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https://www.advisory.com/daily-briefing/2018/09/21/drug-prices
Amid an industry-wide debate on how to stem drug price increases, CVS launched a new program to allow self-funded insurers to deny coverage for certain treatments deemed too expensive—a move that is sparking intense industry debate, Vox reports.
Infographic: 5 ways to control the flow of drug expenditures
Under the program, CVS allows self-funded insurers—such as large employers—to exclude coverage for prescription drugs if the list price is above $100,000 for every quality-adjusted year of life gained, according to the Institute for Clinical and Economic Review’s (ICER) quality-adjusted life-year (QALY) metric.
However, the new coverage denial policy would not apply to any drug FDA designates as a “breakthrough” therapy, Vox reports.
The program is intended to give insurers a tool to reduce drug spending, according to Vox. CVS in an August report said the program aims to “put pressure on manufacturers to reduce launch prices to a reasonable level.”
In a Health Affairs blog post published Monday, Troyen Brennan and Surya Singh of CVS wrote, “Until now, PBMs such as CVS Health have had no ability to impact the initial launch price of a drug, which is set solely by the manufacturer, seemingly without regard to the inherent value of the medication or what the payer or patient can afford.”
However, CVS’ program is drawing criticism from industry stakeholders. Robert DuBois of the National Pharmaceutical Council in a dueling Health Affairs blog post published Monday criticized the program’s use of a single cost-effectiveness metric to assess the value of a medication. “To fully assess the value of a treatment, stakeholders must account for other considerations important to patients,” such as whether the drug is designed to treat a previously untreatable illness, DuBois wrote.
He also took aim at CVS’ $100,000 threshold, arguing that ICER’s value framework does not consist of a single metric for determining which treatments are cost-effective, but has a variable threshold (sometimes $100,000, other times $150,000). He argued that the single $100,000 threshold does not take into account the full economic value of a treatment, such as increased productivity or reductions in caregiver burdens.
Dubois added that the program’s exclusion of specific drugs based on QALY fails to account for the varying ways patients react to medications. As a result, Dubois said a drug’s exclusion from coverage would not reflect the drug’s full value to all patients.
Walid Gellad, an expert on prescription drug policy at the University of Pittsburgh, called the debate between CVS and industry a “good” one, because “there really isn’t a right answer.”
Gellad explained that rising drug list prices has left health system stakeholders with few options to restrain costs and that similar programs are likely to appear in the future. Already, Vox reports Veterans Affairs has begun using ICER’s quality assessments to decide whether to cover specific drugs. Gellad said, “Something like this is the inevitable future. Nothing else is talking about launch prices. Some version of this is where everybody is heading.”
However, Gellad said there are definitely flaws with CVS’ program, namely the use of a single metric to determine the value of a drug. “The idea that we base something solely on a cut point determined by one cost effectiveness analysis from ICER is a big step to take. It’s like a giant step forward when you don’t really know how to walk yet,” Gellad said (Scott, Vox, 9/17; CVS report, August 2018).
Prescription drug expenditures are the fastest growing component of health care spending. And while reducing unwarranted prescribing variation is the single biggest improvement opportunity, there are several other near-term chances to reduce spending and grow revenues.
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Utilizing the palliative care “loophole” in chronic pain managementThe DOJ is successfully escalating angst among general practitioners, who are already reluctant to prescribe narcotics above guidelines, (that were established by the CDC), out of fear of being targeted as outliers by the DEA. In turn, many patients with intractable pain are forced to, “make due”, with what pain medication they are prescribed, and tension runs high between appointments as their doctors push for even further tapering.
The U.S. Drug Enforcement Administration has arrested 28 people and revoked the registrations of over a hundred others in a nationwide crackdown that targeted prescribers and pharmacies that dispense “disproportionally large amounts” of opioid medication.
For 45 days in February and March, a special team of DEA investigators searched a database of 80 million prescriptions, looking for suspicious orders and possible drug thefts.
The so-called “surge” resulted in 28 arrests, 54 search warrants, and 283 administrative actions against doctors and pharmacists. The DEA registrations of 147 people were also revoked — meaning they can no longer prescribe, dispense or distribute controlled substances such as opioids.
The DEA said 4 medical doctors and 4 medical assistants were arrested, along with 20 people described as “non-registrant co-conspirators.” The arrests were reported by the agency’s offices in San Diego, Denver, Atlanta, Miami and Philadelphia.
In an interview with AARP, Sessions defended the use of data mining to uncover health care fraud.“Some of the more blatant problems were highlighted in our Medicare fraud take down recently where we had a
but instead were furthering an addiction being paid for by the federal taxpayers. This is a really bad thing,” Sessions said.“It’s a little bit like these shysters who use direct mail and other ways to defraud people. They will keep doing it until they’re stopped. In other words, if we don’t stop them, they will keep finding more victims and seducing them.”
As a growing trend of doctors across America voluntarily leave pain management, their patients are left without medical care. From there, the sick and disabled get bounced back to primary care. General practitioners, no longer in the business of treating pain, can only offer referrals but rarely communicate or follow up with their colleagues to facilitate a comparable continuity of care. These limitations have been further aggravated, through an effective surreptitious recruitment campaign organized by Dr. Andrew Kolodny, Co-Director of Opioid Policy Research at the Heller School for Social Policy and Management, christened PROP (Physicians for Responsible Opioid Prescribing). Armed with government propaganda, Prop docs function as the CDC mouthpiece and have infiltrated teaching universities, medical schools, CME courses,and large HMOs. There they double down and intentionally disseminate biased misinformation, present flimsy evidence as a matter of fact that, more often than not, aggregates chronic pain and addiction. Is there any way around this patient-doctor dilemma?
In an interview with AARP, Sessions defended the use of data mining to uncover health care fraud. “Some of the more blatant problems were highlighted in our Medicare fraud takedown recently, where we had a sizable number of physicians who were overprescribing opioid pain pills, which were not helping people get well, but, instead, were furthering an addiction, [all] being paid for by the federal taxpayers. This is a really bad thing,” Sessions said. “It’s a little bit like these shysters who use direct mail and other ways to defraud people. They will keep doing it until they’re stopped. In other words, if we don’t stop them, they will keep finding more victims and [keep] seducing them.”
As a growing trend of doctors across America voluntarily leave pain management, their patients are left without medical care.
From there, the sick and disabled get bounced back to primary care. General practitioners, no longer in the business of treating pain, can only offer referrals, but, they rarely communicate with, or follow up with, their colleagues to facilitate a comparable continuity of care. These limitations have been further aggravated through an effective, surreptitious
recruitment campaign organized by Dr. Andrew Kolodny, Co-Director of Opioid Policy Research at the Heller School for Social Policy and Management, christened PROP (Physicians for Responsible Opioid Prescribing). Armed with government propaganda, Prop docs function as the CDC mouthpiece, and have infiltrated teaching universities, medical schools, CME courses, and large HMOs. There, they double down and intentionally disseminate biased misinformation, present flimsy evidence as a matter of fact that, more often than not, aggregates chronic pain and addiction.
Is there any way around this patient-doctor dilemma?
The answer might be as simple as a physician order for palliative care — a treatment option already covered by CMS and most private insurance. You can have it at any age and any stage of an illness, but, early on in your illness is recommended.
Palliative care, (pronounced pal-lee-uh-tiv), is specialized medical care for people with serious illnesses. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a specially-trained team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age, and at any stage in a serious illness, and it can be provided along with curative treatment¹
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This week, the Senate passed a major bipartisan bill that addresses the opioid epidemic, one U.S. Senator Maria Catwell says will help in Washington state.
Just two years ago, 700 people in our state died of opioid overdoses, mostly in king, Snohomish and Pierce counties.
“This notion that we are going to arrest out way out of this problem that a pair of handcuffs and a trip to jail that will somehow solve this epidemic is nonsense, “said Snohomish County Sheriff Ty Trenary.
There are four parts of the bill: prevention, expanded treatment coverage, funding for drug courts and holding drug manufacturers accountable.
On Monday, she talked about the problem of doctors over-prescribing opioids and used the example of an Everett doctor who wrote thousands of opioid prescriptions over nine years.
KOMO News learned he’s now retired, but he has a paper trail with the Washington Medical Association, whose Deputy Director said the doctor was sanctioned last year for not meeting the standard of care when prescribing opioids to some chronic pain patients.
“We gotta stop it, otherwise we are going to keep increasing the opportunity for more and more people,” Cantwell said in Seattle at a news conference with local law enforcement, including Attorney General Bob Ferguson.
Cantwell’s ‘more and more people’ refers to more opioids, more addictions and more deadly consequences.
This is what she told lawmakers from the Senate Floor Monday, “In one example a physician from Washington wrote more than 10,000 prescriptions of opioids. This was 26 times higher than the average prescriber in Everett, Washington.”
We found that doctor, Dr. Donald Dillinger.
We wanted to ask him about those 10,000 opioid scripts, but no answer at his home. His Everett medical office closed and his voicemail said he retired.
The Attorney General’s office knows about him, too.
We discovered he’s was named in a lawsuit filed by the Washington Attorney General’s office in January for writing those 10,000 opioid prescriptions from 2007 to 2016.
Cantwell said spikes in drug distribution should be monitored and reported by drug manufacturers. She hopes proposed legislation that ups fines from $10,000 to $100,000 and in some cases up to a half a million dollars for violators will pass muster with other lawmakers.
“However, the drug manufacturer failed to report this suspicious activity,” said Cantwell.
Dr. Dillinger didn’t return our call, but we learned he was disciplined by the state in 2017 for ‘not meeting the standard of care for chronic pain patients’ said Micah Matthews, Deputy Director for the Washington Medical Association.
Public documents show the state restricted his license and put him on a compliance plan.
We learned today, the commission reopened its investigation after learning of the AG’s lawsuit.
“When the lawsuit was filed it became clear we didn’t have access to all the relevant records,” said Matthews.
The Commission is reviewing those additional records now.
“That’s disgusting to me honestly,” said Kelly an assistant occupational therapist, when she learned that Dr. Dillinger wrote thousands of prescriptions for opioids.
Kelly who is not connected to the case or the doctor said she encounters countless patients addicted and desperate for pain meds all the time.
“You see it all the time, they shop doctors and if they can’t get it from doctors they get it from the streets,” Kelly who didn’t want to reveal her last name.
Like the senator, she thinks the buck stops with manufactures and overprescribing doctors.
“They don’t need to prescribe so much meds because a patient will think they need to take all that,” said Kelly.
WMC’s Deputy Director said Dillinger disagreed with the charges and initial findings and took his case all the way to a formal hearing.
He said the commission determined the doctor violated the standard of care and assigned him two compliance officers.
It’s their job to make sure Practioners comply and are rehabilitated to good practice.
In October, Matthews said Dillinger informally surrendered his license to the WMC.
Matthews said since there was no mechanism in place to officially receive his medical license at the time, the state is currently negotiating the formal surrender of his license.
Matthews said reopening the investigation to look at records connected to the AG’s case may end up a moot point if they reach agreement on Dillinger’s license surrender.
In those cases it limits the amount of opioids that can be dispensed at one time and requires monitoring and education requirements for providers.
Those new rules take effect in January of 2019.
Imagine this… the doctor wrote 10,000 prescriptions over 10 years.. that is NINETEEN Rx PER WEEK… or about FOUR RXS PER DAY… and the bureaucrats determined that he did not meet the standard of care for chronic pain patients
This TV station is really having to scrape the bottom of the barrel that the only quote that they could get from someone in health care that would tell them what they wanted to hear was:
“That’s disgusting to me honestly,” said Kelly an assistant occupational therapist, when she learned that Dr. Dillinger wrote thousands of prescriptions for opioids.
Kelly who is not connected to the case or the doctor said she encounters countless patients addicted and desperate for pain meds all the time.
“You see it all the time, they shop doctors and if they can’t get it from doctors they get it from the streets,” Kelly who didn’t want to reveal her last name.
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Dear Mr. Ariens:
Thank you for writing to me regarding pain management and access to prescription pain medication. I have heard from many Floridians about their difficulties obtaining prescribed pain medication, and I appreciate your bringing this issue to my attention.
I support efforts by the State to rein in prescription drug abuse and prevent drug overdose, but I also want to make sure people who need their prescribed medications for chronic pain management have access to the treatment they need.
On March 8, I became a cosponsor of S. 2260, the Opioids and STOP Pain Initiative Act, to allocate $5 billion for a new non-addictive pain management initiative at the National Institutes of Health. The initiative would expand research on our understanding of pain and non-addictive treatments for chronic pain, including new non-addictive drugs, non-pharmacological treatments, and effective models of health care delivery for pain management. The STOP Pain Initiative Act would also implement a strategy to create national registries and datasets for chronic pain conditions and to use precision medicine to prevent and treat pain.
I am committed to finding a balance between the need for responsible drug oversight and the rights of patients and healthcare providers. The Comprehensive Addiction and Recovery Act (P.L. 114-198), which I cosponsored and was signed into law on July 22, 2016, authorizes funding for drug abuse education and prevention programs and creates best practices for prescribing pain medication. This law and other efforts can reduce the prevalence of opioid addiction, while protecting access to medication for legitimate chronic pain patients.
I will keep your views in mind should the Senate consider additional legislation on this issue. If you have any other concerns, please do not hesitate to reach out to me again.
Sincerely,
Bill Nelson
Bill Nelson believe that chronic pain pts should WAIT until some entity discovers a NON-ADDICTIVE MED for pain.. IF ONE EXISTS… and it will only take 10-15-20 yrs for such a drug – if discovered – would take to get it thru clinical trials and available to be prescribed for chronic pain pts…
ISN’T THAT ENCOURAGING ?
Nelson and 98 other Senators voted IN FAVOR OF THIS BILL… only a Republican Senator from UTAH for NO.
Nelson and 32 other Senators are up for RE-ELECTION in NOV.. and it is reported that they are anticipating 50 million dollars on his re-election campaign. Remember that Nelson was one of most/all of the Democratic Senators that VOTED NO on the Medicare Part D program that is now providing medication to Medicare pts .. which there was no coverage for… for the first 40 yrs of Medicare
Nelson was also one of the Democratic Senators that voted against the recent TAX CUT for individuals.. which was suppose to put abt $1000 in middle American’s pocket and Rep Pelosi(D) referred to $1000 as “CRUMBS” and if the Democrats take back control of Congress have said that they are going to raise your taxes and take that $1000 back.. and who knows if they will stop at just that $1000.
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http://www.wdrb.com/story/39115785/lawsuit-blames-mans-suicide-on-st-matthews-pain-clinic
LOUISVILLE, Ky. (WDRB) — The family of a man who committed suicide last year said he did so because a doctor at Commonwealth Pain and Spine wouldn’t sign off on a pain medication prescription that the man needed.
Brent Sloane texted his wife “they denied script im done love you” (sic) on Sept. 18, 2017. Thirty minutes later, he killed himself. According to the lawsuit filed against Commonwealth Pain and Spine in Jefferson Circuit Court on Tuesday morning, the text and suicide could have been prevented.
The suit say Slone was involved in a serious car wreck in 2011 that left him with significant injuries. After the procedure, Slone entered an inpatient recovery center in San Diego, California. While there, he was prescribed oxycodone and oxycontin.
According to the suit, while on a visit to Louisville, Slone went to the emergency room at Baptist Health for a dislocated hip and ulcer. He was prescribed a small amount of pain medication as he had run out of the prescription from the San Diego clinic and was advised to follow up with Commonwealth Pain and Spine. According to the suit, after he was discharged, he called Commonwealth Pain and Spine and requested a “bridge prescription.”
The suit says that notes from the clinic indicated that Dr. Stephen Young said he “needed to see the records from this facility in California.”
Later that day, the suit says Slone faxed the documentation to Commonwealth Pain and Spine. However, Young still refused to fill the prescription, because, according to call log notes, the documentation was from July, and there had been no communication since that time. Slone was advised that he would need to wait for six days for his appointment.
Slone killed himself a few hours later, the suit says.
“The intention of the lawsuit is bring light to that fact that people who experience pain should not be disregarded and tossed aside,” said Hans Poppe, an attorney for the family of Slone.
A lawsuit presents only one side of the arguments in the case. A message sent to an attorney for the clinic was not returned.
The suit claims Slone killed himself because he was not able to deal with the pain from various procedures and complications from the wreck in 2011.
“This is a problem that will only get worse,” Poppe said. “Mismanagement of pain medication and often leads to suicide or an addiction to heroin.“
Last summer, Kentucky lawmakers tightened restrictions on prescribing pain medication to patients. The change was hotly debated by opponents who said the changes would make it too difficult for people truly in pain to receives necessary medications.
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