“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
I have a specific example of how these PBM’s … in our case … Silver Scripts/Caremark which is part of CVS Health. Barb has a prescription that she has taken for 10+ yrs
This particular medication has always required a PA (Prior Authorization) from Silver Scripts, and they wanted a $600+ copay meaning that it was a Tier 4 medication. Which means that the total price of the 90 day prescription was in the $1500+ arena.
I asked the independent pharmacy that we patronize what their “cash price” was and it was $325.00. I started making some phone calls and found that a BIG BOX store would fill the prescription for CASH for $88.00
And the third time that I got it filled at the same BIG BOX store .. the CASH PRICE was $44.00.
It use to be that the pt was suppose to be charged the PBM contracted price in this particular case .. the copay would be abt 40% of a total price of abt $1500.00 ($600.00) OR the pharmacy’s CASH PRICE and in the first case would be $325.00. Maybe they have changed the contracts so that they can EXTRACT extra money out of pts.. especially those on Medicare Part D… most who are trying to make ends meet on their social security check.
In reality on this particular medications, CVS/Caremark/Silver Scripts was actually charging me – the pt – more than the cost of the medication – they actually had a POSITIVE CASH FLOW when we had that particular Rx filled, and we no longer had to screw around with a PRIOR AUTHORIZATION BS… every year.. when Barb had taken this chronic medication for over a DECADE.
To me, the “savings” from the Medicare Part D program is more “smoke and mirrors” than any real savings to Medicare pts.
When I must tell a patient that she or he has cancer, that diagnosis comes with the explicit promise that I will provide timely treatment, including medicines aimed at curing cancer or extending life as long as possible.
But an insidious interloper now often comes between me and my patients. I’m talking about pharmacy benefit managers (PBMs), the middlemen that have introduced a bureaucratic and nightmarish system of delays and denials into filling prescriptions.
I’m not alone.
An oncologist in Florida determined that her patient with metastatic kidney cancer needed to start taking a standard, first-line oral medication. But the patient’s pharmacy benefit manager decided it knew better and refused to authorize the medication unless a surgeon first performed surgery to remove a tumor on the patient’s kidney — despite the fact that the patient’s surgeon had already determined that the procedure was too risky and the patient wasn’t a candidate for surgery, something the surgeon had previously told the PBM.
For three months, the patient’s oncologist and surgeon appealed the pharmacy benefit manager’s denial so the patient could receive the treatment he desperately needed. Although the PBM ultimately relented, the patient will never get those three months back. For anyone battling cancer, delaying treatment and allowing the disease to progress by even a week can mean the difference between life and death.
There’s the story of a young mother in Tennessee who was beating the odds against stage 4 pancreatic cancer but was left with a dangerously suppressed immune system. She was forced to delay critical treatment because the medicine she needed was on backorder at her pharmacy benefit manager’s mail-order pharmacy and the company wouldn’t pay for her to get it from her doctor’s office.
Working with cancer care providers across the country, the Community Oncology Alliance has compiled hundreds of these horror stories. They demonstrate time and again how pharmacy benefit managers come between patients and their doctors, with little regard for the pain and suffering they inflict.
Pharmacy benefit managers were supposed to help bring down the cost of drugs by negotiating with competing drug companies and by “encouraging consumers to use the most cost-effective drugs.” But they have done the opposite, fueling higher drug prices through manufacturer rebates and by extorting fees from pharmacy providers.
Those rebates and fees were the focus of a Senate Finance Committee hearing featuring top executives of five pharmacy benefit managers last month. The chair of the committee, Iowa Republican Chuck Grassley, noted that “the current system is so opaque that it’s easy to see why there are many questions about PBMs’ motives and practices.”
For health care professionals on the front lines of delivering timely care to people with cancer, there is no debate about the need for transparency: Pharmacy benefit managers are a roadblock to potentially lifesaving cancer care. For many of our patients, the groundbreaking cancer drugs they see in headlines are often out of reach because of PBM practices that restrict or delay access. While they won’t admit it, there is no doubt that every dollar a pharmacy benefit manager saves by stopping or redirecting a prescription means more upside for their profits.
The pharmacy benefit manager business model is built on a lucrative and shadowy network of drug manufacturer rebates and pharmacy fees squeezed from every level of the health care system. Congress is right to look into these rebates and fees to better understand exactly what roles pharmacy benefit managers play in the complex economics of drug prices.
A veneer of governmental indifference seems to be helping pharmacy benefit managers protect their egregious profits. But the system isn’t working for patients with cancer or the millions of other Americans who struggle to overcome red tape to get the medications they need.
Americans deserve better from our health care system and we should be able to count on our elected officials to support affordable, convenient, cutting-edge, patient-centered care. This includes access to the cancer therapies they need, when and where they need them.
The White House, members of Congress, policymakers, and the American public should ask themselves this important question: If your mom was facing breast cancer or your son had brain cancer, do you want a pharmacy benefit manager determining their care, or their doctor?
Jeff Vacirca, M.D., is CEO of New York Cancer and Blood Specialists and the immediate past president of the Community Oncology Alliance. The author reports being medical director of ION Solutions and on the board of directors of OneOncology, Odonate, and Spectrum Pharmaceuticals.
In a huge victory for patients and pharmacists, Georgia governor Brian Kemp signed two PBM anti-steering bills into law yesterday.HB 233 is a bill that prohibits pharmacies from profiting off of prescriptions “steered” from their PBM and insurance affiliates, and HB 323 restricts PBM and insurer patient “steering,” strengthens anti-mandatory mail order, adds additional audit protections, prohibits PBMs from knowingly misleading patients, and restricts mining of patient data. These bills are the first in the nation of their kind to become law. Congratulations to the Georgia Pharmacy Association and all the Georgia pharmacists who worked hard to get these bills passed.
A 69-year-old woman was arrested at a Disney World checkpoint when an Orange County Deputy found CBD oil in her purse. She then spent 12 hours behind bars before being released on a $2,000 bond.
Hester Jordan Burkhalter, a great-grandmother from North Carolina, began using CBD oil for her arthritis after her doctor recommended it, Fox 35 in Orlando reported. She even had a note from the medical professional in her purse at the time of arrest, but it didn’t matter.
Burkhalter told Fox 35 that she had been planning on the trip for two years. “I have really bad arthritis in my legs, in my arms and in my shoulder,” she said. “I use (CBD oil) for the pain because it helps.” When she was stopped by security outside of the Magic Kingdom, however, she was arrested. “I’ve never had one speeding ticket in my life.”
Despite the fact that it’s sold on store shelves across the state, CBD oil is still technically illegal in the state of Florida (unless the user has a prescription). This has created a confusing situation in the Sunshine State.
Jennifer Synnamon, a Florida attorney, told Fox 35, “a little drop of oil, with the CBD, is a felony. Meanwhile, you can have up to 19.9 grams of leaf-marijuana, and it’s a first-degree misdemeanor.”
While the Orange County Sheriff’s Office told Fox 35 that their deputy was just following the law, the charges against Burkhalter eventually dropped.
When Lauren Lollini went to the hospital for kidney surgery in 2009, she was shocked when she left with hepatitis C and a liver infection.
“My life dramatically changed because now I am a 40-year-old woman with a 1-year-old daughter who is so fatigued I can’t work,” Lollini said.
Hospital technician Kristen Parker had infected Lollini and at least 18 others by stealing their pain medication and then leaving contaminated syringes for reuse. She’s now serving 30 years in jail.
“She was taking them off surgical trays, using them for herself, her own use, and then filling them with saline and putting them back on trays,” Lollini said. “I really was angry at the broken system. The hospital that hired her — unbeknownst to them that she had been let go from other jobs.”
A new report that will be released Tuesday by data firm Protenus finds that this so-called “opioid diversion” is a growing problem. In 2018, more than 47 million doses of legally prescribed opioids were stolen, an increase of 126 percent from the year before.
Protenus found 34 percent of these incidents happened at hospitals or medical centers, followed by private practices, long-term care facilities and pharmacies. Only 77 percent of the cases identified a particular drug, but the most common was Oxycodone, followed by hydrocodone and fentanyl.
Sixty-seven percent of the time, doctors and nurses are responsible. Dr. Stephen Loyd of Tennessee was one of them.
“What I didn’t realize was how quickly it would escalate. Going from that half of a five milligram Lortab, to within three years about 500 milligrams of Oxycontin a day. That’s about 100 Vicodin,” he said.
For three and a half years, he siphoned drugs away from his patients.
“There was no requirements on what happened to those pills. They could go down the toilet or they could go in my pocket,” Loyd said.
He warns that people who work in the health care industry are at high risk of abuse.
“They’ve got high stress jobs. A lot of them, like myself, have workaholism. And not only that, you have access,” Loyd said.
He’s now been clean for 15 years and was the director of Tennessee’s Mental Health and Substance Abuse Services division before running a rehab facility in Murfreesboro, Tennessee. Loyd implores addicted health care workers to admit they need help, which he knows was the hardest part for him until he was confronted by his own father.
After confessing to his dad fears of losing his house, car and career should he come clean, his father responded, “None of those things are gonna do you any good if you’re dead.”
Kira Caban of Protenus said the firm’s findings are likely a “tip of the iceburg” considering only a fraction of opioid diversions are uncovered because an addict admits to the behavior or a patient gets sick. The Department of Justice established an Opioid Fraud and Abuse Detection Unit to combat this issue, but it’s operational in less than a third of the country.
Do you or does someone you know have a pain pill prescription? Did naloxone come with the prescription?
More Ohioans can expect to discuss that option as a result of a new rule for doctors.
Doctors who regularly prescribe pain patients high doses of opioids are now required to talk to them about opioid safety, including the use of naloxone.
The State Medical Board of Ohio made the rule that went into effect late in December. It’s for patients receiving new, high-dose prescriptions for pain lasting more than six weeks.
“It is meant to safely manage pain,” said Tess Pollock, spokeswoman for the medical board. “We are not taking opioids away from patients who need them.”
Pollock said that’s something the medical board has been careful about during the opioid epidemic, which has been blamed in part on the overprescription of pain pills. The state continues to try to educate the public about the dangers of opioid medications, and the new rule is one way to prevent accidental overdose deaths, she said.
Naloxone is a non-narcotic that blocks the effects of opioids, restoring breathing in overdosing patients. Higher doses of pain pills, or even an extra pill taken by mistake, can induce overdose.
A recent survey shows that most Ohio pain-pills patients (81%) know if their prescribed medication is an opioid. Most (82%) have heard of naloxone. And most (70%) think it’s a good idea to have it around for safety.
But among those surveyed, few had heard any of that from their physicians.
“We have strong majorities having heard of naloxone, but a small fraction had heard from their own providers,” said Doug Usher, a partner of the research group, Forbes-Tate Partners of Washington, D.C.
The survey wasn’t only for people who get high-dose pain-pill prescriptions, so respondents didn’t necessarily fit the profile of patients who fall under the state’s rule. The minimum strength for the rule is an 80 morphine equivalent dose.
Forbes-Tate surveyed 511 Ohioans in February who’d either been prescribed pain medication or had a family member prescribed it. The market research was commissioned by Adapt Pharma, the maker of Narcan, the brand for naloxone.
Thom Duddy, spokesman for Adapt Pharma, praised Ohio for creating the rule for doctors, noting, “There’s a significant percentage of patients out there that are at risk every day.”
He said Adapt Pharma’s concern isn’t just the prescription of Narcan. “I don’t care if they prescribe syringes and vials of naloxone instead of Narcan,” Duddy said.
The company has committed to the opioid-overdose fight, he said. In 2017, Adapt Pharma provided 25,000 free Narcan kits to Hamilton County alone as part of the region’s initiative to expand access to try to cut overdose deaths.
These days, chronic pain patients often are prescribed opioids at lower doses than that, said Dr. Harsh Sachdeva, who practices at UC Health West Chester and is the director of the pain fellowship program at UC College of Medicine.
“In our chronic pain practice, 70 percent of our patients are under that dose,” Sachdeva said. Patients get additional pain help, including spinal implants and psychological intervention.
Regardless, Sachdeva said his patients are being prescribed naloxone as a safety measure to prevent unintentional overdose.
Not all of them want it, he said.
“I hear it all the time. ‘Why are you giving it to me?’ ” Sachdeva said.
But Ohioans and others nationally might have to get used to the idea of having naloxone awaiting them at a pharmacy along with their pain pills.
The practice of prescribing the two together probably will become routine, medical professionals say.
Young doctors are being taught about the state rule, said Dr. Michael Binder, assistant professor of clinical medicine at UC College of Medicine.
But that’s not all:
“We’re teaching them to have a discussion with all patients about the risks and benefits of their opioid prescriptions,” Binder said. “That’s standard now.”
I have a specific example of how these PBM’s … in our case … Silver Scripts/Caremark which is part of CVS Health. Barb has a prescription that she has taken for 10+ yrs
