Pharmacies sue GoodRx, accusing the company of conspiring with PBMs

https://www.healthcare-brew.com/stories/2024/11/19/pharmacies-sue-goodrx-accusing-company-conspiring-pbms

It’s not all good news for GoodRx.

The drug discount company is facing at least three separate class-action lawsuits from independent pharmacies accusing it of “conspiring” with pharmacy benefit managers (PBMs) to fix reimbursement rates in a way that boosts the PBMs’ profits. Also named in two of the three suits are four PBMs: Caremark, Express Scripts (owned by Cigna), Medimpact Healthcare Systems, and Navitus Health Solutions.

PBMs are companies that negotiate between drugmakers, insurers, and pharmacies to decide which drugs insurers cover and how much pharmacies are reimbursed for dispensing those drugs.

The lawsuits come as PBMs face increasing scrutiny, with the Federal Trade Commission bringing a lawsuit against the country’s top three PBMs in September for allegedly boosting profits by inflating the price of insulin.

What’s the issue?

The crux of the class-action lawsuits—filed in late October and early November—relates to a new line of business GoodRx started in 2023 called the “integrated savings program” that deals with generic drugs, which make up about 90% of drugs dispensed in pharmacies in the US.

Under the program, the independent pharmacies serving as plaintiffs allege that GoodRx has formed partnerships with certain PBMs in which the PBMs pay GoodRx to use its database of proprietary pricing data to lower the amount PBMs pay in reimbursement fees to dispensing pharmacies.

The program involves drug discount cards, which consumers can receive from PBMs to get cheaper prices on specific drugs at partner pharmacies. In 2021, discount cards made up 5.4% of all prescription drug transactions, according to data from the Association for Accessible Medicines.

As an example, let’s say Caremark, one of the top three PBMs in the US, gives a consumer a drug discount card for the diabetes drug metformin.

Without the GoodRx program, after a customer picks up their metformin prescription from the pharmacy, the pharmacy submits a claim for reimbursement to Caremark. Then Caremark reimburses the pharmacy a previously agreed-upon amount—say, $10—and the transaction is complete.

But GoodRx’s integrated savings program allegedly introduced a new step to the process, Miranda Rochol, SVP of provider solutions at health tech company Prescryptive Health, told Healthcare Brew. Prescryptive operates in the pharmacy benefits space and advocates for increased transparency among PBMs.

But that’s not all, Rochol added. GoodRx also allegedly charges the pharmacy a transaction fee—which is usually between $5 and $10, according to the lawsuits—that it splits between the other PBMs it compared its prices with, further lowering the amount of money the pharmacy gets paid, Rochol said.

“These partnerships amount to price-fixing agreements that enable the PBMs to allocate discount card transactions amongst one another in real time, ensuring the PBMs pay the lowest possible reimbursement rates to pharmacies on every transaction,” according to one of the lawsuits filed by Old Baltimore Pike Apothecary and Smith’s Pharmacy in the US District Court for the District of Rhode Island on November 1. “By targeting generic drugs, [the] defendants are attacking a stream of revenue on which independent pharmacies depend for most of their survival.”

Another lawsuit, filed by Keaveny Drug, Inc. in the US District Court for the Central District Of California Western Division on October 30, claims that thanks to the GoodRx program, the PBMs listed in the suit could end up underpaying pharmacies about $35 million just in 2024. The third lawsuit was filed in the same California court on November 1 by Community Care Pharmacy.

All three lawsuits allege that the integrated savings program favors chain pharmacies that are affiliated with PBMs, such as CVS, which owns Caremark. They also allege the arrangement violates the Sherman Antitrust Act, a federal law that prohibits practices that stifle competition.

“The premise of these lawsuits is categorically false,” Express Scripts spokesperson Justine Sessions said in a statement sent to Healthcare Brew. “Our partnership with GoodRx helps promote lower prices for patients at the pharmacy counter by directly integrating discount card pricing with customers’ pharmacy benefits. This program is an important part of our work to protect people from high drug costs, particularly for those with high deductible plans.”

Caremark spokesperson Michael DeAngelis told Healthcare Brew that the PBM “generally reimburses independent pharmacies at higher levels than chain drugstores, including CVS pharmacies. Our Caremark Cost Saver program also helps lower out-of-pocket drug costs for our clients’ members. These lawsuits are entirely without merit, and we will vigorously defend against them.”

Neither GoodRx nor the other PBMs named in this story responded to Healthcare Brew’s requests for comment.

The bigger picture

Independent pharmacies are already struggling to keep their doors open.

The National Community Pharmacists Association (NCPA) said in March that nearly one-third of the country’s roughly 19,000 independent pharmacies are in danger of going out of business. And in 2023, about one independent pharmacy closed per day in the US, according to the NCPA.

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Chronic Pain Is Rising, and It’s Not Clear Why

More Americans are living with pain now, CDC data show

https://www.medpagetoday.com/neurology/painmanagement/113149

A new CDC report indicated that the percentage of Americans with chronic pain rose considerably in recent years, and it’s not clear why.

In 2023, 24.3% of U.S. adults had chronic pain lasting 3 months or longer. In 2016, that figure was 20.4% and in 2021, it was 20.9%

The numbers came from the National Health Interview Survey (NHIS), a cross-sectional poll conducted annually by the CDC’s National Center for Health Statistics. The NHIS methodology and questions have not changed, the CDC said.

“What is clear is we have an astounding and growing public health crisis of chronic pain,” observed Sean Mackey, MD, PhD, of Stanford School of Medicine in Palo Alto, California, who co-authored the CDC’s analysis of chronic pain prevalence in 2016.

“This crisis touches everyone and requires a broader public health approach to reverse this concerning trend,” he noted.

Aging and Other Risk Factors

Several reasons may account for rising chronic pain percentages, Mackey said. “Chronic pain prevalence increases with age,” he told MedPage Today. “The U.S. population has a growing proportion of older adults, which may contribute to higher rates of chronic pain overall.”

The COVID-19 pandemic may have played a role, he added. “The pandemic led to delays in healthcare access and surgeries, increased sedentary lifestyles, and heightened mental health challenges such as anxiety and depression, all of which are associated with chronic pain,” Mackey noted. “Even outside COVID, we appear to have a more highly stressed population.”

Economic disparities, reduced access to healthcare, and environmental factors in rural or non-metropolitan areas also may have exacerbated chronic pain rates, he said.

An overall decline in health in the U.S. could be another factor, suggested Beth Darnall, PhD, also of the Stanford School of Medicine. Type 2 diabetes rates are increasing and obesity is widespread, she indicated. “There is a clear connection between obesity and chronic pain, and it is multifactorial,” she told MedPage Today.

It’s not just diabetes and obesity, Darnall emphasized: many chronic disease rate are accelerating, and most of these diseases are associated with different types of chronic pain.

Changes in Pain Management

The U.S. opioid crisis also rose to the forefront between 2016 and 2023, and changes in pain management   guidelines followed.

“Efforts to reduce opioid prescriptions may have led to inadequate pain management for some individuals, potentially increasing reports of chronic and high-impact pain,” Mackey said. “We have been concerned about this unintended consequence for a long time.”

The new CDC numbers reflect the reality that many patients are facing, noted Charles Argoff, MD, of Albany Medical College in New York, who is president of the American Academy of Pain Medicine (AAPM), and Antje Barreveld, MD, of Newton-Wellesley Hospital in Newton, Massachusetts, who is AAPM’s president-elect.

“Those with the greatest need for chronic pain care too often do not have access to the type of pain management care that is most likely to help,” wrote Argoff and Barreveld in an email to MedPage Today.

“We need to leverage technology, including telemedicine and other approaches, to be able to offer team-based care to all those who can benefit from it,” they added.

“We will continue to see higher rates of chronic pain in our population unless we change how we deliver optimal care to all people. This will require a coordinated effort across not only all medical specialties, but also all payers,” Argoff and Barreveld continued. “Pain medicine specialists comprise less than 1% of the medical workforce so we need to truly work as a team with others if we are going to be able to address this chronic pain crisis effectively.”

Some providers feel unequipped to treat pain despite the availability of many effective treatments, they pointed out. “A fear of opioids and misconceptions about what else besides medications can help reduce pain also has led to many healthcare providers being afraid to treat chronic pain.”

Better Treatment Needed

“We need better comprehensive treatment for acute and chronic pain alike,” noted Darnall. “If we treat acute pain better, we will have fewer people transitioning to the chronic pain state.”

The new CDC data also showed that 8.5% of U.S. adults had high-impact chronic pain — pain severe enough to restrict daily activities.

“Currently, people with high-impact chronic pain are over-medicalized with costly and often risky treatments that offer limited benefit, while we undertreat with the lowest-risk behavioral treatments. The idea isn’t to prevent medical care, but to ensure access to low-risk evidence-based behavioral options for symptom management,” Darnall said.

“Encouragingly, we see a clear trend toward offering behavioral treatments as standard care — meaning everyone gets them, with no screening applied,” she added.

Argoff and Barreveld emphasized the importance of “appropriate care to all patients experiencing chronic pain, whoever they are and wherever they live.”

“We must work together to combat obstacles, like the fact that insurers are more likely to pay for a pill or invasive procedure than for comprehensive multidisciplinary team-based care, which is often more effective,” they said.

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Warren Blasts United Health CEO for Monopolistic Practices that Harm Patients

Here is a 5 minute video of Senator Warren “ripping” the president of UHC over how they financially operate.

UnitedHealth Pays Its Own Physician Groups More Than Others

https://www.medpagetoday.com/special-reports/features/11314

UnitedHealth Group pays many of its physician practices “significantly more” than other groups “in the same markets for similar services,” a STAT investigation found

The “above-market payments” were discovered in an analysis conducted in partnership with health analytics company Tribunus Health. It looked at data that UnitedHealth reported to the federal government revealing what its commercial insurance unit pays 16 Optum-branded physician groups for common or expensive services.

Ultimately, the analysis found that insurance subsidiary UnitedHealthcare paid 13 of the Optum practices more on average for common services than market price, STAT reported. The finding varied from 3% to 111% above market price.

“The higher prices reward UnitedHealth at the expense of almost everyone else,” STAT wrote. “Patients end up paying more when they see their doctors and struggle to afford recommended follow-up care. Employers counting on the insurance giant to control ever-rising costs get little or no relief. And doctors trying to compete with UnitedHealth’s practices find themselves frozen out of the higher rates the company is paying its own providers, making it more difficult to remain independent and keep their doors open.”

STAT noted that its analysis had limitations and was not comprehensive. UnitedHealth’s data files were “imperfect” and did not include certain information, the outlet noted. And the analysis included just a subset of common services.

Prior to publication, STAT shared its analysis and a list of questions with UnitedHealth. Though the company declined to make a representative available for an interview, spokesperson Eric Hausman provided a statement to STAT that called the analysis “flawed.”

The company further told STAT that it ran its own analyses and asserted that, “UnitedHealthcare pays Optum Health consistent with other payers in the market.” It declined to share its analyses with the outlet.

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The first SS check was issued in Jan 31, 1940 for a total sum of $22.54 and employees & employers each paid 1% of the first $3,000 a person earned.

By the time I graduated college (1970) SS taxes were 4.6% of the employee’s first $7,800 and of course the employer had to pay a equal amount.

Prior to 1984, Social Security benefits were entirely exempt from federal income taxes

The new tax policy established that beneficiaries with total income exceeding certain thresholds would be required to pay federal income tax on a portion of their benefit income

The initial thresholds set in 1983 were:

• Single beneficiaries with modified adjusted gross income greater than $25,000
• Married couples filing jointly with modified adjusted gross income greater than $32,000

For those above these thresholds, up to 50% of their Social Security benefits became subject to federal income tax

In 1993, additional legislation extended the taxation of benefits:

• It increased the taxable portion from 50% to 85% for higher-income beneficiaries
• New thresholds were introduced: $34,000 for single filers and $44,000 for joint filers

It’s worth noting that these income thresholds have not been indexed for inflation since their introduction, which has resulted in an increasing proportion of beneficiaries becoming subject to this tax over time

Today that $32,000 trigger in 1984 to require the person to pay taxes on 50% of their SS income, would be ~ $98,000 in 2024

Today that $44,000 trigger in 1993 to require the person to pay taxes on 85% of their SS income, would be ~ $96,000 in 2024

The average couple receiving social security would get ~ $46,000/yr. in 2023, and the average couple back in 1993 would get ~$15,300/yr.

BTW, a fellow by the name of Joe Biden was in our Senate and voted for both of these increase in taxes, and voted not to index the income dollars at which SS income would be considered taxable.

After getting the notice that those on SS would get a 2.5% increase as of the first of Jan 2025. So I put all the $$ figures into a spread sheet.  All that I could compare is Medicare Part B premiums, deductible and our supplement premium and deductible and off course our Part D premium and deductible.

I won’t bother you with the RAW DOLLARS, but collectively all those fixed costs, will be ~ 2.5 times in 2025 than they were in 2024! So, what is suppose to be a COST OF LIVING INCREASE… will not cover the increase in our basic healthcare costs.

In regards to our medication, our Part D deductibles and premiums will be close to $2,000 for 2025, before we get the first PENNY in coverage for our medications.

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DOJ suspends DEA searches at airports over civil rights concerns

https://nypost.com/2024/11/23/us-news/doj-suspends-dea-searches-at-airports-over-civil-rights-concerns/

(The Center Square) – The U.S. Department of Justice told the Drug Enforcement Administration to suspend consensual searches at airports and other mass transit facilities after hearing about potential civil rights violations.

Department of Justice Inspector General Michael Horowitz announced the suspension after hearing concerns about in the DEA’s transportation interdiction efforts, which include conducting consensual searches.

During such searches, the DEA Task Force Groups approach people at airports, ask for consent to speak with the person and, if the Special Agents or Task Force Officers think it warranted, ask for consent to search the individual’s belongings.

The practice has raised civil rights concerns after video of one search went public.

Horowitz said the DEA wasn’t following its own policies on those searches, which often included seizing cash. Such seizures put the onus on the traveler to prove the money wasn’t from drug trafficking to get it back. 

Horowitz said the DEA wasn’t complying with its own policy to document each consensual encounter despite the agency having promised to do so in 2015.

The Office of Inspector General’s office also said the DEA had suspended its transportation interdiction training in 2023. Such training is required by DEA policy and has not restarted, according to the memo. 

The alert came after a search earlier this year involving a traveler who was approached for a consensual encounter by a DEA Task Force Officer while boarding a flight.

The practice has raised civil rights concerns after video of one search went public.

Horowitz said the DEA wasn’t following its own policies on those searches, which often included seizing cash. Such seizures put the onus on the traveler to prove the money wasn’t from drug trafficking to get it back.

Horowitz said the DEA wasn’t complying with its own policy to document each consensual encounter despite the agency having promised to do so in 2015.

The Office of Inspector General’s office also said the DEA had suspended its transportation interdiction training in 2023. Such training is required by DEA policy and has not restarted, according to the memo. 

The alert came after a search earlier this year involving a traveler who was approached for a consensual encounter by a DEA Task Force Officer while boarding a flight.

The OIG concluded that continuing such searches could “imperil the Department’s asset forfeiture and seizure activities.”

“Absence of critical controls, such as adequate policies, guidance, training, and data collection, the DEA is creating substantial risks that DEA Special Agents and Task Force Officers will conduct these activities improperly; impose unwarranted burdens on, and violate the legal rights of, innocent travelers; imperil the Department’s asset forfeiture and seizure activities; and waste law enforcement resources on ineffective interdiction actions.”

The Deputy Attorney General issued the directive to the DEA suspending all consensual encounters at mass transportation facilities “unless they are either connected to an ongoing, predicated investigation involving one or more identified targets or criminal networks or approved by the DEA Administrator based on exigent circumstances.”

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Here is Pam Bondi’s re-election TV video in 2014 for Florida Attorney General

And the state AG of Florida is an attorney married to a DEA Agent!

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Optum audit shows possible law violation, lower payments to independent pharmacies

https://mississippitoday.org/2024/11/07/optum-audit-shows-possible-law-violation/

The findings of a recent audit of a major company that manages prescription benefits revealed it may have violated Mississippi law.

The review of Minnesota-based Optum’s business practices by the Mississippi Board of Pharmacy indicated that the company paid independent pharmacies in Mississippi rates lower than chains and Optum-affiliated pharmacies for the same prescription drugs. 

The audit uncovered over 75,000 instances in which Optum-affiliated pharmacies’ lowest payments for a prescription drug were higher than at unaffiliated pharmacies in one year, including chain and independent drug stores. 

Mississippi state law prohibits pharmacy benefit managers from reimbursing their affiliate pharmacies, or ones they own, at higher rates than non-affiliate pharmacies for the same services. 

In some cases, patients footed the bill: consumers were almost twice as likely to pay the full cost of a prescription drug claim without contributions from their insurance plan at independent pharmacies than at affiliated pharmacies. 

The Board of Pharmacy will hold an administrative hearing based on the alleged violations of Mississippi law on Dec. 19. Board staff declined to answer questions about the audit or its findings. 

“I think this proves that we need to have more transparency, we need to have more PBM reform in Mississippi and across the country and even on a federal level,” said Robert Dozier, the executive director of the Mississippi Independent Pharmacy Association, an organization that advocates for 180 pharmacy members.

Optum declined to answer specific questions about the audit. The company has identified errors in the audit’s findings and methodology and submitted them to the Board of Pharmacy, said Isaac Sorenson, a spokesperson for Optum. 

“The pharmacy – and local pharmacists – play a vital role in supporting people’s health and we are committed to paying them fairly,” he said. “…For pharmacies in rural and underserved communities, Optum Rx is deepening its commitment to support their role by launching new programs, expanding existing initiatives and launching a new pharmacy network option for customers.” 

He said the new pharmacy network option will provide pharmacies with increased reimbursements. Generic drugs will be reimbursed at 5% higher rates and brand name drugs at .2% higher rates. 

Optum is owned by health care behemoth UnitedHealth Group Inc., the U.S.’ most profitable health care company and the owner of the nation’s largest health insurance company, UnitedHealthcare. In 2023, the company reaped $32.4 billion in earnings. 

Pharmacy benefit managers are private companies that act as middlemen between pharmacies, drug manufacturers and insurers. They process prescription drug claims, negotiate pricing and conditions for access to drugs and manage retail pharmacy networks. 

Optum is one of the largest three pharmacy benefit managers in the U.S., which together account for 79% of prescription drug claims nationwide. 

The results of the audit echoed some of the conclusions of a Federal Trade Commission report published in July: large pharmacy benefit managers pay their own, affiliated pharmacies significantly more than other pharmacies and set reimbursement rates at untenably low levels for independent drug stores, or retail pharmacies not owned by a publicly traded company or owned by a large chain, said the report. 

Mississippi Today reported last month that many Mississippi independent pharmacists fear they may be forced to close their businesses due to low reimbursement rates from pharmacy benefit managers. 

Pharmacy benefit managers have an incentive to steer customers towards their affiliate pharmacies and compensate them at higher rates, which can disadvantage unaffiliated pharmacies and lead to higher drug costs, said the Federal Trade Commission. 

Optum’s affiliate pharmacies include Optum Home Delivery Pharmacy and Optum Specialty Pharmacy. 

The audit revealed that Optum uses 49 different maximum cost lists, or schedules created by pharmacy benefit managers that determine the highest price they will pay pharmacies for generic drugs. Maximum cost lists are proprietary and confidential, even to the pharmacies that are reimbursed based on the lists, and change continuously.

“I think that’s 48 too many,” said Dozier. “There should only be one MAC list.”

Fifteen are used exclusively at independent pharmacies and 22 are used solely at chain pharmacies. 

An analysis of the maximum allowable cost lists showed that independent pharmacies were reimbursed at rates 74% lower than chain pharmacies on average.

An analysis of a generic drug used to treat bacterial infections yielded a payment to an Optum-affiliated pharmacy that was eight times higher than the lowest-paid independent pharmacy on the same day. Chain and affiliate pharmacies were paid over 20 times as much as independent pharmacies for a generic drug used to treat stomach and esophagus problems.

Pharmacies’ attempts to contest low reimbursement rates were often unsuccessful, showed the audit. 

Ninety-eight percent of pharmacy appeals were denied, most commonly because they did not include information about how much the pharmacy paid to acquire the medication from a wholesaler. 

Mississippi law prohibits pharmacy benefit managers from reimbursing pharmacies at rates below their cost to acquire the drug, even when using a maximum allowable cost list. But the audit revealed over 400 times that Optum denied pharmacies’ appeals on those grounds, saying that the maximum cost list was accurate. 

The audit, which studied Optum in 2022, was the first commissioned by the Mississippi Board of Pharmacy after revisions to state law in 2020 gave it more regulatory authority over pharmacy benefit managers. 

It took the board several years to hire staff to enact the law and receive approval to increase its budget due to the high costs of audits, the board’s executive director Susan McCoy told lawmakers at the House Select Committee on Prescription Drugs Aug. 21 at the Capitol.

The board also has pending administrative proceedings with the other largest pharmacy benefit managers in the country, Express Scripts and CVS Caremark. Neither is the result of an audit. Both hearings are scheduled for Nov. 21. 

Optum has already faced scrutiny for its business practices in Mississippi. In August, Attorney General Lynn Fitch filed a lawsuit alleging that Optum and several other pharmacy benefit managers stoked the opioid epidemic by plotting with manufacturers to increase sales of the addictive drugs and boost their profits. The suit also named Evernorth Health and Express Scripts, along with the companies’ subsidiaries.

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Chronic Pain Affects One in Four Americans, CDC Reports

Nearly 9% have pain severe enough to restrict daily activities

https://www.medpagetoday.com/neurology/painmanagement/113052

Chronic pain affected nearly one in four U.S. adults, new CDC survey data showed.

In 2023, 24.3% of adults had chronic pain lasting 3 months or longer, reported Jacqueline Lucas, MPH, and Inderbir Sohi, MSPH, of the CDC’s National Center for Health Statistics (NCHS).

Moreover, 8.5% of U.S. adults had high-impact chronic pain — pain severe enough to restrict daily activities — Lucas and Sohi wrote in NCHS Data Brief

The percentage of adults with chronic pain was higher in women, in people who were American Indian or Alaska Native, in older adults, and in those living in nonmetropolitan areas.

The analysis was based on data from the 2023 National Health Interview Survey (NHIS), a cross-sectional poll conducted annually by the NCHS. Previous NHIS survey data showed the percentage of adults with chronic pain was 20.9% in 2021, similar to the pre-pandemic estimate of 20.4% in 2016.

What accounted for the jump in percentage since last year was unclear, but shifting demographics — including more older Americans now than in years past — may play a role. The methodology of the survey and the interview questions did not change over time, a CDC spokesperson said.

Lucas and Sohi used NHIS data to provide updated percentages of adults who experienced chronic pain and high-impact chronic pain in the past 3 months by selected demographic characteristics.

“Chronic pain and pain that often restricts life or work activities, referred to in this report as high-impact chronic pain, are the most common reasons adults seek medical care, and are associated with decreased quality of life, opioid misuse, increased anxiety and depression, and unmet mental health needs,” they wrote.

Chronic pain was determined by responses of “most days” or “every day” to a survey question about pain frequency in the past 3 months. High-impact chronic pain was defined as adults who had chronic pain and who responded “most days” or “every day” to a survey question asking how often pain limited life or work activities in the past 3 months.

The 2023 survey data showed that women were more likely to have chronic pain than men (25.4% vs 23.2%) and to have high-impact chronic pain (9.6% vs 7.3%).

The percentage of adults with chronic pain in the past 3 months rose with age, ranging from 12.3% in young adults under age 30 years to 36.0% in those 65 and older. Likewise, the percentage with high-impact chronic pain in the past 3 months increased from 3.0% in adults under age 30 to 13.5% of those ages 65 and up.

American Indian and Alaska Native adults had higher percentages of both chronic pain (30.7%) and high-impact chronic pain (12.7%) than other groups.

Chronic pain percentages were 20.5% in large central metropolitan areas and 31.4% in nonmetropolitan areas. High-impact chronic pain percentages were 7.3% in large central metropolitan areas and 11.5% in nonmetropolitan areas.

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Oxygen Company Too Big to Ban?

We expanded our independent pharmacy into providing Home Medical Equipment (HME) in the early 1980’s. Providing home Oxygen and other respiratory services turned out to be a large part of our HME business. After a decade in the business, with annual inflation being in the 3%-4% range, Medicare never gave HME vendors a increase in what we were paid. As we approached the middle of the 90’s decade, there were rumors stirring that Medicare was going to CUT REIMBURSEMENTS. I knew that we could not take care patient properly after not getting any increase in payments for a decade and then having to deal with a cut in payments. I sold the pharmacy and HME business in late 1996 and 2 yr later Medicare cut reimbursement by about 40% of what we had been paid for abt 15 yrs.  Abt another 15 yrs, Medicare cut reimbursement again and was only paying abt 22% of what we were being paid in the early 1980s. Adjusting for inflation, Medicare was paying about 10% of what they were paying in early 1980 and they add many mandatory services without any reimbursements.  As is stated in this article: Lincare customers aren’t pleased with the services they receive; it only has a 1.3 out of 5 on the Better Business Bureau site.

It would seem that Medicare & Lincare are at a standoff. Taking care of home oxygen/respiratory pts is both labor and equipment intensive and Medicare has ran so many small vendors out of the market place that no small/independent vendor would enter into providing HME services/products to respiratory pts with what Medicare is offering as payment. Medicare apparently found it acceptable for pts to deal with POOR SERVICE, than to pay what the service is worth.

Oxygen Company Too Big to Ban?

https://www.medpagetoday.com/special-reports/features/113015

Despite decades of misbehavior — from overbilling to violating kickback laws — Medicare has never banned Lincare, the largest distributor of home oxygen equipment in the U.S., ProPublica revealed

In 2023, HHS placed Lincare on probation — a “corporate integrity agreement” with a “death penalty” provision. Yet Lincare was already under that form of probation and had been on and off it for years. The company regularly violated the terms of probation with little punishment, according to ProPublica.

Part of the reason Lincare has gotten away with this for so long is because Medicare fraud is so rampant that a lot of bad behavior gets through. Plus, the company has a near-monopoly, begging the question whether it’s too big to ban, the article stated.

In addition, paying multimillion-dollar legal settlements has been affordable to the company. “As long as that [settlement] check is less than the amount you stole, it’s a good business proposition,” Lewis Morris, former chief counsel to HHS’ Office of Inspector General, told ProPublica.

Lincare customers aren’t pleased with the services they receive; it only has a 1.3 out of 5 on the Better Business Bureau site, with one reviewer writing that Lincare is “running a scam where they have guaranteed income” and that “the customer can’t do a thing.”

ProPublica’s reporting found “a dismal picture of a company with a sales culture that depends on squeezing infirm and elderly patients and the government for every penny.”

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Abandoned in Pain: A Family’s Fight Against UCHealth’s Neglect

https://www.coloradoswitchblade.com/p/abandoned-in-pain-a-familys-fight?triedRedirect=true

Exposing the Healthcare System’s Betrayal of Chronic Pain Patients—Share to Demand Accountability

This article is an opinion piece based on my personal experiences and interviews. The views expressed here are my own and do not necessarily represent those of any organization or publication.

I remember it was a cold and windy day as I helped my wife out of our beat-up grey Subaru. I got her walker from the trunk, carefully wrapping the blanket around her shoulders before helping her take each labored step toward the side door of our local medical clinic.

She had six broken ribs that day, a result of the life-saving CPR I had given her, along with the paramedics and the robotic Newton machine that continued compressions as they drilled an IV into her shin bones. It was the first time Shilo died in my arms.

We were lucky to get her back, but her survival was tenuous. For weeks, she hovered between life and death in a medically induced coma, her body battling cascading organ failure. The doctors told us to say goodbye. Those conversations with my daughters remain among the hardest of my life—second only to the next time Shilo died in my arms, this time for good.

Shilo had spent her life battling chronic pain caused by atypical Crohn’s disease and deep adhesion scarring throughout her abdomen. Her condition was so severe that even drinking water caused excruciating pain. For decades, doctors successfully managed her condition, giving her a semblance of normalcy that allowed us to build a life, raise our daughters, and hold onto hope.

Then everything changed. The very doctors and institutions that had cared for her abandoned her, citing fears of regulatory scrutiny and rigid opioid guidelines implemented by the CDC in 2016. When they stopped treating her pain, Shilo turned to alcohol for relief. I understood why—she was trying to numb the unrelenting agony—but I couldn’t allow it around our daughters. I found her an apartment close by, and though we were separated, we remained as close as ever.

After I was able to nurse Shilo back to health and convince her doctor to prescribe pain medication again, her recovery was remarkable. She moved back in, reconnected with our daughters in profound and meaningful ways, and grew closer to me than ever before. Those two years were truly a blessing to our family—two of the best years of my life.

The night she passed for the final time had started as a good day. We celebrated her birthday that weekend, cooked dinner together, and watched a movie. But later that evening, Shilo had her final seizure—the one she couldn’t wake up from.

That night, after the paramedics told me there was nothing more we could have done, I felt her spirit lift from her body. For the first time in decades, she was free from pain. I told her, “It’s okay. You can go. I’ll take care of the girls. You go, experience the universe without pain. I’ll see you when my own time is through.”

A Systemic Crisis

Shilo’s story is not unique. Thousands of chronic pain patients across the country face the same fate, abandoned by the healthcare system meant to protect them. This weekend, I was reminded of this cruel reality when my friend and pain management physician, Dr. Mark Ibsen, reached out with an urgent plea for help.

He told me about Monique Barela, a patient whose story mirrored my wife’s. Monique has been abandoned by her doctors despite her chronic pain being fully documented and protected under Colorado law.

“Monique doesn’t want to die,” her mother told me. “But she can’t live like this anymore.”

Monique’s desperation is not an isolated incident—it’s the result of a systemic failure to provide compassionate and competent care to chronic pain patients.

Monique Barela’s Fight for Survival

Monique’s battle with chronic pain began when she was just eight years old. A bacterial infection from a gym class injury led to years of surgeries, misdiagnoses, and escalating health complications. By her twenties, she was living with Complex Regional Pain Syndrome (CRPS), osteoporosis, and severe arthritis.

For a time, Monique managed her pain with carefully calibrated doses of oxycodone and oxycontin. With her pain under control, she was able to work two jobs and attend school. But in 2016, her providers began tapering her medication, not because her condition had improved, but in response to vague opioid-prescribing guidelines.

“They made me sign a taper form,” Monique explained. “They said if I didn’t, they wouldn’t prescribe anything at all. What choice did I have?”

Her once-stable life unraveled. Malnourished and in unbearable pain, Monique dropped to 87 pounds and was hospitalized. Even then, doctors dismissed her suffering. “They told me to try Tylenol or meditation,” she said, her voice trembling.

Abandoned by the System

Despite Colorado’s SB23-144—legislation explicitly prohibiting forced tapering and mandating individualized treatment plans for chronic pain patients—Monique’s cries for help have been ignored.

“I showed a doctor the law—SB23-144—to prove they wouldn’t get in trouble for treating me,” she recounted. “He refused to even look at it. He just walked out of the room.”

Even when Monique has found doctors still willing to help her, pharmacies have refused to fill her prescriptions, citing vague “red flag” policies. “I’ve driven hours to find a pharmacy that would give me what I need,” Monique said. “And most of the time, they still say no.”

The Insurance Ping-Pong Game

Adding insult to injury, many chronic pain patients are subjected to a cruel cycle of referrals and appointments with specialists who know they won’t provide treatment.

“Doctors know from the start that they’re not going to treat the patient’s pain,” Dr. Ibsen said. “Instead, they refer them to another specialist or clinic. It’s a cycle of false hope and wasted resources.”

Monique has lived this nightmare. “I’ve been sent to so many different clinics, and none of them ever actually treated me,” she said. “Meanwhile, my insurance gets billed for every appointment, every test, and I’m still left in pain.”

This practice raises serious legal and ethical questions. By repeatedly billing insurance for services that don’t address the patient’s needs, healthcare providers exploit the system while patients suffer.

A Call to Action

UCHealth has a choice: to honor the law and provide compassionate care or to perpetuate a system that abandons those who need it most.

To my readers: Speak out. Share Monique’s story. Demand accountability from UCHealth and other providers. Contact your legislators and insist they enforce SB23-144.

If this is an issue you or a loved one are facing, I urge you to contact Governor Jared Polis himself. He signed this law into effect, and it is failing our fellow Coloradans. Plead with him to demand accountability and ensure this legislation is upheld.

No family should endure what mine has. Shilo deserved better. Monique deserves better. Chronic pain patients deserve better.

Read the full text of SB23-144 here.

Shilo’s story, along with our family’s harrowing journey through the medical system as she faced chronic pain—her triumphs, setbacks, and ultimate sacrifice—will form the backbone of my next non-fiction book, currently titled Shilo’s Story. This memoir will explore our unconventional life together as creatives, artists, and writers while shedding light on our healthcare system’s systemic failures. It will highlight the resilience of those the system abandons and honor the enduring legacy of a woman whose courage continues to inspire. Stay connected for updates on this deeply personal and important project.

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