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Is this a good example of why our judicial system should not be in charge of dealing with people and addictions? The recommendation to this person is that he should get off his medication and use ABSTINENCE to maintain his sobriety. Does this suggest that those within/around our judicial system consider addictions a CHOICE?

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Medicare Advantage woes pose growing threat to hospitals: S&P

https://www.beckershospitalreview.com/finance/medicare-advantage-woes-pose-growing-threat-to-hospitals.html

As Medicare Advantage continues to grow and health insurers prioritize their margins in the segment, hospitals are the most vulnerable healthcare provider to rising administrative and financial MA burdens, according to a new report from S&P Global.

The Aug. 15 report shared with Becker’s highlights the major growth Medicare Advantage has seen over the last several years, with 32.8 million people, or 54% of the eligible Medicare population, now enrolled in an MA plan.

“This growth poses challenges to healthcare service providers’ credit quality, given growing risks to reimbursement from MA plans relative to traditional Medicare, as well as the payment risk and higher complexity around prior authorization requirements,” S&P’s analysts wrote. “We also see future risks to providers if at some point CMS addresses the MA program’s higher-than-expected spending.”

As MA enrollment has grown, so too have the financial headwinds facing major carriers — government scrutiny is rising, CMS regulations and payments are tightening, and the cost of care is rising.

In response, Aetna, Humana and Centene are among the insurers that have said they will exit some markets in 2025 — and potentially reduce benefit offerings — to accommodate the changing reimbursement environment and rising costs. Notably, UnitedHealthcare and Elevance Health have said they are prepared to weather the changing landscape and priced their 2025 MA plans to reflect that.

“However, if already elevated utilization rates remain high for an extended period we would expect payors to further squeeze payments to providers,” S&P’s analysts wrote. “Overall, we expect these challenges coupled with further expansion of MA as a percentage of total Medicare beneficiaries will continue to pressure margins on the Medicare portion of the provider payor mix.”

“Thus, we expect insurers to prioritize margin over membership, and we expect large insurers will use their scale and market clout to limit provider rate increases over what will prove to be a challenging contract negotiation season.”

In 2023, Becker’s began reporting on hospitals and health systems nationwide that dropped some or all of their Medicare Advantage contracts in response to administrative and financial challenges. In 2024, at least 17 systems have ended an MA contract with an insurer.

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Heat spells trouble for mail-order medications

https://www.beckershospitalreview.com/pharmacy/heat-spells-trouble-for-mail-order-medications.html

Mail-order pharmacies run well-coordinated supply chain operations to ensure medications are safely delivered to patients’ doorsteps, but extreme temperatures are complicating the process, The New York Times reported Aug. 13.

Pharmacists and physicians told the Times that high temperatures inside delivery trucks could cause certain medications such as insulin or epinephrine injectors to overheat, degrade and become less effective.

Delivery drivers have reported temperatures as high as 150 degrees Farenheit inside their trucks, which far exceeds national drug handling standards of 68 to 77 degrees. A 2023 study published in the Journal of the American Pharmacists Association also found that simulated medication shipments spent 68.3% of transit time outside acceptable temperature ranges across all shipment methods, carriers and seasons. In addition, FDA regulations do not apply to medications being transported to patients, leaving oversight to state authorities. 

The Times interviewed more than a dozen patients who said they believed their medications were damaged by heat and humidity in transit. In some cases, patients reported serious health issues after taking the drugs, according to the report. 

Mail-order pharmacies said they use special precautions to protect the integrity of temperature-sensitive drugs, including weather-resistant packaging. Bryan Rabakon, senior vice president of supply chain and engineering for OptumRx, told the Times it monitors the duration of shipments and automatically sends a new package if transit times exceed a certain threshold. The company discontinued use of temperature-sensitive tags due to a high rate of false positives, he said. Cigna, which owns Express Scripts, did not respond to the Times’ request for comment. 

Read the full article here.

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Collectively we are in the process of 10,000+ pharmacies have or will be closing.  Many of the major mail-order pharmacies are owned by the same major insurance/pbm companies, and they will be pushing and creating financial incentives for people to use them currently, they are pushing back on state pharmacy boards that are trying to create requirements that mail order prescriptions be properly shipped and protecting against ambient temperatures that can/may harm medications in shipment.  If/when all these pharmacies close their doors, one can just imagine all the long lines and wait times for pts to get their medications, as well as how far the pt is going to travel to get their Rxs filled.  Back in the day, most people patronized a particular pharmacy, the pharmacy was within 2 miles of their home or where they worked.

Study Shows Mail-Order Prescriptions May Be Often Exposed to Unsafe Temperatures

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Walgreens will close a significant number of US stores, shutting down many unprofitable locations

Rite Aid Bankruptcy Explained: Three Reasons Why Pharmacy Giant Failed

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Where VP picks stand on pharmaceutical costs

https://www.beckershospitalreview.com/pharmacy/where-vp-picks-stand-on-pharmaceutical-costs.html

JD Vance and Tim Walz, the Republican and Democratic candidates for vice president, respectively, have both voiced support for aspects of the Inflation Reduction Act, a landmark law that aims to lower prescription drug prices. 

Here are each candidate’s records on rising pharmaceutical costs, which are projected to increase 3.81% by summer 2025, according to Vizient. 

JD Vance

In a 2022 interview with AARP, the Ohio senator expressed support for giving Medicare the authority to negotiate prescription drug prices. That same year, President Joe Biden signed the Inflation Reduction Act, which grants CMS negotiation powers for a selective number of drugs with no generic or biosimilar competition. 

However, Mr. Vance has criticized the act’s allocation of at least $370 billion over a decade for incentives in wind, solar and other clean energy sources.

“It’s dumb, does nothing for the environment, and will make us all poorer,” he said in a 2022 post on X. 

Mr. Vance has also been vocal on addressing the opioid crisis. In 2016, he founded a charity to address the epidemic, though it shuttered within two years. 

Tim Walz

Two years before the Inflation Reduction Act passed — which he supported — the Minnesota governor signed the Minnesota Prescription Drug Price Transparency Act. The law requires drugmakers to report and provide reasons for significant price increases of prescription drugs to the state health department. 

In June, the state published its first list of 364 drugs from 76 manufacturers that are subject to this law.

Mr. Walz has also advocated for affordable insulin. In 2020, he signed the Alec Smith Insulin Affordability Act, which ensures eligible individuals in urgent need of the hormone can go to their pharmacy once in a 12-month period and receive a one-time, 30-day supply for a $35 copay. 

Since then, the nation’s largest insulin manufacturers have significantly lowered their prices to about $35 for a month’s supply.

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The ideal time for a pt to get their flu shot is the last 2 weeks of Sept thru the first 2 weeks of Oct. Getting your flu shot during this time frame will help assure that the pt’s “blood titer” is as high as possible during what should be the peak flu season. Pts getting their flu shot this early when peak flu season comes around and/or it is a little later than normal. The chain pharmacists may start recommending that the pt get a second flu shot to boost their flu blood titers, to help protect the pt during the peak of the flu season. Of course, getting a booster will take ~ 2 weeks for the pt’s blood titer to peak again, and the protection that the pt has may be sub-therapeutic for 1+ weeks.

Retailers begin to roll out flu, RSV shot appointments

https://drugstorenews.com/retailers-begin-roll-out-flu-rsv-shot-appointments

Walgreens, Rite Aid and Bartell Drugs in the Pacific Northwest are just a few of the retailers who have begun offering the vaccines.

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We had our independent pharmacy for 20 yrs, we were not in a rural area but a small city/county seat with ~ pop of 30,000.  One very memorial day – at least for me – I had a regular pt & wife come in. He wanted his blood pressure taken.  That was before “free-standing blood pressure units” where the pt takes their own blood pressure. It was before digital blood pressure cuffs. I took blood pressure with a BP cuff and a stethoscope.  As I listened to his heart rate it was very erratic and I asked him if his heart rate was always very erratic?  NOPE!. I suggested that he go over to the hospital/ED -<1 mile away. He claimed that he would go home first and then go to the hospital – I knew him very well, that he would not follow thru.  I called Barb out of her office and got her to take the fellow and his wife over to the hospital. He didn’t push back, he knew I was right. A couple of days later, his adult Daughter – also one of our pts – came in and thanked me for saving her Dad’s life. He had been admitted and put in the cardiac care unit and lived to be discharged and sent home. Beside the pharmacy we were a very large home medical equipment (HME) vendor. We normally had 200+ respiratory/oxygen pts – many were home-bound, enteral feeding pts (tube feeding), home IVs, etc, etc. We had a well-trained, experienced staff and I am sure that collectively, we had helped many pts and their QOL health issues. Many I was indirectly involved with. I wonder how these PBMs & mail order pharmacies are going to help pts with their QOL issues?

Local Pharmacies Save Lives, While PBMs Don’t

https://www.realclearmarkets.com/articles/2024/08/01/local_pharmacies_save_lives_while_pbms_dont_1048679.html

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Who put those requirements in place?  The LOWEST COST FOR HEALTHCARE WILL PROVIDE THE BEST PT OUTCOME?

Mark Cuban’s big warning for employers

https://www.beckerspayer.com/workforce/mark-cubans-big-warning-for-employers.html

Mark Cuban is issuing a big warning to self-insured employers: If your company receives pharmacy rebates through employee benefits, prepare for an eventual lawsuit.

“It’s not a question of if, it’s a question of when,” he wrote on X on July 22. “The inevitable class action suit will dwarf the tobacco settlements.”

Mr. Cuban’s comments come as large employers are beginning to face lawsuits from their workers over claims of mismanaging health and pharmaceutical benefits and violating their fiduciary duties under the Employee Retirement Income Security Act. 

ERISA requires self-funded employers acting as health plan fiduciaries to make an effort to find the lowest costs for healthcare services. In 2021, the Consolidated Appropriations Act amended ERISA to create new requirements for consultants and benefits brokers to disclose to employers any direct or indirect compensation they receive. Price transparency requirements enacted the same year also means that employers have gained more tools and are under more pressure to fulfill their obligations to employees.

“But unlike employers who hold a fiduciary responsibility, consultants and brokers do not hold a fiduciary relationship with employees, thus there is no obligation to prioritize the employer’s interest over their own,” researchers wrote in an AJMC study published July 19, and cited by Mr. Cuban.

“In light of recent legal action, employers may wish to better understand the financial incentives of their consultants and brokers when accepting their recommendations for rebate contracting strategies and pharmacy benefit design.”

In the most recent example, Wells Fargo was sued by employees in July for allegedly paying inflated prices to its contracted pharmacy benefits manager, Express Scripts. 

A February lawsuit against Johnson & Johnson accuses the company of paying inflated costs for generic prescription drugs designated as specialty medications to Express Scripts, thereby harming employees through higher costs, premiums, deductibles, copays and lower or limited wage growth. J&J’s employee health plan paid more than $10,000 for a 90-day prescription of a generic drug used to treat multiple sclerosis, which is available for as little as $40 without insurance at retail pharmacies, according to the suit.

“No prudent fiduciary would agree to make its plan and beneficiaries pay a price that is two-hundred-and-fifty times higher than the price available to any individual who just walks into a pharmacy and pays out-of-pocket,” the plaintiff’s attorneys wrote.

With employers increasingly feeling the pressure, some have sued their health plan and third-party administrators directly in an effort to access complete medical claims data. 

In June 2023, Kraft Heinz alleged Aetna used its role as third-party health plan administrator “to enrich itself to Kraft Heinz’s detriment” through undisclosed fees and processing medical and dental claims without human review. The food manufacturer voluntarily dismissed the lawsuit in December and moved it to private arbitration.

But employers can’t always point the finger at third-party administrators, Christin Deacon, an attorney and principal owner at VerSan Consulting, previously told Becker’s. For example, if an employer signed a bad contract that allowed egregious behavior, the TPA could turn around and ask why the employer didn’t act upon that. 

“I think that definitely plays into the fear factor of employers not being more aggressive,” Ms. Deacon said. “There’s plenty out there that are going to get on the bandwagon of being more aggressive with their carriers. Nobody wants to be the first, but everybody wants to be a fast follower.”

“I think the first step is get a handle on all of your existing contracts and relationships and ask for your claims data. Document everything you’re doing to try to be a good fiduciary to the plan,” Ms. Deacon said. “Get your contracts, read your contracts, get your data and put processes in place that are going to help you protect yourself again from that fiduciary liability.”

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PBMs Overpay Their Own Pharmacies to the Detriment of Insurers, Taxpayers, FTC Says

https://www.medpagetoday.com/pharmacy/pharmacy/111338

You’re busier from open to close, but making less than you did the last year, every year

Cash crunch pushes independents to the brink, data shows PBMs the cause

Pharmacy benefit managers (PBMs) often reimburse their own affiliated pharmacies at higher rates than they do independent pharmacies, to the disadvantage of insurers as well as taxpayers, the Federal Trade Commission (FTC) said.

“We see evidence PBMs pay their own pharmacies inflated prices,” said Suzie Jing of the FTC’s Office of Policy Planning, who presented interim results from the agency’s report on PBMs at a commission meeting Thursday. For example, she said, in the case of generic abiraterone (Zytiga) for prostate cancer, “it costs $229 to buy the drug, but the big three PBMs pay their affiliated pharmacies about $6,000 per month on average. That’s double the price paid to unaffiliated pharmacies … This means that the PBM is overpaying itself at the expense of — first, private insurance plans, which can lead to higher patient insurance costs; and second, at the expense of taxpayers who pay for Medicare.”

Jing noted that the top six PBMs manage 94% of pharmacy claims. In addition, “based on our review to date, we find that there’s often no negotiation for contract terms,” she said. “The PBMs’ internal memos reference ‘unilateral’ or ‘passive’ contracts, which are more like notifications — often sent via fax — outlining terms that take effect automatically, without the need for affirmative consent or signature. Reimbursement rates in these contracts can be unfavorable and potentially untenable, especially for local community pharmacies.”

The FTC also found examples in which the PBMs’ rebate contracts with drug manufacturers “are designed to limit access to affordable drugs and will exclude generic drugs from formularies … this is disturbing,” Jing said.

The report was quickly criticized by an industry representative. “Unfortunately, the interim report falls far short of being a definitive, fact-based assessment of the PBM industry,” Austin Ownbey, spokesman for the Pharmaceutical Care Management Association, a trade group for PBMs, said during the meeting’s public comment portion. “It’s devoid of empirics and built entirely around unsupported assertions. It also overlooks the volume discounts provided by the PBMs that demonstrate the value that they provide to America’s healthcare system by reducing prescription drug costs and increasing access to medications.”

On the other side of the issue, several independent pharmacy owners testified that PBMs’ business practices had hurt their business or even forced them to close. “My wife and I were owners of four pharmacies in central Ohio, [but we] closed all four locations in February of this year,” said Joe Craft. “The interim report insights are exactly in line with what I’ve witnessed over my 29 years as a pharmacist.”

“To put it simply, PBM abuses, of which there are many, put us out of business,” he continued. “We owned four stores, and we were having the same problem at each location — we weren’t making enough to cover our cost of operations because of low reimbursement. The PBMs dictated what we were paid and stole from us so we could not succeed no matter how busy we were.” In three of the closed locations, there were no other pharmacies in that same ZIP code, so “the PBMs have created pharmacy deserts where we closed,” he added.

Mallika Kopalle, who operates four independent pharmacies in Utica and Syracuse in New York State, said she also was having financial difficulties. “As we speak, [one large PBM] is taking $21,000 from our small pharmacy,” she said, adding that the PBM’s explanation was that the action was a result of something that happened in 2021. “This is on top of hundreds of thousands of DIR [direct and indirect remuneration] fees which were charged to us. They won’t give us an explanation and they won’t give us any further markdown … We need PBM reform sooner rather than later.”

One speaker told a darker story. “We lost our 22-year-old son to the tactics and greed of PBMs,” said William Schmidtknecht of Windsor, Wisconsin. “My son went into a pharmacy to fill a routine prescription that he would have paid less than $70 for in 2023; 10 days into 2024 he went in there to get his prescription at a pharmacy, and his price was changed to over $500.“

His son was unable to fill the prescription due to the high cost; “he got rushed to the ER on the 15th of January with cardiac arrest due to asthma and died 6 days later,” Schmidtknecht said. “My son’s death is just one of many out there … The reality is the greed, the tactics, the deception, is killing people in this country. You guys can fix that. We need your help.”

On the other side of the issue, several business owners said PBMs had allowed them to offer good health benefits to their employees. “PBMs helped me offer top-notch prescription drug coverage for my employees and kept us competitive in the job market,” said Coby Cullins, a former business owner in Missouri. “The report completely ignores Big Pharma’s use of anticompetitive [tactics that cost] taxpayers billions of dollars in savings. By only focusing on PBMs, the FTC is shifting the blame away from the big drug companies and on to the only market entity successfully lowering the price of prescription medications.”

“PBMs are instrumental in helping employers like me be able to offer prescription drug benefits,” said Alicia Cantrell of Houston. “They provide us with the flexibility and options we need in order to design the best benefits for our business so our employees and their families can stay healthy.” Like Cullins, Cantrell also criticized pharmaceutical companies, saying that they “undermine competition in the prescription drug marketplace by constantly engaging in anticompetitive practices so they can extend the monopolies on drugs … They have engaged in baseless claims to encourage policymakers to narrowly focus on PBMs instead of others in the prescription drug supply chain.”

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