Filed under: General Problems | 2 Comments »
When healthcare providers end up really being healthcare deniers
Posted on January 13, 2024 by Pharmaciststeve
I got the email below on Jan 1, 2024. This pt’s story is not a unique issue. Another example of bureaucrats and politicians attempting to “solve” our fabricated opioid crisis by creating a “one size fits all” on pain management.
After having this blog for 12-13 yrs, I have developed a fairly sizeable network of chronic pain pts, chronic pain advocates, and numerous healthcare practitioners. I shared this woman’s email with a couple of select people that I believed might be able to STEP UP. And one did:
When a pt’s long term medical records mean nothing when seeing a new practitioner
When everything seemed to start to fall into place for this young lady. This young lady’s pharmacist and the mid-level practitioner who was forcing her to reduce her pain meds had to step in to make sure that things were not going to change the way that this mid-level practitioner wanted things to happen. Here is a video this young lady sent that she personally explains what has happened.
Hi Steve,
I have sent you my story before. I am a single disabled palliative care sick patient in Maine. In September of 2021, my doctor and I were targeted by the assistant attorney general, Michael Miller. We think it was for 2 reasons-he was very effective at getting patients disability, testings, procedures, equipment, etc and because I require a high dose of opiates to physically and mentally function. Dr. Lommler believes Michael Miller made a deal with the insurance companies and profited somehow for taking him out. Michael Miller used at least 2 agencies to target, harass, and destroy us. They suspended Dr. Lommler’s license for going over the 100 MME limit on my prescription. However, Maine has a palliative care exemption that allows people (like me) to have access to opiates for pain control and disease treatment options. It also allows us to go over the 100 MME limit. They refused to lift the suspension unless he transferred to a “board approved” facility. He chose to retire because he wanted to stay at his independent office with his 200 complicated and unique patients. They gave neither one of us any due-process! They used backdoor methods and I believe they were illegal! There was a covering LNP seeing me for a year. We tried to find a doctor everywhere in Maine to see me but because of the Opiate Task Force and doctors getting red-flagged for going over the 100 MME limit and being dragged in front of the board, no one would see me. I was forced to transition to the hospital where all of my specialists are. You see, Maine and New Hampshire were the 2 states prescribing the most Opiates so they created a New England Opiate Task Force and sent them to work with the Governor Mill’s administration to red-flag doctors prescribing over the 100 MME limit and drag them in front of the board of medicine! They have forced independent providers to either retire or transfer to a “board approved” facility. These “board approved” facilities all have anti-opiate one-size-fits-all policies. The hospital that I am at has an anti-opiate provider masquerading as a “pain specialist.” She believes Opiates are life threatening and dangerous to everyone. She is force tapering me off all my pain medication! I am complicated and unique-I have multiple health conditions. I had an original medical nightmare that left me with life altering physical deformities and severe debilitating pain. I have Crohn’s disease, vitamin and bone deficiencies, and neuropathy-all of these cause malabsorption so I have to take double doses of all of my medication! I cannot have the conventional pain management treatments because I am allergic to everything and sensitive to anything and I have a prosthetic heart valve. I have Scoliosis and severe Osteoporosis with dangerously low Scores. I am 46 in an 86 year old’s body.
They are stereotyping anyone on opiates as addicts and forcing them off pain medication. The only option they give you is Suboxone-I cannot take this because the side effects would be catastrophic to my body. I had nothing but recovery and progress with my 8 1/2 year stable pain regimen. I was able to semi function independently with a decent quality of life. Since this provider has been force tapering me, I can no longer function independently at all and I have zero quality of life! According to Maine’s own definition and standards, what this facility and provider are doing to me is disability abuse! I tried to contact patient services for an advocate but was told there wasn’t one. The woman I spoke with for 2 minutes, asked me what my concerns were. I explained to her what was happening to me. 2 days later I received a letter stating my concerns were forwarded to the Medical Director and Operations Manager and they agree with the provider force tapering me. They also said there was no medical justification for my pain medication. I filed a public accommodation discrimination complaint with the Maine’s Human Rights Commission but haven’t heard a word since intake months ago! The letter gave an 800 number to call if you disagreed with their decision. It was the board of licensure telling you to submit a complaint. I already filed a complaint with the board of medicine and nurses months ago. So, you have to go to the same people that are red-flagging and harassing doctors going over the 100 MME limit. I won’t hold my breath! These are the same people that asked Dr. Lommler how he didn’t know that I was taking half of my pain medication and selling the other half! Dr. Lommler provided them with 7 1/2 years worth of passed urine screens and passed frequent random pill counts! I wasn’t even allowed to attend or participate into the investigation into my opiate use-I could’ve answered that question myself-I have never misused my pain medication! In fact, I did everything that I was supposed to do! How in the world can I trust they will help me!
Since this provider has been forcing me off my pain medication, I have had sky high blood pressures-202/129, severe bloody noses, I have been discharged from aquatic therapy-which I needed to get into my Crow Walker boot, I am completely dependent on my sons, I have had to quit tutoring for supplemental income, I can no longer walk on my crutches so I am trapped in my wheelchair, and I cannot mentally or physically function! My counselor and former providers have tried talking with this provider but she refuses to listen because she knows best. I had to spend my Christmas in the ER and I am now watching my right leg and foot do exactly what my left leg and foot did in my original medical nightmare. When my body is in severe stress, my multiple conditions play off of one another and wreak havoc on my body. Last time, the severe stress was an allergic reaction to hardware (we didn’t know why at the time, it took years to figure it out). This time, it is force tapering my pain medication! This time, it’s the providers choice to force taper me because of her personal feelings about a medication! Medical providers are supposed to do what is in the best interest of the patient, not what is in the best interest of their personal feelings! I have cellulitis in my right leg and foot with ulcers everywhere! I maintain my left leg and foot with Cuban for compression. I tried to wrap my right leg and foot but it’s not used to being wrapped, and I get continuous Charley Horses. They are intolerable with all of my pain medication being taken away! I have severe PTSD and zero trust in doctors from my original medical nightmare! I never ever wanted to go back to that sick person trapped in a wheelchair, I thought I left it behind for ever! This time, I don’t have a heart valve to lose! I am petrified and profoundly devastated because I worked so hard for 8 1/2 years to recover and progress and now that has been destroyed! I see people helping doctors that have been arrested but what about people, like me, who have been targeted, harassed, discriminated against, and literally going through disability abuse-who tells our story and helps us?
My counselor gave me a brochure for adult protective services and she told me to call because what they are doing to me is discrimination and disability abuse. I called and the lady said there is no process for this situation. She told me that it does qualify but the only thing I can do is file a complaint with the board of medicine and nurses because they are the only entities that have authority and jurisdiction over medical providers. I told her that I already filed complaints but it will take months because they only meet one day a month! I told her my body won’t make it that long and I asked her, “what if I die in the meantime?” She said, “let’s hope it doesn’t come to that but good luck!” WHAT? It’s like a nightmare that I cannot wake up from! I have contacted every politician in Maine and asked for their help. Crickets…I requested assistance from Governor Mills but she doesn’t even think she has to answer to her constituents. I have reached out to every volunteer lawyer’s projects and disability rights groups but they all claim no to have the resources to help me. I have documented, taken pictures, recorded videos, screenshot messages from my portal between her and I, audio recorded my video appointments exposing her discrimination and disability abuse! I cannot find an attorney in Maine to help me. This provider only saw me one time in person! She never looked at any areas causing my pain, she’s not monitoring my vitals or everything that is happening to me, she doesn’t even have the correct MRI’s-she’s going by a 2008 one when I was a normal person and could walk on my own, and she’s retaliating against me for filing a complaint! I need help and I don’t know where or who to go to! I even have an appointment with cancer care, January 23rd. I have MGUS and the blood work markers and symptoms all point to it turning into Multiple Myeloma. I asked her to please pause the force taper until I can get into my appointment. She said, “Oxycodone will not cure Multiple Myeloma so the force taper will continue!” How cruel is that!
I was hoping that you may have some direction or advice to help me. If I knew how to file a civil lawsuit against the hospital and provider, I would do it myself. Since September of 2021, I have had to be my own advocate, case manager, and attorney!
I already missed about 6 years of my sons’ lives because of my original medical nightmare! I can do no physical activity without my pain medication! I really don’t think my body will make it through this force taper! Opiates are literally life saving for me! They knew that I wouldn’t be able to find another doctor to see me and Michael Miller and the board of medicine took 2 doctors from me! The provider force tapering me filed a complaint against the LNP that saw me for a year. In it, she said that she felt compelled because Kaye endangered my life by prescribing these life threatening and dangerous medications. She also accused me of bribing Kaye in her complaint. That is ludicrous-I have never bribed anyone! Kaye made it very clear in her response that no one forced or bribed her. She also made it clear that I was the only patient she ever prescribed narcotics for in her entire medical career! I have been accused of selling half of my pain medication and bribing doctors! I am a law abiding Mainer and American just trying to live my life!
Thank you for taking your time to read my email. You can reach me any time at xxx.xxx.xxxx
Filed under: General Problems | 4 Comments »
most societies/communities have 1 or more agitators, disruptors, false prophets, scammers, traitors, saboteurs and cult leaders
Posted on September 11, 2022 by Pharmaciststeve
Some believe our country is on the verge of a Civil War, they may be right, but it won’t be a bilateral war like our last Civil War.. Our society has voluntarily divided itself in – for lack of a better description – TRIBES.
The chronic pain community is not all that different from our country of as a whole.
Recently a fellow chronic pain pt who had been advocating for end stage pediatric pts in a large hospital system that has a “no opiate” policy. All of a sudden the advocated was told that he was no longer permitted to advocate for these end of life pediatric cancer pts. I suppose that this major hospital system will return to treating these pediatric pts with NSAIDS and Acetaminophen and let them live the rest of their lives in a torturous level of pain.
There are rumors as to who said what and to whom… I am not going to elaborate. However, they know who they are and what was said to cause this to happen. One can only imagine the deprived mental status of those who have been involved in this.
Some have told me that this tribe of malcontents have monetized chronic pain pts’- personal information and several other covert processes. I started my blog in 2012 and have tried to motivate and educate chronic pain pts in some ways that they can navigate their way to getting their pain management back. Some chronic painers have told me that I should charge for my advice. My Pharmacy degree, license and career has provided for Barb and myself a comfortable retirement.
After this issue with these end of life pediatric pts, Going forward… I am going to ASK of people that want my advice to make a contribution to one of the four national charities listed below, these are all about THE KIDS… and charities we support. Maybe in some small way, my advice can help more than just one person/family.
https://www.stjude.org/ St. Jude Children’s Research Hospital – deals with kids dealing with cancer and/or life threatening health issues
https://lovetotherescue.org/ Shriners Hospital – deals with kids, born with “broken bodies” and birth defects
https://rmhc-kentuckiana.org/ Ronald Mc Donald House – this is near us and just a few blocks from a very large regional pediatric hospital ,3 other major hospitals within blocks, one being a teaching hospital and having the only LEVEL ONE TRAUMA CENTERS for 100 miles and part of a medical university and helps provide housing for families with kids in the hospital
https://t2t.org/ Tunnel to Towers Foundation – helps get handicapable housing for veterans, first responders with “broken bodies” , families with spouse/parent killed in the line of duty and Gold Star Families
Filed under: General Problems | 2 Comments »
CVS’ Oak Street Health to pay $60M to settle Medicare Advantage kickback allegations
Posted on September 19, 2024 by Pharmaciststeve
CVS’ Oak Street Health to pay $60M to settle Medicare Advantage kickback allegations
CVS subsidiary Oak Street Health has agreed to pay $60 million to settle accusations that it violated the False Claims Act by offering kickbacks to third-party insurance agents in return for referring older adults to its primary care clinics.
The U.S. government claimed that in 2020, Oak Street Health, a primary care provider, launched a program to grow its patient base. According to a Sept. 18 news release from the Justice Department, as part of this program, third-party insurance agents reached out to older adults eligible for or enrolled in Medicare Advantage, promoting Oak Street Health’s services.
These agents then allegedly connected interested individuals with Oak Street Health staff through a three-way phone call, known as a “warm transfer,” or by submitting their information electronically. In return, Oak Street Health paid the agents $200 for each person it referred. According to the release, these payments encouraged agents to prioritize financial gains for Oak Street Health over the best interests of the older adults.
The settlement addresses allegations that, between September 2020 and December 2022, Oak Street Health knowingly submitted false claims to Medicare by offering illegal payments to agents, violating the Anti-Kickback Statute.
CVS acquired Oak Street Health for $10.6 billion in May 2023.
Filed under: General Problems | 1 Comment »
Are the Medicare-C “dominoes” starting to fall?
Posted on September 19, 2024 by Pharmaciststeve
Texas system shutters Medicare Advantage plan
https://www.beckerspayer.com/payer/texas-system-shutters-medicare-advantage-plan.html
Southwestern Health Resources will not offer Medicare Advantage plans in 2025, D Magazine reported Sept. 17.
In emails obtained by D Magazine, the company said it decided to sunset its Medicare Advantage plan because of increasing competition and utilization, and regulatory requirements.
“Medicare Advantage plans continue to face significant headwinds nationally related to challenging regulatory changes and increasing benefit utilization,” a spokesperson for Southwestern Health Resources told Becker’s. “We remain committed to providing high-quality services to our partners and members through this enrollment period. There will be no change for our members in 2024.”
Farmers Branch, Texas-based Southwestern Health Resources operates Care N’ Care, an MA insurer. The company has around 26,000 Medicare Advantage members, according to CMS enrollment data.
Southwestern Health Resources is a joint venture between UT Southwestern Medical Center and Texas Health Resources.
In regulatory documents filed Sept. 5, Southwestern Health Resources said it would lay off 129 employees. D Magazine reported 125 health plan employees were notified their jobs would be eliminated.
“After careful consideration, we adjusted our organizational structure and aligned the staffing model to meet current business needs as the health care landscape continues to evolve. We are working to maximize value, quality, and service for our customers,” a Southwestern Health Resources spokesperson told Becker’s.
Most of these jobs will end in January, D Magazine reported, with some roles staying on to manage the wind-down of the plan.
“In an effort to give impacted employees the best opportunity to successfully transition to another role, we have provided more than the required 60 day notice, as well as support and resources. In addition, we are working to place them in open roles within the organization,” the spokesperson said.
Several insurers have cut back on their Medicare Advantage offerings, facing increasing medical utilization and lower reimbursements from CMS.
Humana, CVS Health and Centene have all said they will exit some markets in 2025.
In June, Blue Cross and Blue Shield of Kansas City said it would exit the MA market at the end of 2024, also citing increasing regulatory requirements and financial headwinds.
Other health systems have shut down their affiliated Medicare Advantage plans in recent years. In 2023, Fredericksburg, Va.-based Mary Washington Healthcare ended its MA plan.
In 2022, Inter Valley Health Plan, affiliated with Pomona Valley Hospital Medical Center, ended its Medicare Advantage operations.
Read more here.
Filed under: General Problems | Leave a Comment »
“we” are very proud of Bidenomics
Posted on September 19, 2024 by Pharmaciststeve
Filed under: General Problems | 1 Comment »
2275 pharmacies have closed so far in 2024
Posted on September 17, 2024 by Pharmaciststeve
2275 pharmacies have closed so far in 2024
https://benjaminjolley.substack.com/p/2275-pharmacies-have-closed-so-far
“It’s not the way I wanted it to go,” he says sadly. “You do what you’re supposed to do. You go to college, get a doctorate, start a small business in a small town, support the community and it’s not even close to being a viable option.”
“This isn’t because the community didn’t support us. It’s because we lose money on every prescription we fill.”
Those are the words of Tom Wullstein, owner of Brandon Pharmacy. He is talking about his own pharmacy, but the same words could have been said by over a thousand pharmacy owner/operators this year alone.
In pharmacy policy circles, a lot of numbers get thrown around trying to variously prove that a) small business pharmacy is dying and needs change or b) small business pharmacies are doing fine, there’s more of them than ever before! Whenever I see these white papers, especially those put out trying to prove hypothesis b, I feel like the authors are saying “who ya going to believe, me or your lying eyes?” So, I decided to tackle the question myself, recruiting help as I could from like-minded people.
Over the last several weeks, I’ve worked on a dataset of pharmacies that were active in the National Council of Prescription Drug Programs (NCPDP) database on 1/1/2024 and were no longer active on 9/1/2024. Pharmacies can be de-listed in NCPDP for basically 2 reasons:
- The pharmacy closes
- The pharmacy comes under new ownership and obtains new numbers (NCPDP, NPI, DEA, state license, etc.)
I wanted to sort out how many of the de-listings from NCPDP were closures and how many were changes of ownership, so here’s what I did (with help from a ton of volunteers):
- Pull a list from NCPDP of Community/Retail Pharmacy NPIs that were present on 1/1/2024 and were no longer present on 9/1/2024. This yielded a list of 2577 pharmacies.
- I assumed that CVS/Walgreens/Rite Aid don’t randomly get new NPIs and I assumed that their corporate HQ is competent in maintaining their NCPDP profiles so I just marked all of them as “Chain Closure.”
- Winn Dixie very publicly closed all of their pharmacies and sold files to CVS/Walgreens in the process of selling their chain to ALDI, so I just marked all of theirs similarly as “Chain Closure”
- I put out the list to a few groups of pharmacy employees nationally with ~6000 members total, and asked folks to mark stores they knew about from their local area
- I googled every remaining pharmacy and marked as closed if the Google Maps location was permanently closed or the reviews said it was closed.
- I ran the remaining phone numbers through a phone number validation service to weed out disconnected numbers, which were marked as closed.
- I and several other volunteers placed phone calls to the remaining pharmacies. If the person on the other end answered “pharmacy”, I verified that they were still operating at the same address, and if not, I marked as closed — mostly those were scenarios where a location had acquired the records of a nearby pharmacy.
I estimate that in total, about 40 man-hours of effort was put into this project. The results are as follows:
- 1139 chain closures of large chain pharmacies as per my steps 2 and 3.
- 1136 Closures of independents and small to mid-sized chains as per steps 4-8.
- 298 changes of ownership
- 4 records were duplicates1
The raw spreadsheet where I did this work is available here.
Since starting this project, many people have asked how to interpret this information. To start with, this data shows that nearly 2300 pharmacies’ worth of employees have been laid off. Most pharmacies employ about 10 people, so that’s about 23,000 pharmacy staff laid off. Additionally, about 1100 entrepreneurs have had their dreams of pharmacy ownership crushed just this calendar year, and can probably resonate with Tom Wullstein’s comments.
For context, on 1/1/2024, there were 60,867 active Community/Retail NPIs/locations in NCPDP, and there have been 857 new NPIs added in the relevant time frame23. While I find “netting out” of openings and closures very distasteful, this means that there are 1720 net closures since 1/1/2024, or in other words a 2.8% drop in number of pharmacy locations nationwide. You can also contextualize this information against any number of academic papers on the same topic, Guadamuz, Alexandar, Zenk, et al. in JAMA in 2019, for example, shows that an average of 1631 pharmacies closed each year as reported in NCPDP from 2010 to 2015, with and average of 2435 pharmacies opening each year for a net average figure of 804 openings every year in that period.
To reiterate, on average every day since January 1, 2024:
- ~5 pharmacy owner-operators have closed their businesses permanently
- ~5 chain pharmacy Pharmacists-in-Charge have had their stores closed
- ~11 neighborhoods lost their pharmacy
- ~110 pharmacists and pharmacy technicians have been laid off
For those that have read this blog before, I think this is unnecessary to say, but the root causes of this incredible number of closures are obvious to me:
- PBM reimbursements are insultingly low – see the bit about “dispense fee” here
- PBM reimbursements are based on competition on nonexistent prices outside of 340b — AWP minus 26.3% is not reasonable or relevant, kids.
- PBM reimbursements are unevenly distributed, with the lion’s share of the money going to “specialty drugs” instead of evenly across prescription drugs – see also: every drug that Mark Cuban talks about when he talks about PBMs.
- The largest wholesalers charge prices to independents that are much higher than the prices charged to chains, which is visible in the NADAC fluctuations over the last 6 months
- The opioid litigation has put the largest pharmacies into a lot of debt, which combined with 1, 2 and 3, has resulted in mass closures of pharmacies, particularly Rite Aid, which just exited bankruptcy.
- Our payment system largely pays variable prices for the service of dispensing based on the exact identity of the pills in the bottle, not based on the service rendered. In other words, PBMs are concentrating all of the profit into a small fraction of items, which their integrated mail-service and “specialty” pharmacies can capture the lions share of the volume from.
I don’t know 100% how to solve this problem of pharmacy closures, but I have ideas about some good places to start:
- H.R. 9096, the Pharmacists Fight Back Act, would go a long way to resolving my concerns 1,2,3 and 6 – it would ensure payments to pharmacies be based on actual cost of goods plus a 2% markup plus a cost-of-dispensing based professional dispense fee across all of the major government programs: Medicaid, Medicare, Federal Employees and TRICARE. I think that if anything like this bill becomes law, ACA exchange plans should be included. This bill would make the pharmacy payments system fair and legible, instead of illegible and slot-machine-esque.
- A Glass-Steagall for Healthcare – Glass-Steagall was a New Deal era law that structurally separated community banking and investment banking. Similarly, I think that in healthcare, we desperately need to outlaw “payvidors.” The opportunities to take advantage of your competitors, evade reasonable regulation, and exploit anyone not inside your system are far too numerous and pervasive to continue to allow United Healthcare and OptumRx to own Optum Specialty Pharmacy and Optum Physicians Group, or to allow CVS/Caremark and Aetna to own CVS/Pharmacy. Pharmacies should not own PBMs, PBMs should not own pharmacies. Health Insurers should not own physician practices. In short, if your job is to manage other people’s money to buy healthcare products and services, you should not be ALLOWED to be in the business of selling those same products and services. These vertically integrated companies are simply too big to care.
- Robinson Patman Act enforcement – the existence of thousands of different prices for identical products in the PBM and pharmaceutical wholesaler businesses is proof that the big 3 in each market have far too much power to twiddle, and in a regime with visible and agressive enforcement of the RPA, none of this nonsense would exist.
All of these solutions are centered in government policy, because even the most red-blooded free-market fundamentalist has to recognize that pharmacy as it exists today is a product of government policy. Medicaid, Medicare, ACA, the FEHBP, state public employee plans, and TRICARE together account for somewhere north of 70% of a typical pharmacy’s revenue. My profession as it exists, exists primarily at the behest of and mercy of the folks in Washington DC and in the various State Capitols. The policy choices that have been made over the last 20+ years are why my profession is struggling and dying. We need help. I hope that we’ll be able to make it so that when an entrepreneurial person gets a doctorate, saves some money, opens a pharmacy to serve their community, and the community chooses to support that pharmacy, that pharmacy thrives.
Most likely for incorrectly coded Long Term Care/Retail “Combo Shops” – each of these were places with two discontinued NPIs for identical pharmacy names/addresses/phone numbers. If you run a combo shop, please make your Long Term Care NPI record have a meaningfully different name than your retail NPI, if only for the sake of seniors using Medicare.gov to compare prices at your pharmacy. If you are “Corner Drug” for the retail NPI, can you make the NPI record be “Corner Drug LTC” for your LTC? If this is not possible due to CMS/NPPES regs of some kind, can we please change that? LTC/retail combo shops are more and more common, and differentiating them in medicare.gov is important!
NCPDP is an excellent source of pharmacy OPENINGS, and less reliable for counting closures. This is because a pharmacy MUST be listed in NCPDP to be able to receive e-prescriptions via the Surescripts network. The NCPDP ID number assigned to the pharmacy can be thought of like a routing number for a bank – you want e-prescriptions routed to you, you get an NCPDP ID. Pharmacies are not under the same obligation to de-list their location in NCPDP, and so a decent fraction of pharmacies do not report their closure promptly to NCPDP.
A large fraction of the new pharmacies listed since 1/1/2024 appear to be 340b-covered-entity-owned pharmacies. This is not surprising, as the 340b program represents more than half of all gross margins earned in dispensing pharmacies today. It does, however, mean that the usual definition of “independent” vs. “chain” as “>5 pharmacies under common ownership” becomes a more fraught concept. When I think “independent pharmacy” I usually think of a small business, a mom-and-pop shop owned and operated by the pharmacists. Many 340b covered entity (340b-CE) owned pharmacies are certainly not small businesses by any stretch of the imagination – most frequently they are a relatively small business unit of an entity with hundreds of millions if not billions in revenue annually. In the ongoing argument between PCMA/PBMs and independent pharmacy advocacy organizations like NCPA, these 340b-CE-owned pharmacies are usually counted as “independents” because they may have 5 or fewer pharmacy locations. Additionally, a large and growing fraction of mom-and-pop independents that operate as contract pharmacies for 340b-CEs are being asked to sell to the CE. In some cases, where the pharmacy is co-located, the CE is pushing out the independent when the lease expires (I personally know of 5 such instances). I think that in NCPDP, if it doesn’t already exist, a flag of “is this pharmacy’s owner a 340b-CE” would be very helpful for teasing this out. I will also note here that comparing NPIs to OPAIS data is extremely difficult right now because OPAIS data has no NPIs. HHS’ OPA should include NPI numbers of contract pharmacies and CE-owned locations in OPAIS for a number of reasons beyond my desire to understand how many “independents” are 340b-CE owned, including facilitation of state medicaid programs’ efforts to ensure that FFS medicaid is not illegally a source of 340b discounts.
Filed under: General Problems | 4 Comments »
If Einstein was still alive – who would he vote for ?
Posted on September 14, 2024 by Pharmaciststeve
Filed under: General Problems | 4 Comments »
Walgreens paying $106.8 million to settle US prescription billing fraud charges
Posted on September 13, 2024 by Pharmaciststeve
Walgreens paying $106.8 million to settle US prescription billing fraud charges
Sept 13 (Reuters) – Walgreens Boots Alliance (WBA.O)
, opens new tab agreed to pay $106.8 million to settle charges it fraudulently billed the U.S. government for prescriptions that were never dispensed, the Department of Justice said on Friday.
The Justice Department said Walgreens violated the federal False Claims Act between 2009 and 2020 by submitting payment claims to Medicare, Medicaid and other healthcare programs for prescriptions it processed but which were never picked up.
This caused the pharmacy chain to receive tens of millions of dollars for prescriptions it never provided to patients, the department said.
“Federal health care programs provide critical health care services to millions of Americans,” said Brian Boynton, head of the Justice Department’s civil division. “We will hold accountable those who abuse these programs by knowingly billing for goods or services they did not provide.”
Walgreens, based in Deerfield, Illinois, did not admit liability in agreeing to settle.
“Due to a software error, we inadvertently billed some government health care programs for a relatively small number of prescriptions our patients submitted but never picked up,” Walgreens said in a statement.
“We corrected the error, reported the issue to the government and voluntarily refunded all overpayments.”
Friday’s settlement resolves three whistleblower lawsuits filed in Florida, New Mexico and Texas.
The Justice Department said the payout took into account Walgreens’ cooperation and its “significant” steps to upgrade its in-house pharmacy management system to ensure that the billing problems don’t happen again.
Walgreens previously refunded $66.3 million for the settled claims and is being credited for this amount.
The chain recently operated about 8,600 stores in the United States, but said in June it plans to close a significant number of underperforming stores over the next few years.
Steven Turck, a former Walgreens pharmacy manager who filed the Texas case, will receive $14.92 million from the settlement. Andrew Bustos, a former Walgreens district pharmacy supervisor who filed the New Mexico case, will receive $1.62 million.
Walgreens Boots shares closed on Friday up 37 cents, or 4.2%, at $9.21.
Jumpstart your morning with the latest legal news delivered straight to your inbox from The Daily Docket newsletter. Sign up here.
Filed under: General Problems | 2 Comments »
Pain med prescriptions did not cause opioid epidemic courts rule
Posted on September 9, 2024 by Pharmaciststeve
Pain med prescriptions did not cause opioid epidemic, courts rule
Filed under: General Problems | 8 Comments »
PBM reform: The end of the beginning
Posted on September 7, 2024 by Pharmaciststeve
PBM reform: The end of the beginning
https://chaindrugreview.com/pbm-reform-the-end-of-the-beginning/
The recent release of an interim report by the Federal Trade Commission about what the agency characterizes as “prescription drug middlemen” represents a vindication of sorts for pharmacy advocates who have long contended that PBMs employ business practices that skew the market to their advantage.
Following the British victory over the Axis powers at El Alamein, Prime Minister Winston Churchill said, “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.” The battle, in November 1942, proved to be a turning point in World War II, but more intense fighting was in store.
The same dynamic is now at work in community pharmacy’s contest with the big pharmacy benefit managers. Coming on the heels of reporting in The New York Times and The Wall Street Journal that also called PBM practices into question, the FTC report asserts that PBMs have an adverse impact on the accessibility and affordability of prescription medications.
“The FTC’s interim report lays out how dominant pharmacy benefit managers can hike the cost of drugs — including overcharging patients for cancer drugs,” said FTC chairwoman Lina Khan. “The report also details how PBMs can squeeze independent pharmacies that many Americans — especially those in rural communities — depend on for essential care. The FTC will continue to use all our tools and authorities to scrutinize dominant players across health care markets and ensure that Americans can access affordable health care.”
The report, the release of which was backed by Khan and three of the FTC’s four other members, focuses on the nation’s six largest PBMs — CVS Caremark, Express Scripts, OptumRx, Humana Pharmacy Solutions, Prime Therapeutics and MedImpact Healthcare Systems — and how they wield their power to the detriment of patients and pharmacy operators. Parts of corporate con0glomerates, the six big PBMs together account for 90% of the 6.6 billion prescriptions filled last year, with the top three — Caremark, Express Scripts and OptumRx — handling 80%, according to the report. Seventy percent of revenue generated by specialty medications flows through pharmacies linked to the industry leaders.
That scale enables them to exercise considerable, often decisive, leverage in determining where Americans fill their prescriptions, what those medicines cost and how pharmacy operators are paid. The report indicates that vertically integrated PBMs distort the marketplace, citing one instance in which the top three positioned affiliated pharmacies held onto $1.6 billion in revenue over and above product acquisition costs for two cancer medications in less than three years.
The findings of the interim report, together with Khan’s pledge to make the health care sector a high priority, bode well for community pharmacy, but many obstacles need to be surmounted before the industry can expect any substantial relief. In opposing the release of the report, FTC commissioner Melissa Holyoak said that the work was “plagued by process irregularities … and leaves us without a better understanding of the competition concerns surrounding PBMs or how consumers are impacted by PBM practices.”
Additional evidence supporting the majority view at the FTC emerged last month when the House Committee on Oversight and Accountability released the results of its own investigation into PBMs. Chaired by James Comer (R., Ky.), the committee asserted that pricing practices of the three dominant players raised the cost of medications, negatively impacted patient care and hurt community pharmacies, while simultaneously enriching the PBMs. Comer, who said the conclusions were based on 140,000 pages of documents and communications that demonstrate PBMs’ anticompetitive tactics, summarized the findings: “Simply put, the committee’s investigation has found that — while PBMs’ position as middlemen should have enabled them to reduce the costs of prescription drugs and improve Americans’ health outcomes — they have not. Instead, the cost of prescription drugs has gone up every year for 15 years. Instead, patients have less choice and worse health outcomes.”
Among other findings, the report indicates that agreements between PBMs and pharmaceutical companies often prevent the inclusion of generic drugs and biosimilars on formularies, thus increasing costs for patients, government and payers in the private sector. At the same time, PBMs are establishing operations outside the United States in order to mitigate the impact of federal and state regulations. Most troubling of all, such PBM practices as prior authorizations, fail-first policies and formulary manipulation damage patient outcomes.
It will come as no surprise that PBMs are contesting that characterization. CVS Caremark president David Joyner, who testified at the House hearing (along with Patrick Conway, chief executive officer of OptumRx, and Express Scripts CEO Adam Kautzner), asserted, “The way we have done our work over the past few decades has driven greater cost savings, better care and more robust benefits for the Americans we serve. Our work is rooted in greater simplicity and transparency for those who pay for pharmacy benefits, for people who take medicine and for the pharmacies that serve our patients.”
CVS Caremark pledged to redouble efforts to deliver greater affordability, improve transparency and enhance relations with pharmacy operators. At the beginning of August, David Cordani, CEO of Cigna — Express Scripts’ corporate parent — promised the company would adopt a more forceful stance in communicating what he asserted was the positive role that PBMs play in the nation’s complex health care system.
Up until now, the PBM industry has been very resourceful in defending itself, successfully fending off most efforts to rein in its business practices. The tide appears to finally be turning, but it’s certain that PBMs won’t go down without a fight.
As members of Congress and the FTC continue to evaluate the PBM industry and move closer to regulatory action, community pharmacies are struggling to maintain their financial viability. A recent survey of independent drug stores found that, without changes in the reimbursement model, as many as a third could go out of business by the end of the year.
At the same time, the top three drug chains are shuttering thousands of unprofitable or redundant locations. With the ongoing closures (a trend that will accelerate if Walgreens Boots Alliance follows through on plans to terminate a large number of underperforming stores — a group that comprises 25% of its outlets), pharmacy deserts are developing in many parts of the U.S., especially rural areas. As patient access to care diminishes, the situation should increase pressure on elected officials to address issues that have pushed many pharmacies to the brink. PBM reform is at the top of the list.
Early this year, pharmacy advocates were cautiously optimistic that Congress would take up legislation to rein in PBM practices related to direct and indirect remuneration under Medicare. Hopes have dimmed amid the fractious politics of a tumultuous presidential campaign season. Odds of regulatory action by the Centers for Medicare and Medicaid Services (CMS) diminished with the Supreme Court’s decision to overturn the Chevron Deference, which had given federal agencies considerable leeway in deciding how laws passed by Congress are best implemented.
All of which means that pharmacy advocates must double down on efforts to secure meaningful PBM reform. The reports from the FTC and House Oversight Committee are further evidence that their cause is gaining traction. The question is how long it will take to convert that momentum into measures that relieve the increasingly heavy financial burden that pharmacies bear. By exhibiting the per-severance that Churchill did during the Second World War, pharmacy operators can still win their long battle for fair and adequate remuneration.
Filed under: General Problems | 1 Comment »
Is this what “covert genocide” looks/sounds like
Posted on September 6, 2024 by Pharmaciststeve
Filed under: General Problems | 4 Comments »
Humana prepares for ‘frustration’ over Medicare Advantage changes, 13 market exits
Posted on September 5, 2024 by Pharmaciststeve
Humana prepares for ‘frustration’ over Medicare Advantage changes, 13 market exits
Humana will stop offering Medicare Advantage in 13 counties in 2025, CFO Susan Diamond said Sept. 4.
Speaking at an investor conference, Ms. Diamond said the company will no longer offer several plans in 2025. The exits will affect around 560,000 beneficiaries, 10% of Humana’s MA membership. The company expects to retain around half of the members affected by plan exits.
In most areas where Humana is ending plans, the insurer has another plan available, Ms. Diamond said. She did not specify which counties Humana planned to exit.
“There are very few places, literally 13 counties, where we will have no presence at all — completely insignificant,” she said.
In July, Ms. Diamond said the company expected to lose a few hundred thousand members in 2025.
Humana ended plans that did not have a path to profitability, Ms. Diamond said.
Rising medical costs and lower reimbursements from CMS led Humana and other insurers to plan market exits in 2025.
CVS Health executives said they expect to lose up to 10% of Aetna’s MA membership next year. Centene is also planning to exit Medicare Advantage markets in six states.
There will be disruption across the MA industry as Humana and its competitors exit markets and adjust benefits to account for rising costs, Ms. Diamond said.
Ms. Diamond said the company acknowledges that there is “going to be a lot of frustration” among beneficiaries about the level of changes being made.
“Even if they’re frustrated by the level of benefit change we made, if that plan is still the best option, they will typically stay in the plan,” Ms. Diamond said. “That’s what we’ve seen historically in cases where we’ve had to make so many types of changes.”
Filed under: General Problems | Leave a Comment »