviation from morphine milligram equivalent dosage recommendations or thresholds specified in state or federal opioid prescribing guidelines or policies, including but not limited to the Guideline for Prescribing Opioids for Chronic Pain issued by the Centers for Disease Control and Prevention and Minnesota opioid prescribing guidelines.”
• “A physician, advanced practice registered nurse, or physician assistant treating intractable pain by prescribing, dispensing, or administering a controlled substance in Schedules II to V of section 152.02 that includes but is not limited to opioid analgesics must not taper a patient’s medication dosage solely to meet a predetermined morphine milligram equivalent dosage recommendation or threshold if the patient is stable and compliant with the treatment plan, is experiencing no serious harm from the level of medication currently being prescribed or previously prescribed, and is in compliance with the patient-provider agreement as described in subdivision 5.”
• “A physician’s, advanced practice registered nurse’s, or physician assistant’s decision to taper a patient’s medication dosage must be based on factors other than a morphine milligram equivalent recommendation or threshold.”
• “No pharmacist, health plan company, or pharmacy benefit manager shall refuse to fill a prescription for an opiate issued by a licensed practitioner with the authority to prescribe opiates solely based on the prescription exceeding a predetermined morphine milligram equivalent dosage recommendation or threshold.” 

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If you click on the graphic, it will enlarge, might have to click it a second time to enlarge it a little more and/or magnify on your laptop screen with “CTRL” + “+” key… this was a graphic that someone else made and I just copied & paste into the post.

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Trump Cabinet teams up to end animal abuse

Bondi says prosecutors will be placed in every state to handle animal cruelty cases

https://www.foxnews.com/media/trump-administration-launches-multi-agency-strike-force-crack-down-animal-abuse

https://www.foxnews.com/video/6386776126112

Senior officials in President Donald Trump’s administration say they are cracking down on animal cruelty, rolling out coordinated actions across the Justice Department, the Department of Agriculture (USDA) and the Department of Health and Human Services (HHS) to target dogfighting, puppy mills and animal testing.

“We are forming a strike force… and we’re going to have designated U.S. attorneys in every state to prosecute these [animal abuse] cases,” said Attorney General Pam Bondi on “My View with Lara Trump” on Saturday.

Bondi appeared with Agriculture Secretary Brooke Rollins and Health and Human Services Secretary Robert F. Kennedy Jr. to discuss their inter-agency animal welfare initiative.

Bondi said her department would work with the USDA to conduct special training for prosecutors and law enforcement agents on executing search warrants in animal abuse cases.

“We just last week convicted someone, for the first time ever, of using a firearm in a violent crime, and the violent crime was dogfighting,” Bondi said.

In another example that shows “no one is above the law,” Bondi told host Lara Trump that 190 dogs were seized from former NFL player LeShon Johnson. 

“That was the most seized from one single defendant. So we’re coming after you if you’re going after these babies,” she said, holding a small black puppy named Guru in her lap.

Rollins said the USDA is taking a tougher approach to shutting down abusive puppy mills, moving away from issuing warnings and toward stricter enforcement of the Animal Welfare Act.

“Compliance with the Animal Welfare Act, which is from the 1960s, was hovering around 65, 67% until the last few years. We’re now closer to 92%, but it’s that 8% that we’re really going to focus on.”

She described the poor conditions dogs can face in these mass-breeding operations. “No more puppy mills where you have puppies stacked on top of each other, where, if you don’t sell them, then you drown them in a barrel because it’s the cheapest way to do it.”

Kennedy said all the major sub-agency heads at HHS are “all deeply committed to ending animal experimentation.”

He said new studies on animal testing show “that the predictivity of animal models is very, very poor for human health outcomes. There are much more efficient ways of predicting human health outcomes. We are using, even in their nascent stages, computational modeling and AI,” which he said provides much better results.

The HHS chief said there are about 100,000 primates in research labs across the country.

“There are another 20,000 that are imported every year, and we’re very concerned about that. We’re trying to put an end to that completely,” he said, adding that his department was “re-educating researchers” to improve the predictability of human health outcomes. 

In September, the National Institutes of Health (NIH) changed its rules to ensure funding could be used to “retire their primates to sanctuaries after the experimentation is done.”

“Until now, there was no option like that, no alternative, except the researcher euthanized that animal after they were through. Now we’re developing sanctuaries across the country,” he said.

I made this post on Laura (Trump) My view on “saving dogs/animals – not one “like” or another post about chronic pain pts being harmed.”

“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey, Pharmacist, VP

So the harm to dogs/animals is important to the “general public” but just like chronic pain pts die/suicide. Doesn’t that give you the “warm fuzzies” on how the general population concern about chronic pain pts being harmed? Interesting show concerning the protecting of animals, likewise this week I got a text from our Indiana Senator Jim Banks – with a one question survey about my position on abortion.. and about saving more lives. I am a retired Pharmacist and there is abt 100 + million chronic pain pts that the DEA is interfering with chronic pain pts getting their necessary and legally prescribed medications. The DEA is forcing – thru intimidation – for prescribers, drug wholesalers, pharmacies/pharmacist to reduce or stop their medically necessary medications. Forcing them to use the MME system (Morphine Milligram Equivalents) that has no real clinical studies supporting it conclusions and ignoring/ totally discounting DNA testing ( Pharmacogenomic testing) that does have real clinical studies that document that a pt’s liver metabolism affect the amount of medication(s) they need. Resulting in untold number of chronic pain pts to be forced to live/exist in a torturous level of pain, and be home, bed, chair confined because they can’t get their necessary medications prescribed or filled. These chronic pain pts are being forced to go to the street to try and get relief from their pain and end up dying from “illicit street opioids” or end up committing suicide. Why is our society not interested in saving these lives?

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Methadone can be a excellent med for pain management, but a decade ago either the state of Washington or Oregon had a mandate that all chronic pain pts that were on Medicaid, could only have Methadone prescribed for pain management, because Methadone was the least expensive opioid. They were having 2-4 pts for every 1,000 chronic pain pts  die from either a cardiac event or overdosed when first put on Methadone.

Generally, pts being prescribed Methadone should have a ECG before starting Methadone and repeated 6 months and 12 months after first prescribed Methadone and then a ECG annually while continuing to take Methadone. Also, the initial dosing of Methadone, the pt’s dose should be titrated up slowly. 

Apparently, when that state initiated a mandatory Methadone prescribing for chronic pain pts on Medicaid, no one tried to educate practitioners on the proper protocol for starting a pt on Methadone for pain management.

Countries using diamorphine (Herion) as analgesic

• United Kingdom

  • Diamorphine is licensed and can be prescribed for acute pain (post‑op, MI, trauma), chronic pain, and palliative care, although morphine is now preferred in many services.

• Historically widely used in palliative medicine, including continuous SC infusions via syringe drivers at end of life.

  Hong Kong

  • Diamorphine is a Schedule 1 “dangerous drug” but remains available by prescription for medical use; non‑prescribed possession and trafficking carry very severe penalties.

    Parts of Europe (niche/regulated roles)

    • Several European countries (e.g., Switzerland, Germany, the Netherlands, Denmark, Spain, UK) have authorized diamorphine as a medicinal product, but primarily for heroin‑assisted treatment (HAT) in treatment‑refractory opioid dependence, not routine pain

      ---

Stop Sidelining Methadone: Make Primary Care an Option Again

https://www.acsh.org/news/2025/12/15/stop-sidelining-methadone-make-primary-care-option-again-49866

American primary-care doctors can prescribe methadone for pain—but not for addiction. Meanwhile, their counterparts in Australia, Canada, and the UK have used methadone to treat addiction for over 50 years. A new randomized controlled trial shows they were right the whole time.

In a Cato Institute policy analysis, Sofia Hamilton and I highlighted that people with opioid use disorder (OUD) in Australia, Canada, and the UK have been able to access methadone treatment through their primary care clinicians for over 50 years. Patients in the US could access treatment from their primary care clinicians before 1972, when the implementation of the Controlled Substance Act (CSA) resulted in the current system, which treats patients with OUD as if they were outcasts and requires them to line up at Drug Enforcement Administration-regulated opioid treatment programs (OTPs) to receive methadone under supervision and oversight.

When COVID-19 hit in March 2020, and daily trips to federally licensed methadone clinics became more difficult for people with OUD, the Substance Abuse and Mental Health Services Administration (SAMHSA) relaxed the rules. It allowed OTPs to provide “stable” patients with up to a 28-day take-home supply and enabled buprenorphine visits to occur via telehealth, rather than requiring in-person appointments. The program was a success. Follow-up studies found the policy improved patient compliance and did not cause buprenorphine or methadone diversion into the black market.

The reforms were compelling enough that SAMHSA eventually made them permanent. Follow-up studies by the Centers for Disease Control and Prevention (CDC) and National Institute on Drug Abuse (NIDA) researchers, published in JAMA Psychiatry in July 2022, showed that methadone-related overdose deaths did not rise after the policy change. The National Institutes of Health (NIH) reached a similar conclusion that month, noting that the proportion of overdose deaths involving methadone actually decreased from early 2019 to August 2021.

It often surprises people that the DEA permits any clinician with a standard narcotics license to prescribe methadone for pain, yet bans them from prescribing it for addiction treatment. According to the National Institute on Drug Abuse, “Methadone diversion is primarily associated with methadone prescribed for the treatment of pain and not for the treatment of opioid use disorders. In one survey, giving methadone away was identified as the most common form of methadone diversion, which aligns with other findings that 80 percent of people who report diverting methadone did so to help others who misused substances.” (emphasis added)

Our policy analysis cited federal pilot programs that have already shown that when primary care clinicians are permitted to prescribe methadone for opioid use disorder, the results in the US are as strong as those long observed in Australia, Canada, and the UK. One such program, overseen by researchers at Yale University, randomly assigned 47 patients to six primary care clinicians and followed them for six months. It concluded:

Our results support the feasibility and efficacy of transferring stable opioid-dependent patients receiving methadone maintenance to primary care physicians’ offices for continuing treatment and suggest guidelines for identifying patients and clinical monitoring.

Today, a new study funded by NIDA was published in the Annals of Internal Medicine, providing even more substantial evidence that allowing primary care clinicians to treat OUD patients with methadone is safe and effective. Yale researchers conducted a randomized controlled trial involving 1,459 adults (905 in the intervention group and 509 in the control group), who received methadone treatment from primary care clinicians supported by telemonitoring across 13 cities in Ukraine. The control group received “standard specialty clinic care.”

The primary outcome they assessed was an overall quality-of-care score at 24 months, based on whether patients received 17 recommended services across primary and specialty care. They also analyzed each category separately—“domain scores,” which show how patients performed within specific areas of care—and several indicators related to methadone treatment.

Patients treated in primary care did better across the board. After two years, they scored about nine points higher on the overall quality-of-care measure than those treated in traditional methadone clinics. The advantage appeared in both primary and specialty care services. When it came to staying on methadone, new patients in primary care were slightly more likely to stay in treatment at 24 months—67 percent versus about 65 percent in specialty programs. Their conclusion:

Integrating methadone treatment into primary care settings improves adherence to guideline-concordant health care without compromising methadone retention and treatment quality.

The research keeps pointing in one direction: patients benefit when methadone is available in primary care.

One week from today, the Cato Institute will host a screening of the award-winning documentary “Shuffle.” Filmmaker Ben Flaherty demonstrates how federal rules—especially those embedded in the Affordable Care Act and Medicaid—have unintentionally allowed predatory rehab operators to profit from the suffering of people with substance use disorder, who deserve care, not exploitation. Instead of reducing harm, these mandates might be supporting—and even expanding—the very problems they were intended to resolve.

In our policy analysis, Hamilton and I argued that letting primary care clinicians prescribe methadone would expand access to effective treatment, reduce overdose deaths, and help more people with OUD reclaim their lives. After seeing in the film how predatory rehab clinics exploit vulnerable patients and siphon off health-care dollars, there’s another clear advantage: expanding office-based methadone would shrink the pool of people these operators can target.

(You can register for the film screening here. The screening will be in-person only, but the panel discussion that follows it will be livestreamed.)

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Rescheduling Isn’t Enough—and Medicare Could Make CBD Worse

https://www.cato.org/blog/rescheduling-isnt-enough-medicare-could-make-cbd-worse

At today’s White House ceremony, President Trump signed an executive order requiring the Drug Enforcement Administration to reschedule cannabis from a Schedule I controlled substance to a Schedule III controlled substance. During the event, Centers for Medicare and Medicaid Services (CMS) Administrator Mehmet Oz announced plans for a new pilot program under which Medicare would pay for certain hemp-derived cannabidiol (CBD) products.

I have written here about why I believe that rescheduling cannabis is a small step in the right direction, but it unfortunately keeps prohibition in place. The CMS initiative introduces its own set of problems.

The CMS announcement runs counter to Congress’s recent effort to “close the hemp loophole,” and the two policies undermine each other. CMS is signaling that CBD has legitimate therapeutic value and should be easier for patients—particularly seniors—to access, while Congress is simultaneously tightening federal restrictions, shrinking the legal CBD market, and increasing compliance costs for manufacturers. One branch of the federal government is trying to normalize and integrate CBD into mainstream health care; another is narrowing supply, complicating legality, and potentially raising prices. Instead of coherent reform, we’re experiencing policy whiplash—expanding coverage on paper while limiting availability in practice.

When Congress set a limit of no more than 0.4 milligrams of THC for hemp-derived products in its recent spending bill, it might have seemed like a minor, safety-focused change. In truth, it could make CBD production economically unfeasible. Hemp naturally contains some THC, and when producers extract CBD at effective levels, they also concentrate THC. To comply, they would need to discard product, perform costly additional processing, or dilute CBD to the point of insignificance. All these actions increase prices, squeeze out smaller producers, and threaten to eliminate a legitimate CBD market under the pretense of “consumer protection.”

Currently, people purchase CBD products over the counter at market prices that generally reflect open competition: Low-end products typically cost about $15–$30; mid-range CBD oils, gummies, and capsules usually range from $30 to $80; and premium products can cost $80 to $200 or more, with most tinctures averaging roughly $0.05–$0.25 per milligram of CBD. If third-party payers begin covering CBD, the pricing structure could worsen. When insurers enter a mostly cash market, manufacturers often respond by raising list prices, knowing insurance will cover much of the cost. As Michael Cannon and I mentioned in our white paper, “Drug Reformation,” that’s precisely what happened after the Affordable Care Act mandated coverage of oral contraceptives, whose prices then increased faster than many other already-insured drugs. If the same occurs with CBD, Medicare beneficiaries may be protected, but people paying out of pocket could face significant price hikes, making CBD less affordable for those without coverage.

It’s not as if seniors lack access to CBD now, nor are these products unaffordable. People can already buy them over the counter at competitive prices. That’s why CMS’s move, however well-intentioned, is unnecessary and could be harmful. Once Medicare gets involved, “coverage” rarely stays straightforward—it brings prescriptions, clinician gatekeeping, documentation requirements, and layers of regulation. This risks medicalizing CBD, limiting who can produce it, and turning a functioning consumer market into a government-controlled one. Instead of helping patients, CMS might just complicate things and make a product that’s already accessible more regulated, less consumer-friendly, and more difficult to access.

If nothing else, the obvious conflict between CMS’s effort to cover CBD and Congress’s recent attempt to “close the hemp loophole” should lead lawmakers to reconsider their new restrictions. Instead of increasing contradictory federal controls, Congress ought to consider repealing its flawed THC cap and enabling a competitive CBD market to continue serving consumers.

All this explains why today’s White House announcement on cannabis rescheduling was underwhelming and why Dr. Oz’s Medicare–CBD proposal was troubling. Instead of clarifying the legal landscape or easing access, Washington appears ready to add bureaucracy to an existing consumer market, risking higher prices, fewer choices, and increased federal control. Seniors already have access to CBD; they don’t need CMS to “help” by medicalizing it. Worse, this initiative could harm the millions of non-seniors who benefit from CBD and other hemp-derived products by raising prices, reducing supply, and making what is now widely accessible more difficult—and more costly—for others to obtain.

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Pay Cuts and Unnecessary Visits: How Medicare Is Compromising Cataract Care

https://www.medpagetoday.com/opinion/second-opinions/119085

It’s time for payment reform and a lasting remote follow-up option

With nearly 1% of Americans undergoing cataract surgery each year, the procedure is the most common operation Medicare covers. For many older adults, it’s a small miracle: a 15-minute procedure and suddenly the world is in focus for the first time in years.

What comes next can be much less miraculous. Patients must arrange rides and caregivers for brief follow-up visits. As an ophthalmologist who cares for these patients, every week I see how, for those who can’t drive, who live alone, or who use walkers or oxygen, these “routine” checkups can be the hardest part of the whole experience.

Meanwhile, Medicare is steadily cutting what it pays for that very surgery — even as Washington can’t decide whether to keep the telehealth flexibilities that would make follow-up easier.

For 2025, the Centers for Medicare & Medicaid Services (CMS) again cut what it pays physicians, marking the fifth straight year of reductions. Since 2018, Medicare’s payment for a routine cataract operation has fallen by about one-fifth, and overall physician pay in Medicare has eroded by roughly one-third since 2001 after adjusting for inflation, making it harder for small community practices to stay open. Now CMS has finalized another double-digit cut for cataract surgery in 2026.

In other words, Medicare is squeezing the margins on a high-volume, sight-restoring surgery that millions of older adults rely on — especially in community and rural settings where cataract surgery is often the only eye care readily available.

During the pandemic, Congress and CMS let Medicare patients use telehealth from home — including audio-only options — with no rural restrictions. Those flexibilities have been extended several times, most recently in a shutdown-ending deal that now runs only through January 30, 2026. After that, unless Congress acts, Medicare’s coverage for non-mental-health telehealth will snap back to the pre-COVID rules that limit services to rural patients in medical facilities — not people recovering from surgery at home.

This is exactly backward for cataract care.

Randomized trials and systematic reviews in recent years have found that virtual or telephone follow-ups for uneventful cataract surgery can match in-person care for safety and patient satisfaction, as long as higher-risk patients are excluded and assuming that concerning symptoms trigger rapid in-person evaluation. Simple web-based vision checks, phone or video visits, and emerging tools like artificial intelligence (AI) phone systems that screen for red-flag symptoms have shown promise for routine cases.

These tools don’t replace in-person exams for people with other eye diseases, complicated surgery, or worrisome symptoms, but they can safely reduce unnecessary travel and free up clinic slots for patients with real red flags. Most surgeons still want at least one early, in-person exam for many patients; the real opportunity is to avoid dragging every low-risk patient back for multiple routine checks when their vision and symptoms are reassuring.

When you combine repeated pay cuts with rigid expectations that every post-op patient trudge back to the clinic, the result is consolidation of facilities, small practice closures, and poorer access, especially in rural and lower-income communities.

For an 82-year-old who no longer drives and lives on a fixed income, automatically requiring every routine follow-up to be in person after an uncomplicated cataract surgery is not “conservative” medicine. It’s avoidable hardship — on top of a system that’s already asking surgeons to do more with less year after year.

It doesn’t have to be this way. If Congress and CMS are serious about keeping cataract care accessible while holding the line on costs, they should pair payment reform with a deliberate shift toward remote follow-up for appropriate patients, rather than letting telehealth die by a thousand temporary extensions.

That would mean making home-based telehealth for postoperative visits a permanent Medicare benefit for procedures like cataract surgery; explicitly allowing early post-op checks to be done virtually under the 90-day global payment that already covers follow-up care — without extra fees — as long as safety standards are met; and funding pilot programs that use telemonitoring to triage which patients truly need to be seen in person.

Telehealth expansions should come with clear guardrails: limiting remote follow-up to low-risk cases, using structured symptom checklists, and maintaining a low threshold to convert virtual visits to in-person exams when something doesn’t look or feel right. At the same time, Congress should replace yearly “yo-yo” cuts with stable, inflation-linked updates to Medicare’s physician payment formula.

Done right, the result would be straightforward. If a surgery was routine and the patient is seeing well, they could complete part of their follow-up at home — on a smartphone, landline, or computer — with clear instructions about when to call or come in. If anything looks concerning, the system connects the patient to an in-person, human doctor quickly. For clinicians, it would mean a payment system that stops penalizing the very surgery that restores sight for millions and a telehealth policy that recognizes reality: much of postoperative cataract care is about screening for rare problems and answering questions, both of which can be supported by remote tools.

At the moment, Washington is sending mixed messages: one set of rules tells surgeons to absorb pay cuts; another tells them to keep seeing every patient in person, even when the evidence says they don’t always need to. Fixing that mismatch — by stabilizing payment and embracing telehealth for routine cataract follow-up — is a concrete way to protect both patients’ vision and the future stability of their care.

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The impact of the PBM/Insurance industry is mentioned very little in the article and not until near the end of the article. Little/no mention of lower profit margins for that part of our drug distribution system that other countries do not have within their healthcare system.

Most Favored Nation’ Pricing May Cut Drug Costs. It May Also Cut Off Rural America

https://www.medpagetoday.com/opinion/prescriptionsforabrokensystem/119052

The system is far more complex than Trump’s proposal conveys

Americans pay too much for prescription drugs. On that point, there is almost universal agreement.

In 2019, the U.S. spent more than $1,000 per person on prescribed medicines — more than any other high-income nation. An Organization for Economic Cooperation and Development (OECD) analysis put U.S. per-capita retail pharmaceutical spending at more than twice the OECD average. The Kaiser Family Foundation has shown Americans often pay more for the same drugs that cost far less across Europe and other wealthy countries.

Prices must come down, but how we get there matters. A lot.

The Trump Administration’s Proposal

In November, the Trump administration resurrected a Most Favored Nation (MFN) reference pricing policy, which would tie drug prices paid in the U.S. to the lowest prices paid in other developed countries. The White House has sold the idea as a tough negotiation tactic for bloated drugmakers and a gift to patients at the pharmacy counter.

Tie U.S. prices to those in other countries, the logic goes, and Americans will finally stop being the world’s ATM for brand-name drugs.

The plan outlined in November is an agreement between the U.S. and two pharmaceutical manufacturers, Eli Lilly and Novo Nordisk, and it concerns only a handful of drugs. But these prescriptions — for weight-loss drugs — represent the highest annual expenditures in the U.S.

According to the White House, under the president’s plan, the prices of semaglutide (Ozempic and Wegovy) will fall from $1,000 and $1,350 per month, respectively, to $350, while the price of tirzepatide (Zepbound) and orforglipron (if approved) will fall from $1,086 per month to an average of $346.

Sounds great, right? Let’s go deeper.

MFN Pricing Will Destroy Healthcare in Rural America

Because MFN does not operate in a vacuum, the president’s plan is dangerous.

Indeed, the MFN plan will sit on top of a landscape where rural hospitals are closing, small pharmacies are fragile, Medicaid is under pressure, NIH budgets are being cut, tariff threats inject uncertainty into global supply chains, and FDA practices have become less predictable for innovators.

Layer MFN on top of that landscape, and you do not just squeeze drug company margins — you compress the ecosystem that gets life-saving drugs to people. And that ecosystem is weakest in the very communities that can least afford another hit.

Consider a hypothetical, but familiar, patient: a 63-year-old woman in a rural county who relies on an infused biologic for rheumatoid arthritis. Her local independent pharmacy closed last year. The nearest hospital with rheumatology and infusion services is 90 minutes away. She lives on a fixed income; her copay assistance and manufacturer bridge program are the only reasons her treatment is sustainable.

Now dial in MFN. It is not that, amid price compression, a company will sit in a boardroom and say, “Let’s cut off rural patients.” But every thin margin in the distribution chain will get thinner. Wholesalers will negotiate harder. Pharmacies will drop low-volume products. Assistance programs that do not directly show up in a stock price get trimmed. When an infusion suite decides which therapies to carry, the high-complexity drug used by a small panel of rural patients will not be at the top of the list.

Incremental decisions will slowly erode care in rural communities.

Urban centers will likely be more resilient in the short term. Greater provider density, stronger hospital networks, and the presence of academic medical centers and specialty pharmacies mean that large cities can better absorb some shocks. Patients in Boston or San Francisco may see lower prices and relatively stable access — at least initially.

But MFN cannot insulate those cities from broader consequences. If MFN, coupled with tariff threats and regulatory volatility, makes the U.S. a less predictable market for high-risk innovation, investment will slow. If price compression contributes to drug shortages — a problem that has already been worsening for generics and sterile injectables — those shortages will hit big cities and small towns alike. And while urban centers have more hospitals, they also have deeper structural disparities. Lower prices alone have never been enough to fix that.

MFN Threatens Innovation, Especially for Rare Diseases

Speaking of innovation: the U.S. accounts for a disproportionate share of global pharmaceutical revenue and, in turn, global research and development. RAND estimated that in 2022, the U.S. represented 62% of total drug sales across OECD countries, but only 24% of volume.

That gap is precisely what funds the high-risk, high-cost development of new therapies.

We are already seeing how aggressive price regulation can delay or dilute access to innovative drugs. Analyses of external reference pricing (ERP) in Europe showed that when countries peg prices to one another, manufacturers often delay launches or skip smaller markets entirely rather than lock in lower prices. One study found ERP was associated with a 73% reduction in the likelihood of launching a drug within 9 months of regulatory approval.

The problem is even more acute for orphan drugs. European Federation of Pharmaceutical Industries and Associations (EFPIA) data show that patients with rare diseases often face years-long delays after European Medicines Agency approval — or never see certain drugs launched at all — because price regulation and fragmented country-by-country negotiations make it unattractive to bring those therapies to smaller markets.

If we import the most aggressive pieces of that model without creating stronger safety nets, we risk importing the delays and access problems while retaining our underlying inequities.

It’s Time for Whole System Reform

Americans want lower drug prices. Kaiser polling consistently finds large majorities of both Republicans and Democrats support policies like allowing Medicare to negotiate prices.

But the price a patient pays at the register is more complex than a politician’s talking points portray. Prices are the reflection of a byzantine system of rebates, pharmacy benefit manager (PBM) negotiations, insurance design, and manufacturer assistance programs. When you crush prices at the top without redesigning the plumbing underneath, the system will not suddenly become fair. It will become brittle.

Manufacturer-funded assistance programs are a prime example. Companies spend billions each year subsidizing access for low-income and underinsured patients. If MFN cuts revenue sharply, these programs will get cut first. The Americans already skipping doses because of cost — nearly one in seven, in some surveys — will be the first to feel those cuts.

We absolutely should not accept a status quo, but if we want to fix drug pricing without sacrificing equity and innovation, we need a balanced approach. We need real oversight of PBMs, transparency in the rebate system, support for rural pharmacies and hospitals, sustained NIH funding, stable FDA leadership, and coverage expansions that ensure people are insured.

Otherwise, MFN will not stand for “Most Favored Nation.” It will mean “Most Forgotten Neighborhood.”

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