“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
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
Everyone should watch the first half of this TV show. Investigation of how military healthcare HIDES and refuses to disclose to families how the military healthcare system refuses to provide the medical records of their loved one who is harmed or dies under military healthcare.
At the tap of a buyer’s smartphone, Chinese chemical sellers will air-ship fentanyl ingredients door-to-door to North America. Reuters purchased enough to make 3 million pills. Such deals are astonishingly easy – and reveal how drug traffickers are eluding efforts to halt the deadly trade behind the fentanyl crisis.
A cardboard box half the size of a loaf of bread bore a shipping label declaring its contents: “Adapter.” It was delivered in October to a Reuters reporter in Mexico City.
There was no adapter inside that package. Instead, sealed in a metallic Mylar bag was a plastic jar containing a kilogram of 1-boc-4-piperidone, a pale powder that’s a core ingredient of fentanyl. It was enough to produce 750,000 tablets of the deadly drug.
Reuters reporter had ordered the chemical six weeks earlier from a seller in China. The sales assistant, “Jenny,” used a photo of a Chinese actress as her screen avatar. The price was $440, payable in Bitcoin, delivery by air freight included.
“We can ship safely to Mexico,” Jenny had written in Spanish on the encrypted message platform Telegram in July 2023, when the reporter first inquired about the chemical. “No one knows what we ship.”
Transactions like this are part of the biggest upheaval in the global narcotics trade since the war on drugs began half a century ago. The manufacturing of fentanyl, the synthetic opioid that’s killing tens of thousands of Americans a year, has become an endlessly inventive and ruthlessly efficient global industry.
The trade hinges on chemicals known as “precursors,” which are the drug’s essential ingredients. Compounds called piperidines are the core of fentanyl’s structure. Other precursors provide the remaining building blocks. Combined through chemical reactions, these precursors create a drug 50 times stronger than heroin.
The problem for regulators: Many of the same chemicals used to make fentanyl are also crucial to legitimate industries, from perfumes and pharmaceuticals to rubber and dyes. Tightly restricting all of them would upend global commerce. And because of fentanyl’s potency, even small quantities of these precursors can produce vast numbers of tiny pills using a simple manufacturing process – rendering the ingredients, the final product and the supply chain easy to conceal from authorities.
Anyone with a mailbox, an internet connection and digital currency to pay the tab can source these chemicals, a Reuters investigation found.
In the early 80’s we expanded our independent pharmacy into providing Home Medical Equipment as hospitals’ reimbursement was changed to a new prospective DRG program. Basically, the hospital was paid a flat $$ when the pt was admitted, based on the pt’s diagnosis. If the hospital cost to treat the pt was more than the DRG amount – they lost money, if they spent less on treating this pt was less – they made money. Back then, the phrase came about of “discharging pts quicker and sicker”. It created a pt’s need for home medical equipment (HME).
Our small 1200 sq ft pharmacy quickly grew to have 5,000 sq ft for retail/display area and office space for our customer service and billing staff along with a fitting room for our prosthetic, orthotic, and mastectomy fittings, and off-site 2,800 sq ft warehouse for storing rental equipment and a place to provide maintenance and repair of our rental equipment pool.
We eventually became the largest HME vendor in two counties.
Is this Mobile, ALA hospital using artificial intelligent software to re-invent the “discharge pts quicker and sicker” to a new level to add to their bottom line?
Breaking throughput barriers: A hospital’s AI-powered approach to improved efficiency
Mobile, Ala.-based Springhill Medical Center is among the forward-looking organizations identifying new ways to boost operational efficiencies.
In this session, Sharon Barincle, the hospital’s executive director of revenue cycle, will share their experience implementing predictive analytics and AI solutions to tackle operational challenges and increase patient throughput.
Find out how the 270-bed community hospital:
Aligned care teams around precise discharge targets for proactive planning based on forecasted demands
Streamlined patient discharges to reduce delays and optimize length of stay.
Expedited evaluation of outpatients in inpatient beds to reduce prolonged stays and increase capacity
Established effective communication between nursing, case management and administration to escalate barriers affecting length of stay and discharge planning
Patients are overdosing on compounded semaglutide due to errors in measuring and self-administering the drug and due to clinicians miscalculating doses that may differ from US Food and Drug Administration (FDA)–approved products.
The FDA published an alert on July 26 after receiving reports of dosing errors involving compounded semaglutide injectable products dispensed in multidose vials. Adverse events included gastrointestinal effects, fainting, dehydration, headache, gallstones, and acute pancreatitis. Some patients required hospitalization.
Why the Risks?
FDA-approved semaglutide injectable products are dosed in milligrams, have standard concentrations, and are currently only available in prefilled pens.
Compounded semaglutide products may differ from approved products in ways that contribute to potential errors — for example, in multidose vials and prefilled syringes. In addition, product concentrations may vary depending on the compounder, and even a single compounder may offer multiple concentrations of semaglutide.
Instructions for a compounded drug, if provided, may tell users to administer semaglutide injections in “units,” the volume of which may vary depending on the concentration — rather than in milligrams. In some instances, patients received syringes significantly larger than the prescribed volume.
Common Errors
The FDA has received reports related to patients mistakenly taking more than the prescribed dose from a multidose vial — sometimes 5-20 times more than the intended dose.
Several reports described clinicians incorrectly calculating the intended dose when converting from milligrams to units or milliliters. In one case, a patient couldn’t get clarity on dosing instructions from the telemedicine provider who prescribed the compounded semaglutide, leading the patient to search online for medical advice. This resulted in the patient taking five times the intended dose.
In another example, one clinician prescribed 20 units instead of two units, affecting three patients who, after receiving 10 times the intended dose, experienced nausea and vomiting.
Another clinician, who also takes semaglutide himself, tried to recalculate his own dose in units and ended up self-administering a dose 10 times higher than intended.
The FDA previously warned about potential risks from the use of compounded drugs during a shortage as is the case with semaglutide. While compounded drugs can “sometimes” be helpful, according to the agency, “compounded drugs pose a higher risk to patients than FDA-approved drugs because compounded drugs do not undergo FDA premarket review for safety, effectiveness, or quality.”
Medscape Medical News recently reported on how some endocrinologists are addressing the ongoing shortage.
Interest on the federal debt in June was equivalent to 76% of all personal income taxes collected, which is the Treasury’s largest revenue source, with three-quarters of it being used solely for interest.
The fact 76% of all personal income tax collected last month was allocated to servicing the $34 trillion national debt has profound implications for America’s financial security. Analyzing different aspects of fiscal policy, economic stability and future financial planning is essential to understand the consequences.
Financial Security Concerns
Reduced Fiscal Flexibility
Impact on Budget Allocation: With the majority of personal income tax revenue being used to pay off debt, less money is available for other essential government services and programs. This can lead to underfunding in critical areas such as healthcare, education, infrastructure and social services.
Increased Borrowing: The need to service such a large debt may force the government to borrow even more, creating a vicious cycle of debt dependency. Increased borrowing can lead to higher interest rates, further exacerbating the debt crisis.
Economic Stability Risks
Investor Confidence: High levels of debt and significant portions of tax revenue going towards debt servicing can undermine investor confidence. If investors perceive the national debt as unsustainable, they may demand higher interest rates for government bonds, increasing the cost of borrowing.
Inflationary Pressures: Large-scale borrowing and debt servicing can lead to inflation if the government resorts to printing more money to meet its obligations. This devalues the currency and erodes purchasing power, impacting the overall economy.
Long-term Financial Health
Intergenerational Equity: High debt levels burden future generations with repayment obligations, potentially limiting their economic opportunities and financial security. This raises ethical concerns about intergenerational equity and the responsibility of current policymakers.
Potential for Austerity Measures: To manage the debt, the government might implement austerity measures, including cuts to public spending and increased taxes. Austerity can slow economic growth and lead to social unrest, as seen in other countries with high debt burdens.
The centers will be located in a clinical office space formerly occupied by Walmart Health.
CenterWell, the health care services business of Humana plans to lease clinical space and open senior-focused primary care centers at 23 Walmart Supercenter retail stores in Florida, Georgia, Missouri and Texas.
The centers will operate under the CenterWell Senior Primary Care and Conviva Care Centers brand names and will provide seniors in these communities with greater access to primary care services designed specifically for older adults.
The new centers will be conveniently located next to Walmart stores in clinical office space that was formerly occupied by Walmart Health. CenterWell expects the centers to be equipped, staffed and opened no later than the first half of 2025. Financial terms of the agreement were not disclosed.
“CenterWell is committed to providing seniors with high quality health care that is accessible, comprehensive, and most of all, personalized. We are excited by the unique opportunity to lease space from a world-class community partner such as Walmart and offer seniors in these four states greater access to our integrated approach to care,” said Sanjay Shetty, president of CenterWell. “These nearly two dozen primary care centers are specifically designed for seniors, and each location’s design, including dedicated entrances and easy parking, offers patients the access that they have come to expect at our clinics across the nation. We are eager to expand on our mission to help patients lead happier, healthier lives.”
“We are looking forward to welcoming CenterWell into these purpose-built healthcare spaces to offer quality care to communities in four states,” said Brian Setzer, executive vice president of Walmart Health & Wellness. “Leasing these spaces to a well-known and successful healthcare delivery organization is a win for customers and patients, as we continue to focus on our core health & wellness business of Pharmacy and Optical.”
CenterWell Senior Primary Care, along with its sister brand Conviva Care Centers, represents the largest, fastest-growing senior-focused, value-based primary care provider in the country. Together, the businesses comprise Humana’s Primary Care Organization, delivering care to about 318,000 seniors in nearly 300 centers across 15 states as of March 31, 2024.
CenterWell Senior Primary Care and Conviva Care Centers locations are designed specifically with the needs of seniors in mind, and include a staff of board-certified physicians, nurse practitioners and medical assistants that coordinate care alongside care coaches, social workers, behavioral health specialists and clinical pharmacists. These teams are dedicated to treating the unique medical and social needs of seniors and take the time to listen to and partner with patients on their healthcare journey, collaborating on a care plan that is evidence-based and centered on the patient.
CenterWell Senior Primary Care and Conviva Care Centers locations accept patients on many different Medicare Advantage health plans, as well as those who have Original Medicare.
In connection with this lease agreement, CenterWell plans to open senior-focused primary care centers adjacent to Walmart Supercenter locations in the following metropolitan areas:
This blog post is not about a particular politician but about the TERRIBLE financial state that all politicians have put our country in – THAT IS NOT TALKED ABOUT!
In 2009 when Pres Obama came to office, our country had amassed a 9 trillion dollar national debt since our founding in 1776 – (233 yrs). https://www.usdebtclock.org/ When Obama left office we were nearly 20 Trillion in debt and when Trump left office, we were 25 Trillion in debt, we are now 35 TRILLION in debt. In 16 yrs – abt 6% of our entire timeline history – our national debt has nearly QUADRUPLED. In 12 of those 16 yrs, There is a common denominator in 75% of this time, Joe Biden was part of the administration. In 2008 our interest on our national debt was $380 billion.
And it is projected that within the next decade, our national debt may exceed 50 TRILLION.
Just watch the first video and this presidential candidate is promising all sorts of benefits to just about every segment of our population and a “promise of freedom” with our society being shackled to that much increasing national debt and increasing interest payments that we have to make on that debt?
Please watch the second video starting at ~ 3 minutes with a scrolling part of the screen with all the things that have happened in spending money we don’t have.
Please watch the third video at 7:30 where there seemed to be support of a 70%-80% federal tax level to help pay for all these promises.
When will this honeymoon be over and when irreconcilabledifferences between promises and reality come home to roost?
Pharmacists & techs – urgent request to speak with a national reporter!
Dear pharmacists and technicians, especially chain pharmacists. I have a one day deadline on this one. It’s a tough one, but I’ll ask. I’ve had CVS pharmacists from locations across the nation say that they also get medications hot to touch that are coming from hot UPS and USPS trucks from central fill locations to the local pharmacies.
These medication are then put on shelves and given to patients without considering the impacts on heat. Is there anyone who is willing to speak to a reporter on this issue? I can ask for anonymity from the public for those who are willing to speak.
Sadly, some of the pharmacists or techs ask me to report to the state boards, but I know most state boards already know this is happening and turning their heads. Some also want to see a better future of medication handling but some are afraid to speak to a reporter. Will you be brave with me?
Maybe, I’ve almost sadly given up home especially here in Missouri.
I have more hope in reporters sharing the stories of patients and pharmacists to apply the pressure on state boards over many (not all) state boards doing the right thing and ensuring safe temperature storage on their own.
If you’re willing to speak message me or email loretta@uniteforsafemeds.com
Critically injured trauma patients without insurance had a higher risk of being taken off life-saving care sooner than their insured counterparts, according to findings from a retrospective cohort study of more than 300,000 U.S. adults.
After adjustment for patient and hospital characteristics, those without insurance had significantly earlier withdrawal of life-sustaining therapy (WLST) when compared with Medicaid recipients (HR 1.53, 95% CI 1.45-1.62) or the privately insured (HR 1.57, 95% CI 1.49-1.65), reported researchers led by Graeme Hoit, MD, of the University of Toronto.
In contrast, no such difference in time to WLST was observed between the Medicaid and privately insured groups (HR 1.03, 95% CI 0.98-1.08). Unadjusted numbers showed mean times to WLST of 6.5 days in the uninsured group, 8.9 days in the Medicaid group, and 7.8 days for the privately insured group.
This would appear to go against the Emergency Medical Treatment and Labor Act, which requires that all critically ill patients in hospitals receive optimal care regardless of insurance status or financial means.
But more than two-thirds of uninsured trauma patients are at risk of catastrophic health expenditures, noted Hoit and colleagues, and if these patients are unable to pay, the financial responsibility may shift to the institutions caring for them. One study from 2013opens in a new tab or window estimated a $2.8 billion annual tab for uninsured trauma care in the U.S.
Under ideal circumstances, the decision to WLST involves a shared decision between clinicians and a patient’s surrogate or substitute decision-maker (SDM), the researchers pointed out.
“However, the nature of severe traumatic injury means that trauma patients are typically younger, less likely to have preexisting care directives, more likely to be estranged from their families and SDMs, and more likely to belong to marginalized social populations compared with the general critical care population,” they wrote. “These factors complicate WLST decisions and may increase the likelihood of practitioner, caregiver, or institutional biases impacting decisions and timing.”
The new findings, said Hoit and colleagues, build on prior trauma studies linking uninsured status with increased mortality.
“When presented with decisions about whether or not to proceed with tests, procedures, or care continuation, institutions and/or SDMs may both have concerns with the cost of care and be less likely to pursue extensive measures, resulting in earlier mortality,” they wrote.
In an accompanying commentaryopens in a new tab or window, Zara Cooper, MD, MSc, a trauma surgeon at Brigham and Women’s Hospital and Harvard Medical School in Boston, said “it is incumbent upon individual clinicians and health systems to closely and uncomfortably examine how bias either creeps or marches into the life-and-death decisions we make for everyone under our care.”
In fact, she suggested, meaningful differences between the study groups — namely alcohol or substance use and mental health disorders — may have influenced WLST decisions. Self-inflicted injuries, for example, were associated with a greater risk of earlier WLST (HR 1.54, 95% CI 1.36-1.73), “suggesting that even though depression is a treatable disorder, comorbid depression may have biased clinicians and surrogates toward WLST.”
But Cooper added that “one of the more important findings in this study is that having any insurance vs no insurance is more important than having public vs private insurance in terms of risk of treatment withdrawal.”
Compared with injured adults in non-expansion states, noted Cooper, people in expansion states “are more likely to survive hospitalization, have shorter hospitalizations, and are more likely to receive rehabilitation postdischarge.”
The study from Hoit’s team included 307,731 critically ill trauma patients ages 18 to 64 admitted to an intensive care unit (ICU) in the U.S. from 2017 to 2020. Data were captured from level I and level II trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP) registry. Analyses excluded patients who died on arrival or in the emergency department, as well as individuals with a “do not resuscitate” order.
Mean age was 40 years, three-fourths were male, about two-thirds were white, and 19% were Black. The most common mechanism of injury was motor vehicle collision (35%), followed by falls (22%), firearms (12%), and motorcycle (10%) or pedestrian (9%) accidents. More than three-fourths of the injuries were unintentional, while 15.8% were related to assaults and 2.8% were self-inflicted.
A majority (52%) of the cohort had private insurance, while 19% were uninsured, and the rest were insured through Medicaid.
Uninsured patients tended to be younger than those with private insurance (37.8 vs 41.7 years); were more likely to be male (82.6% vs 73.2%), have a history of substance abuse (12.5% vs 0.8%), and be victims of assault (24.2% vs 7%); they were less likely to be white (56.1% vs 73.8%) and generally had lower rates of chronic illness. The uninsured population was more similar to the Medicaid group.
Hoit’s team noted that TQIP defined life-supporting interventions as ventilator support (with or without extubation), kidney replacement therapy, medications to support blood pressure or cardiac function, and surgical, interventional, or radiological procedures.
Overall, 12,962 patients (4.2% of the total cohort) underwent WLST during their ICU admission, including 5% of those without insurance, 4.2% of those with Medicaid, and 3.9% of those with private insurance. Overall, the average time to WLST was 7.8 days.
Besides self-inflicted injuries, another variable associated with earlier withdrawal of care was firearm injuries (HR 2.01, 95% CI 1.79-2.27). WLST was less common in Asian, Black, and Hispanic patients (as compared with whites) and for those treated at teaching or for-profit hospitals.
Study limitations cited by the authors included a lack of variables captured in the TQIP registry — including income, religious/spiritual beliefs, marital status, language ability, and education level — that may have influenced decisions related to WLST. Also, researchers did not assess the types of care that had been provided before it was withdrawn.
When is the last time you took a stand on something that you believed in? Here, at HLA, we stand up everyday for clients across the country who we believe in and who are in serious need of help, whether that be against PBMs, payors, the federal government, or some other industry giant looking to crush them and their livelihood. It’s not easy, and anyone who promises specific results should not be taken at their world. With us, however, you can be assured that we will represent you fiercely at every turn. It’s just who we are and what we do based on decades of experience at the highest levels of industry. Today’s lawsuit is one example of that commitment.
Texas Lawsuit to Stop Optum PBM Audit Termination
PBMs like Optum have motivations behind their audits that are not always apparent. However, our founding partner, Anthony Mahajan, previously served as the Chief Compliance Officer of United Health, with oversight over both Optum and United Healthcare. We used to work for them, now we fight for you.
You can read HLA’s complaint HERE, a summary of the relief requested HERE, and our legal arguments HERE. Among other claims, we allege that our client was selected for termination because Optum wanted to reverse or transfer to its internal, mail-order pharmacy claims for beneficiaries of United Healthcare plans. The lawsuit alleges that United Health is losing money on its Part C Medicare Advantage capitated plans given rising medical loss ratio, and therefore is particularly incentivized to audit and recoup on prescription claims using its corporate affiliate, Optum Rx.
Alleged Violations of Texas PBM Audit Reform Laws
We have many clients in the great State of Texas who have been targeted by Optum and other PBMs as a result of their relationship with telemedicine providers. In our client’s case, the pharmacy was targeted for termination due to “mailing on a retail contract.” Nonetheless, in addition to the waiver on mailing arising from the pandemic, Texas has specific PBM reform laws, enacted under Governor Abbott, that expressly prohibit payors and PBMs from barring mail-order delivery in their provider contracts.
With HLA, providers can hold PBMs like Optum accountable to their legal obligations because our PBM audit lawyers have decades of experience litigating federal and state laws.
Alleged Violations of Federal and Texas “Prompt Pay” Laws
PBMs often refuse to reimburse providers for claims that are submitted during the pendency of an audit. This results in a difficult choice for many: should you continue serving patients in good faith, or should you change course to avoid the possibility of the PBM recouping on everything owed.
However, Texas and federal laws prohibit PBMs from refusing to reimburse “clean claims” within certain time periods. These laws may also prohibit PBMs from extending the “look-back” period for claims audits. In addition, certain laws impose significant monetary penalties on PBMs who do not comply.
HLA’s lawsuit alleges that Optum refused to timely reimburse the pharmacy for hundreds of thousands of dollars in clean claims even though Optum’s final audit findings were far lower. If a PBM is refusing to pay reimbursement due and owing, you should understand your rights under these “prompt pay” laws.
Texas PBM Audit Attorneys Fighting for You
If your pharmacy is facing unjust termination from a PBM’s network, or other PBM audit abuses, HLA can help you level the playing field. Our PBM audit defense team has successfully resolved PBM audits across the country because we have a reputation as trial lawyers with the dedication to win.
Contact us today to learn more about how we can advocate for your rights and fight for your continued ability to serve your pharmacy patients.
Everyone should watch the first half of this TV show. Investigation of how military healthcare HIDES and refuses to disclose to families how the military healthcare system refuses to provide the medical records of their loved one who is harmed or dies under military healthcare.
In the early 80’s we expanded our independent pharmacy into providing Home Medical Equipment as hospitals’ reimbursement was changed to a new prospective DRG program. Basically, the hospital was paid a flat $$ when the pt was admitted, based on the pt’s diagnosis. If the hospital cost to treat the pt was more than the DRG amount – they lost money, if they spent less on treating this pt was less – they made money. Back then, the phrase came about of “discharging pts quicker and sicker”. It created a pt’s need for home medical equipment (HME). 
