http://www.sacbee.com/news/local/crime/article188636384.html

The brazen afternoon robbery of a Citrus Heights Rite Aid resulting in the death of an 87-year-old woman brought attention to a growing problem: the rising rate of pharmacy thefts.

In the northeast Sacramento County suburb alone, the number of pharmacy robberies is up to eight in 2017 from two in 2016.

Over the last two years, pharmacy robberies in California are up 163 percent, according to numbers complied by the federal Drug Enforcement Administration.

In 2015, the agency recorded 90 incidents. The number climbed to 154 in 2016. Through Nov. 17, some 237 had been reported to the DEA.

“To see that kind of spike, it is alarming,” said Special Agent Casey Reittig, a spokeswoman for the DEA. She declined to speculate why, but suggested drug users may have become more brazen in response to rule changes tightening access to opioids.

Robbers are after opioids and cough syrup ingredients, said Sgt. Shaun Hampton, spokesman for the Sacramento County Sheriff’s Department. While countywide statistics were not available Thursday, Hampton said he believes Sacramento County is experiencing an uptick.

The opioid epidemic has been well documented, with about 33,000 Americans dying in 2015 from an opioid overdose, according to the Centers for Disease Control and Prevention. The powerful pain-relieving drugs carry significant addiction risks.

Meanwhile, Hampton said large bottles containing promethazine with the opioid codeine – ingredients in prescription cough syrup – can go for as much as $400 on the street. Smaller bottles sell for $50 to $100.

The powerful cough suppressants have been abused for years. Mixed with alcohol, they are used to create an intoxicating mix commonly called “purple drank,” “sizzurp” or “lean.” Consumption of purple drank has been popularized in rap music for years.

The head of the California Pharmacists Association added that a move to increase public safety – restricting cough syrup access to reduce abuse of the drug – may also have inadvertently put more pharmacists at risk.

In 2011, the state Legislature added dextromethorphan to the list of over-the-counter drugs with an 18-and-over age requirement – moving them behind the counter. Advocates for Senate Bill 514, including an array of health and public safety organizations, said teens were stealing cough syrup from drug store shelves and taking doses 8 to 20 times the recommended amount to get high. Many teens thought the drug was less harmful because it involved an over-the-counter cough syrup instead of a prescription drug.

While the legislation stopped the rampant pickpocketing of cough syrup, “now we have active robberies,” Roth said. “It kind of cuts both ways.”

Roth said those robbing pharmacies take cough syrups containing promethazine or dextromethorphan, which is often referred to as DMX.

“My sense is that they are seeking any and all,” Roth said.

Roth said the association continues to support the cough syrup law as a way to reduce the abuse of such products. The association advises members to increase security measures to deter thefts. If robbed, Roth said, pharmacists are advised not to resist.

Rite Aid customer Marilyn Stribley died as a result of the injuries she suffered when she was knocked down Nov. 27 by a suspect running from the store on the 6600 block of Auburn Boulevard. Video of the fatal incident has been widely circulated in the media.

Citrus Heights police announced Friday they had arrested Kimani Randolph, 21, of Sacramento on suspicion of robbery and violating probation. He was located and arrested without incident Thursday in Las Vegas and is scheduled to be extradited to Sacramento next week. He was on probation for being a convicted felon in possession of a firearm.

Police are still trying to identify the two other suspects, previously described as black men between ages 18 and 20. Police said the men had jumped over the pharmacy counter and demanded prescription drugs. Store employees handed over the drugs.

Rite Aid Corp. has offered a $10,000 reward for information leading to the arrest and conviction of the robbers.

Hampton said there was no evidence to suggest a robbery of a Carmichael Rite Aid five days later was connected. He said agencies are sharing information.

Filed under: General Problems | 2 Comments »

https://slate.com/business/2017/12/the-arguments-for-and-against-the-cvs-aetna-merger.html

Big corporate mergers in the health care industry tend to work out poorly for customers. When hospitals combine, they raise prices. When insurers get together, premiums can leap. But when pharmacy giant CVS announced last week that it planned to buy Aetna, the nation’s third largest insurer, in a deal worth $69 billion, some experts were cautiously optimistic. “[T]here’s reason to believe that a combined CVS-Aetna might find ways to reduce costs—and represent an instance when consumers actually come out ahead after health care consolidation,” Austin Frakt, a professor at Boston University’s School of Public Health, wrote at the New York Times.

The optimism isn’t absurd. In theory, merging might help the companies nudge patients into more low-cost and effective care. It could also weed out some of the bad incentives that appear to be driving up prescription drug costs.

But there are also reasons to be wary of the deal, which could help CVS and Aetna unfairly elbow away their competition.

To understand why CVS would be interested in acquiring an insurer, there are a few important things to know. First, many industry watchers seem to be afraid that Amazon is planning to enter the prescription drug business, which would put unbelievable pressure on retail pharmacies. CVS may be girding itself for that future by expanding into other lines of business. Second,

CVS isn’t just a chronically understaffed purveyor of energy drinks, toothpaste, and Lipitor. It’s also a health care provider.

Along with its 9,700 drugstores, CVS runs 1,100 MinuteClinic locations, where patients can walk in without an appointment to deal with their basic health needs, like having a rash examined or getting a flu shot. Buying Aetna and combining it with this network would create a convenient, symbiotic relationship. For instance, Aetna could push its enrollees to use CVS’s inexpensive clinics, staffed with nurse practitioners and physician assistants, rather than visit a primary care doctor every time they come down with a fever. Of course, patients would probably stop by the pharmacy counter to fill their prescriptions, too.

The companies also argue that bringing together an insurer with a web of retail clinics will make it cheaper to treat chronic diseases, which are a major driver of health costs. Diabetes sufferers, for instance, could stop by CVS for check-ins to monitor their health and pick up their supplies. The pharmacy could keep tabs on their blood sugar remotely and send a helpful text when levels are off. This sort of pre-emptive care could prevent major complications from the condition, which would be good for the patient, and Aetna’s bottom line.

This is the sort of value-based care model—where providers make money by keeping patients healthy and expenses down, instead of charging for as many services as possible—that most experts think the U.S. medical system needs to shift toward if we ever want to control our health spending. The U.S. government, for its part, has been trying to nudge hospitals and physicians in this direction for years. And while there are questions about whether CVS can actually pull off its vision, it’s not necessarily an absurd idea to try. “This is certainly going to be difficult to do,” Craig Garthwaite, a professor at Northwestern University Kellogg School of Management who studies the health care industry, told me. “But the first step along that road is to create the economic incentives so that you make more money if you make people healthier.”

There’s another reason wonks are guardedly optimistic about the merger, and it has to do with drug prices. Since 2007, CVS has owned CVS Caremark, the country’s second largest pharmacy benefits manager, which counts Aetna as one of its most important clients. Employers and health insurers hire PBMs, as they’re called, to handle their prescription drug plans, and much of their work involves negotiating discounts from pharmaceutical-makers. But many observers have begun to think that these middle men, who are theoretically supposed to keep drug costs down, may actually be contributing to their rise by encouraging companies like Pfizer and Novartis to hike their list prices, then offer big rebates in order to win business.

A big part of the problem is that PBMs typically take a cut of each rebate for themselves, so they benefit when list prices go up. (If that makes the industry sound like a kickback scheme, well, you be the judge.) This might be less of a problem if there were lots of companies competing by offering to accept a smaller slice of the action in return for their services, but the industry has become incredibly concentrated. According to Bloomberg, about 70 percent of all prescriptions in the U.S. are handled by just three PBMs, including CVS Caremark.

Because their dealings are bound by confidentiality agreements, it’s not clear exactly how much of the country’s spiraling drug cost problem can be traced back to the PBMs. Their role may even be a bit overhyped, since the companies make a convenient scapegoat for pharma manufacturers looking to deflect blame for high prices. When Mylan come under fire for hiking the cost EpiPens last year, for instance, it was quick to blame the “broken system” created by companies like CVS Caremark.

Whether or not these companies are the villains they’re often painted as, though, there seems to be a growing consensus that insurers are better off cutting-out the middle man and managing their own PBMs. The theory is that instead of trying to maximize their own share of each rebate while driving up drug prices in the process, an in-house benefits manager will only be incentivized to keep costs low for the insurer they’re attached to. United Healthcare owns OptumRX, the number-three PBM, which it combined with Catamaran, then the industry’s number-four player, in a $12.8 billion deal. And in October, Anthem announced it would end its contract with industry leader ExpressScripts and start its own internal PBM with CVS’s help. By purchasing Aetna, CVS is continuing a trend that could rationalize the country’s drug distribution system, at least a bit.

So, that’s the upbeat story you can tell about this merger. There are also reasons to doubt it.

For starters, it’s not obvious that sending patients to their local MinuteClinic instead of their family doctor will save all that much money for customers or Aetna itself. America’s astronomical health spending isn’t driven by an excessive number of visits to primary care visits. It’s driven by hospitals, largely, and there’s not much about this merger that suggests it would help Aetna and CVS squeeze those costs. “They don’t have doctors. They don’t have hospitals. They don’t have outpatient centers,” Martin Gaynor, a professor of economics and health policy at Carnegie Mellon, told me. “They have outpatient pharmacies and they have MinuteClinics. What do you do with that?”

As for fixing our broken drug distribution system: United Healthgroup has owned a PBM business for a while now, and there’s no indication that it’s saved customers much if any money. That may be because, despite what the incentives look like on paper, it’s more profitable for the merged companies to keep making profits off of high drug prices and risk losing a few insurance enrollees than it is to try to iron out those costs, David Balto, an antitrust lawyer and former policy director at the Federal Trade Commission’s Bureau of Competition, told me. “Where we have seen insurers and PBMs merge, we’ve seen no efficiencies,” he said.

Finally, it’s possible that letting CVS and Aetna merge will give them new tools to unfairly undercut their competitors. The most obvious concern is that CVS will push Aetna customers to use their pharmacies instead of, say, Walgreens, or their mom-and-pop drugstore around the corner. “When CVS acquires Aetna, will it restrict where Aetna consumers get their drugs? You better believe they will,” Balto said. The National Community Pharmacists Association, which represents the owners of 22,000 pharmacies, including independent shops and regional chains, has voiced the same concern.

The merged companies could have some subtle but unfair advantages over other insurers, as well. CVS might offer Aetna a better deal on prescriptions than, say, United or Cigna, giving its corporate sibling a leg up. Some antitrust advocates, like Open Markets policy director Phillip Longman, are also concerned that Aetna could leverage the vast trove of patient data from CVS’s PBM business in ways that might be unfair to other carriers.* “In the health care business, if one player gets this trove of information, it’s a big competitive advantage,” he said.

Just like the potential benefits of the merger, a lot of these concerns are hypothetical at this point, and there are reasons to think they could be overblown. CVS might not want to alienate other insurers and customers by openly playing favorites with Aetna. Regulators could require CVS to set up a firewall to ensure Aetna doesn’t abuse Caremark’s data. As for independent pharmacies, they may be in trouble anyway if Amazon decides to finally jump into the business.

But the issues deserve careful attention. Unfortunately, we can’t necessarily count on the government to give them that. For several decades, the Justice Department has focused on policing horizontal mergers—where two companies in the same line of business, such as two insurers, combine. But CVS and Aetna would be what’s known as a vertical merger, where companies in two different stages of a supply chain join up. The DOJ has generally given those deals a free pass. It made an enormous exception recently, by suing to stop AT&T from acquiring Time Warner, but many believe that may have been political payback by the Trump administration against Time Warner–owned CNN and not precedent.

So, could the marriage of one of the country’s biggest pharmacies and biggest insurers be a happy one for consumers? Or will it just lead to a more concentrated health care industry without benefiting patients? It’s doubtful that the government is going to stop us from finding out.

Filed under: General Problems | 3 Comments »

Girl has blunt message for insurance company after brain surgery request denied

http://wgntv.com/2017/12/11/girl-has-blunt-message-for-aetna-after-her-brain-surgery-request-was-denied/

Cara Pressman sobbed in the big red chair in her living room. The 15-year-old tried to absorb the devastating news relayed by her parents: that their insurance company, Aetna, denied her for a minimally invasive brain surgery that could end the seizures that have haunted her since she was 9 years old.

“When my parents told me, I went kind of blank and started crying,” she said. “I cried for like an hour.”

Her friends had been lined up to visit her in the hospital for the surgery three days away, on Monday, October 23. Between tears, she texted them that the whole thing was off.

It was supposed to be a joyous weekend. Cara’s grandparents had come to town to celebrate their 90th birthdays, a jubilant party with more than 100 family and friends crowding her home. The party did go on — just with a lot more stress.

Cara had multiple complex partial seizures that weekend. When the seizures strike, her body gets cold and shakes, and she zones out for anywhere from 20 seconds to two minutes, typically still aware of her surroundings. Her seizures can be triggered by stress, by being happy, by exerting herself — almost anything. “It’s like having a nightmare but while you’re awake,” she said.

In the six weeks since the denial, Cara has had more than two dozen seizures affecting her everyday life. Her message to Aetna is blunt: “Considering they’re denying me getting surgery and stopping this thing that’s wrong with my brain, I would probably just say, ‘Screw you.’ ”

Aetna: We’re looking out for what’s best for patients

The Pressman family and, separately, Jennifer Rittereiser, a 44-year-old mom who has struggled with seizures since she was 10, approached CNN in recent weeks after they were both denied, by Aetna, for laser ablation surgery, a minimally invasive procedure in which a thin laser is used to heat and destroy lesions in the brain where the seizures are originating. Aetna is the third-largest health insurance provider in the country, providing medical coverage to 23.1 million people.

Neurologists consider laser ablation, which is performed through a small hole in the skull, to be safer and more precise than traditional brain surgery, where the top portion of the skull is removed in order for doctors to operate. The procedure is less daunting for the patient and parents who make decisions for their children: No one likes the idea of a skull opened and a chunk of brain removed.

In denying Cara her surgery, Aetna said it considers laser ablation surgery “experimental and investigational for the treatment of epilepsy because the effectiveness of this approach has not been established.”

“Clinical studies have not proven that this procedures effective for treatment of the member’s condition,” Aetna wrote in its rejection letter.

The insurance company did approve her for the more invasive and more expensive open brain surgery, called a temporal lobectomy, even though her medical team never sought approval for the procedure.

The laser surgery is approved by the Food and Drug Administration and is widely recognized within the epilepsy community as an effective treatment alternative to open brain surgery, especially when the location of seizure activity can be pinpointed to a specific part of the brain.

Dr. Jamie Van Gompel, a neurosurgeon at the Mayo Clinic, disputes Aetna’s assessment. He is not involved in Cara’s care nor Rittereiser’s treatment, but he said Aetna’s assessment is wrong.

“I would not call it experimental at all,” said Van Gompel, who is leading a clinical trial on the surgery at Mayo as part of a larger national study. “It’s definitely not an experimental procedure. There’ve been thousands of patients treated with it. It’s FDA-approved. There’s a lot of data out there to suggest it’s effective for epilepsy.”

Van Gompel said a temporal lobectomy carries a much higher risk of serious complications, including the possibility of death. “It’s a big jump to go to a big invasive procedure,” he said.

Recovery time after open brain surgery can range from six to 12 weeks. By contrast, a patient who undergoes laser ablation can be back to work or at school in less than two weeks. The pain from laser surgery is much less, and extreme headaches are fewer than with open brain surgery, Van Gompel said.

While laser ablation has not yet undergone large randomized controlled trials, Van Gompel said existing data shows it’s effective more than 50% of the time. He hopes the current clinical trial will show a success rate of 60% to 70% or better in epilepsy patients. Temporal lobectomies, he said, have a slightly better rate, of more than 70%.

Pressed by CNN for a better explanation on its denial, Aetna stood by its rejection for Cara and Rittereiser, saying it was in the best interest of the patients. But the language was softened slightly.

“Clinical effectiveness and our members’ safety are the primary criteria we use in determining whether a treatment or service is medically necessary,” Aetna said. “There is currently a limited amount of evidence-based, clinical studies related to laser ablation surgery. As noted by the Epilepsy Foundation, only studies with a very small number of participants have been used to report the effectiveness of this procedure. We consistently evaluate any new studies or additional evidence when developing our clinical policy bulletins, and will continue to do so for this procedure.”

Contacted for reaction, the Epilepsy Foundation strongly objected to Aetna’s remarks, saying the insurance company took its information out of context. Laser ablation surgery “has emerged as a new minimally invasive surgical option that is best suited for patients with symptomatic localization-related epilepsy,” said Dr. Jacqueline French, the chief science officer with the Epilepsy Foundation.

“This technology is much less invasive than the alternative, which involves removing a sizeable piece of brain, at a substantially higher monetary and personal cost,” French said. “This path should be available, if the treating epilepsy physician has recommended it, without delay or barriers.”

Phil Gattone, the president and CEO of the Epilepsy Foundation, said insurance denials and other barriers to treatment have become a common battle for thousands of Americans with seizure disorders.

Gattone knows first-hand the pain of what Cara’s parents are going through. His own son began having seizures when he was 4 and underwent brain surgery in the early 1990s. “It was extremely challenging for our family to make a decision to remove part of our child’s skull and brain for a surgery that we hoped would end the devastation of seizures that were stopping his development,” Gattone said. “We took this leap of faith and made the decision, and it worked out the best for him.”

But he added that he and his wife wished laser ablation surgery had been available back then. Laser ablation was approved by the FDA nine years ago. “I know that my wife and I would’ve found much more comfort if we had had (laser ablation) as an option,” he said.

Gattone said people with seizures, their caregivers and their doctors should not be “spending critical time in the midst of a health-care crisis, filing paperwork, making appeals or otherwise going through the motions of administrative paperwork” trying to get approval for a life-changing operation.

“The Epilepsy Foundation can understand no reason why an insurance company would place any barrier to delay a treatment that may save an individual’s life, promote the development of the young child’s brain or bring about seizure control,” Gattone said.

Mom who crashed with kid in car gets denied

Jennifer Rittereiser lost consciousness behind the wheel of her silver SUV while driving with her 7-year-old son, Robert, in April. Her SUV rammed into a car in front of her and struck it again before veering into oncoming traffic. Her vehicle careened down an embankment, flipped over and came to rest on its side amid a tangle of brush. She narrowly missed slamming into a guardrail and several trees.

Mom and son somehow managed to walk free unharmed.

“People were amazed,” she said. “They had a helicopter on the way, actually. I am extremely fortunate just from that sense.”

Rittereiser has battled seizures since she was 10 and has been able to function with an array of medications in the three decades since. For much of her life, she could tell when the seizures might come.

These weren’t like the seizures depicted in Hollywood movies; she wouldn’t fall to the ground and writhe. She would zone out for a spell. She could understand people and could still function but couldn’t speak back — or if she did, her words were garbled.

As an executive in the health care industry, Rittereiser has fallen asleep during meetings. When she senses a seizure coming, she rushes to the bathroom to hide until they go away. One time, she says she urinated on herself at her desk without realizing it.

Rittereiser had a crash in 2014 in which she rear-ended a car after she had a seizure. No one was hurt in that crash, but she stopped driving for more than a year. Her medications were tweaked, and her seizures were largely kept in check, until the crash this April.

She was soon evaluated by an array of doctors and recommended for laser ablation surgery. After 34 years of struggling with seizures, she thought her ordeal might finally come to an end. Surgery was set for June 16.

But in late May, Aetna denied the surgery. She fought Aetna’s decision through a lengthy appeals process. Aetna refused to budge.

“It’s just not right,” Rittereiser said.

She said she recently went to Aetna’s website to look up the company’s values. She felt nauseated. “Everything in their core values is not being shown in the way I’m being treated. They’re talking about promoting wellness and health and ‘being by your side.’ ”

She paused, contemplating the company’s “by your side” catchphrase, saying it’s “the most ridiculous thing, because they are the biggest barrier to my success and my well-being going forward.

“It drives me crazy.”

Dad: ‘You get so angry’

Julie Pressman stood near an elevator at her doctor’s office when word came that Cara’s surgery had been denied. The mom fell to the floor and wept.

She called Cara’s father, Robert. He was at the airport picking up his 90-year-old parents for their birthday party. Mom and Dad rallied for their daughter and gathered strength to break the news. That’s when Cara sat in the red chair, crying inconsolably.

“Telling Cara was horrible,” her mom said. “Horrible.”

“It’s just so frustrating for us to know there’s a solution out there — a way to fix our daughter — and some bureaucratic machine is preventing this from happening,” Robert Pressman said. “You get so angry, but you don’t know who to take it out on, because there’s no particular person that’s doing it. It’s this big bureaucracy that’s preventing this from happening.”

Julie and Robert said the most beautiful day of their lives came on August 20, 2002, when Cara popped into the world and met her 2-year-old sister, Lindsey, for the first time. “That was the day we became a family,” Julie said. “Our love for those girls is amazing. How we got this lucky is beyond us.”

But that luck has been tested. When Cara was 9, she’d complained of extreme headaches for much of the day one evening, and then in the middle of the night, she began seizing uncontrollably. The family had two black Labradors that had gone to her room and barked like crazy to alert her parents. Cara had bitten her tongue, and blood was running down her face when they got to the room.

It was a terrifying scene. She was rushed off in an ambulance and underwent a battery of tests. Mom, Dad and Cara never thought they’d still be battling seizures six years later — let alone an insurance company. She’s had seizures on the soccer field, during softball games, on stage during plays, in the classroom. Almost everywhere.

How does she envision a life without seizures?

“I don’t know,” she said. “I’ve never had a life without seizures.”

“You will. You will,” her dad told her.

“I just don’t know when,” she responded.

Mom: “It will happen, kiddo.”

Her mother calls Cara a feisty, petite powerhouse with big marble eyes and long eyelashes and a funny wit to match. She’s a naturally gifted athlete, singer and dancer, but her parents feel that her seizures have kept her from reaching her full potential.

They long for the day when the seizures are gone. The parents said they have paid $24,000 for insurance with Aetna this year. They’re determined to get Cara laser ablation surgery with or without the insurance company’s help. They will appeal Aetna’s latest rejection — but they’re not optimistic.

In preparation, they’ve begun exploring raiding their retirement funds to pay the $300,000 out of pocket. “Cara is worth every penny, but man,” her mom said. ” ‘Screw Aetna,’ indeed, to quote my kid.”

Filed under: General Problems | 2 Comments »

http://www.pharmacytoday.org/article/S1042-0991(17)31791-7/fulltext

Pharmacy errors can occur in many different ways. A recent case from Missouri reviewed several key sources of pharmacy error and eventually restored an aggravating damages claim in a pharmacy error case.

Background

According to the court, a patient was discharged from a hospital, and a nurse phoned prescriptions to the patient’s pharmacy. The prescriptions were received by a pharmacy technician who had no formal training and had worked in the floral department before being transferred to the pharmacy.

The technician made many errors transcribing the prescriptions. The most significant was confusing once-daily methotrexate for the metolazone that had been prescribed. The pharmacist approved the once-daily methotrexate, later explaining “for some reason I didn’t recognize the weekly versus daily. It didn’t click in my mind.” The pharmacy’s computer system did not flag the once-daily methotrexate dosing schedule.

The patient’s husband picked up the medication. He was asked if he had any questions, to which he replied no. No additional patient education was provided. The patient used the methotrexate daily as instructed on the label, and she died less than 1 month later from the effects of the drug.

A lawsuit was filed against the pharmacy. The pharmacy admitted negligence, and the jury returned a verdict for the plaintiffs in the amount of $2 million. This was reduced to $125,000 based on statutory damages caps. The plaintiffs claimed additional damages for “aggravating circumstances,” but the lower court granted a pharmacy motion to deny these damages.

From this ruling, the plaintiffs appealed.

Rationale

In reversing the lower court, the Missouri Court of Appeals cited four factors that would support an award of additional damages based on aggravating factors.

First, the court noted that in the absence of a computerized “hard stop” for once-daily methotrexate prescriptions, it is imperative that pharmacists conduct their own personal verification of prescriptions. A pharmacy corporate representative testified that, based on her analysis of the facts, “the pharmacist really did not perform a medication review of this drug and of this patient.” The court was skeptical of the pharmacist’s claim that he had reviewed the prescription and concluded that the failure to perform such a review could justify a finding of aggravating circumstances.

Second, the court was critical of the pharmacy technician receiving a new prescription over the telephone. Although the court cited evidence that Missouri is one of only a few states allowing this practice, the court noted the pharmacy’s own policies and procedures that state only pharmacists are allowed to accept prescriptions over the phone.

Third, the court was critical of the pharmacy’s failure to provide patient education when dispensing a high-risk medication like methotrexate. An expert witness for the plaintiffs testified that simply asking if the person receiving a medication has any questions is inadequate. He testified that it is “absolutely inadequate and absolutely deadly in the case of high-alert drugs to not do that counseling.”

Fourth, the court noted that the pharmacy “had made no meaningful changes to its procedures as a result of [the patient’s] death.” The pharmacy corporate representative testified that the pharmacists as a group “have had an in-depth conversation about being more conscientious than we already were, you know, just trying to be more safe in everything that we do.” The court was not impressed.

For these reasons, the appellate court reversed the lower court’s dismissal of the aggravating circumstances claim.

Discussion

This case is a classic example of how pharmacists can be set up to fail by a dysfunctional system. This error did not occur because pharmacists weren’t conscientious and weren’t trying to be safe. Remedial measures after a fatal error of this type must go beyond a platitudinous pep talk.

Computer systems must be designed to implement a “hard stop” when a lethal prescription is entered into the pharmacy computer. Pharmacy technicians must be adequately trained and forbidden to perform functions for which they are unqualified. Patient counseling is absolutely mandatory when dispensing a high-alert drug to a patient for the first time.

Filed under: General Problems | 1 Comment »

http://time.com/4952176/cvs-pharmacy-opioid-epidemic/

With the 64,000 deaths from opioid overdoses last year alone, the medical community is struggling to contain the out-of-control opioid epidemic. Now, CVS, one the nation’s largest pharmacy benefit managers that oversees prescription drug benefits for 90 million people through its CVS Caremark plan, is attempting to address opioid abuse by no longer reimbursing opioid prescriptions beyond the first week for people filling these prescriptions for the first time.

Beginning in February, the company announced, it will adhere to the Centers for Disease Control and Prevention’s (CDC) guidelines for prescribing opioids that limit doses and duration of the drugs prescribed by doctors. The CDC recommends prescribing the painkilling narcotics, which can be highly addictive, in as low a dose as possible for as short a time as needed. Not only will CVS Caremark only reimburse for seven days of prescriptions, but for first-time opioid prescription-fillers it will also dispense short-acting, rather than extended release, versions of the drugs for these patients.

The pharmacy benefit managers who authorize prescriptions for CVS Caremark plan members, as well as pharmacists at CVS retail pharmacies, will be spending more time explaining to patients and doctors why some of their opioid prescriptions won’t be filled as ordered. “We estimated how long it would take for these conversations, and we are staffing up to do that,” says

Dr. Troyen Brennan, chief medical officer of CVS.

https://www.linkedin.com/in/troyen-brennan-494bb533/

Troyen A. Brennan, M.D., M.P.H., is Executive Vice President and Chief Medical Officer of CVS Caremark. In this role, Dr. Brennan provides oversight for the development of CVS Caremark’s clinical and medical affairs and health care strategy, as well as the company’s MinuteClinic and Accordant Health Care businesses.

Previously, Dr. Brennan was Chief Medical Officer of Aetna Inc., where he was responsible for clinical policies, as well as Aetna’s full range of clinical operations, disease management programs and patient management services. Prior to that, Dr. Brennan served as president and CEO of Brigham and Women’s Physicians Organization. In his academic work, he was Professor of Medicine at Harvard Medical School and Professor of Law and Public Health at Harvard School of Public Health.

Dr. Brennan received his M.D. and M.P.H. degrees from Yale Medical School and his J.D. degree from Yale Law School. He has a Master’s Degree from Oxford University, where he was a Rhodes Scholar. He earned a BS from Southern Methodist University. He completed his internship and residency in internal medicine at Massachusetts General Hospital. He is a member of the Institute of Medicine of the National Academy of Sciences.

According to this website  http://www.hipaaspace.com/Medical_Billing/Coding/NPI/Codes/NPI_1174686265.aspx   which indicates that he only licensed to practice medicine in the state of Massachusetts.

Here’s how the changes will work: If a patient has a prescription for several weeks’ worth of opioids and wants to fill the prescription for more than seven days, he will need pre-authorization for the drugs—obtained after the pharmacy benefit manager speaks to the prescribing doctor—and will have to pay for them out of pocket.

Pharmacists already call doctors when they have questions about the duration or appropriateness of medications to treat certain conditions, and Brennan says he anticipates more of those conversations will take place as doctors also make an effort to adjust their opioid prescribing practices to adhere to the CDC guidelines. “A lot of doctors are moving in the direction of the CDC guidelines and counseling patients along the same pathway,” he says. “What we see ourselves doing is reiterating that and doing our part.”

Brennan estimates that the new stricter dispensing policies will affect about 300,000 people who fill prescriptions through CVS. The company is also supporting community-based addiction programs and providing education to its clients about opioid addiction and the benefits of using the drugs in the lowest dose possible for as short a time as possible.

One of the basic functions of the practice of medicine is to create a plan of treatment for a pt that includes the starting, changing, stopping a pt’s medication(s).

It would appear from this article … Dr. Troyen Brennan, chief medical officer of CVS is the person behind the decision – authorizing – the changing of the prescription(s) written by the pt’s prescriber.

It is also ILLEGAL for a prescriber to change a pt’s plan of treatment… without doing a IN PERSON PHYSICAL EXAM…

It is also ILLEGAL for a prescriber to “practice medicine” in a state in which they are not licensed

Since the CVS Health corporation has apparently decided to “play doctor” with all those patients who either have chosen CVS Pharmacy or has the misfortune of having CVS/Caremark as the PBM that processes their prescription claims – regardless of which pharmacy they chose to patronize.

A corporation cannot be a DOCTOR… they cannot have a medical degree… they can’t take a medical licensure test… thus a corporation CANNOT PRACTICE MEDICINE… so who within CVS HEALTH would be the corporate officer that would think they would have the authority to issue such blanket medical mandates ? CHIEF MEDICAL OFFICER OF CVS ?

This statement concerns me:

Here’s how the changes will work: If a patient has a prescription for several weeks’ worth of opioids and wants to fill the prescription for more than seven days, he will need pre-authorization for the drugs—obtained after the pharmacy benefit manager speaks to the prescribing doctor—and will have to pay for them out of pocket.

The DEA has declared as a RED FLAG any pt paying CASH for a controlled substance … that has insurance. So is CVS documenting that a pt with insurance is paying cash for a controlled substance… something that they could provide to the DEA to “mark” doctors, CVS pharmacy competitors, pts that are throwing RED FLAGS ?

So what about Dr Brennan… according to his profile.. he is both a medical doctor and a licensed attorney… so he knows or should know what his limitations are under his medical license that he holds in Massachusetts and apparently ONLY MASSACHUSETTS ?  BUT CVS Health/Caremark manages prescriptions in all 50 states ?

What I suspect they will attempt to do to dodge the claim of practicing medicine without a license is to get the pt’s prescriber to AGREE  WITH THEIR POLICIES/DEMANDS and that way it will be the decision of the pt’s prescriber…  PERFECTLY LEGAL !!!

They will try and take advantage of the prescribers being “pressed for time” and just agree to get it off their plate and out of their face. There is no means of the prescriber to “fund” the time it takes to discuss/argue a prior authorization.  BUT.. the prescriber made his/her decision what was in his/her professional opinion what medication was right for this pt this time.. and for it to be changed was because they were cajoled by CVS staffing…. to make the change…

Should the pt move ahead…  get a statement from the prescriber that he/she was cajoled to change the ordered medication… then file complaints with the Massachusetts’ Medical board and the medical licensing board in the state in which the pt lives… about CVS Health & Dr. Troyen Brennan, chief medical officer of CVS violating the various laws outlined above.

If the pt is covered by Medicare/Medicaid – file complaints with www.cms.gov 800-MEDICARE

If the pt’s insurance is from an employer and the employer is self-funded (ERISA).. file complaints with the dept within the employer over denial of care.. ERISA insurance … the insurances – like CVS Health – are just shuffling the paperwork for the employer and paying the bills for their employers – WITH THE EMPLOYER’S MONEY… and they get paid an administration fee for doing so.

There may be other avenues to be utilized… all I know is that both Barb and myself have had the same part D provider since 2006 and is now owned by CVS/Health/Silver Scripts and I know that our PCP will not cave and I will pursue any/all avenues to allow us to follow our PCP’s medical orders and get Silver Scripts to pay for those same medications.

 

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www.painnewsnetwork.org/stories/2017/12/8/12-myths-about-opioid-pain-medication

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42 U.S. Code § 1395 – Prohibition against any Federal interference

https://www.law.cornell.edu/us code/text/42/1395?qt-us_code_ temp_noupdates=3#qt-us_code_ temp_noupdates

Nothing in this subchapter shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.

(Aug. 14, 1935, ch. 531, title XVIII, § 1801, as added Pub. L. 89–97, title I, § 102(a), July 30, 1965, 79 Stat. 291.)

The information that I have received on this Federal Law is that it only applies to Medicare… Medicare covers 46 million (old age 65+) and 9 million (disabled)… so we are talking about 55 million that could possibly be covered by this law/statue.

Of course, we all know that Federal laws are enforced by the DOJ.. if which, DEA is part of.

So how many federal agencies and their employees are attempting to interfere with the medical services provided to those covered under Medicare – which should include prescriber office visits paid for by Part B and medication paid for by Part D ?

There are a number of OIG’s (Office of Inspector General) that is to oversee the legal operation of a number different federal agencies.  Where are they ?

Where is the ACLU in protecting the rights of all of these elderly/disabled Medicare beneficiaries … ?

Where is the AARP … who claims to be the “CHAMPION” for those over 50+ ?

Does this mean that the CDC did not have the LEGAL AUTHORITY to publish those opiate dosing guidelines ..at least they would not apply to 55 million Medicare citizens. ?

Does this mean that the DEA has no legal authority over prescribers treating/maintaining addicts as their professional discretion indicates ?

Does the DOJ have the legal authority to continue to treat opiate addiction as a crime when Surgeon General states it is a mental health disease ?

Did the FDA have the authority to force the pharma that made Opana ER to take it off the market  because it was the drug of choice of some addicts ?

Does CMS have the authority to dictate dosing guidelines for those on Medicare ?

Who can answer these questions?… Who is suppose to enforce this Federal law/statue ?

 

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Four-Fold Jump In Deaths In Opioid-Driven Hospitalizations

https://www.news-line.com/PH_news28800_enews

People who end up in the hospital due to an opioid-related condition are four times more likely to die now than they were in 2000, according to research led by Harvard Medical School and published in the issue of Health Affairs.

The country is in the throes of a growing, and increasingly deadly, opioid epidemic, yet little is known about how people hospitalized for opioid-related diagnoses fare or how the situation has changed over the years.

The study results, which stem from analysis of opioid-driven hospitalizations in the United States between 1993 and 2014, provide the first comprehensive look of the trend over time among both privately and publicly insured patients hospitalized for opioid-related conditions.

“More than 35,000 people died from heroin and synthetic opioid overdoses last year,”

said study senior author Zirui Song, an assistant professor of health care policy at Harvard Medical School. “In order to avert preventable deaths, we need better, richer data about the multiple dimensions of the epidemic, including clinical and sociodemographic.”

Previous studies have looked at outcomes for all patients admitted to hospitals with opioid-related diagnoses found on any diagnosis field in the discharge record, but this is the first study to focus on patients whose primary diagnosis was related to opioids. It is important to note that the study also included patients with both public and private insurance.

Mortality in opioid-driven hospitalizations increased from 0.43% before 2000 to 2.02 percent in 2014, the study found. The death rates in hospitalizations due to nonopioid drugs and poisons remained unchanged, while the overall chances of a hospitalized patient dying from all other causes declined gradually, likely due to improvements in medical technology, therapeutics and clinical techniques, Song said.

While the rate of opioid-driven hospitalizations has remained relatively stable, the analysis showed, patients are increasingly likely to be hospitalized for more deadly conditions such as opioid poisoning or heroin poisoning.

Before 2000, most opioid hospitalizations were for opioid dependence and abuse. In recent years, the proportion of admissions for opioid poisoning and heroin poisoning have grown. These deadlier conditions are now the major cause of opioid-driven hospital admissions.

These shifts are likely due to a number of factors, the research posited. As the epidemic grows and awareness heightens, patients with lower-severity opioid overdoses may be more likely to be treated in the field or in the community, rather than to be admitted to the hospital—leaving those receiving hospital admission to have higher-severity overdoses on average. The increase in heroin poisoning and opioid poisoning admissions could also reflect the growing potency of heroin and the rising use of fentanyl, a drug that tends to make people sicker faster.

The findings also provide important insight into which population is hardest hit by the epidemic. Patients admitted for the deadlier conditions of opioid poisoning and heroin poisoning were more likely to be white, live in lower-income areas, be Medicare beneficiaries with disabilities and between the ages of 50 and 64.

“These results are just scratching the surface of what health professionals and policymakers could use to help patients and the public, and the picture they paint is concerning,” Song said. “As the United States combats the opioid epidemic, efforts to help hospitals respond to the increasing severity of opioid intoxication are acutely needed, especially in vulnerable and disabled populations.”

LET’S DO THE MATH

People who want to “end the opiate crisis” are throwing around the stat of 60,000 people who die from DRUG OVERDOSES Some will include the fact that abt 40% of those deaths do not involve controlled substances.. Leaving 36,000 dying from some legal/illegal opiates..

According to this study …

More than 35,000 people died from heroin and synthetic opioid overdoses last year

Buried within that above fact is that all Heroin and Synthetic opiods (Fentanyl analogs) are ILLEGAL… being imported from China and Mexico

Do these two FACTS suggests that abt 1000 people died from a OD of a LEGAL OPIATE ? We know that legal opiate prescriptions are decreasing and that suicides by chronic pain pts are increasing… so what is the conclusion ?

We know that 2600 Americans die from some cause EVERYDAY.. using the above 1000 death figure would suggest that 0.1% of those deaths can be related to a prescription opiate – not necessarily legally obtained…  and we do not know how many of those OD’s were intentional (suicide) or accidental ??

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A number of health/disease issues have a correlation to Body Mass Index (BMI)  https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

The common perception is that those who have a higher than normal BMI… are there because the eat too much or exercise too little.

Some of the diseases associated with elevated BMI are:

Hypertension (High Blood Pressure)

Diabetes

Cardiovascular disease

Elevated cholesterol

All of these diseases have physical measurable values when it can be determined that a person is at risk and is usually determined as being PRE-DISEASE status.

What if our health care/insurance system started to limit treatment for anyone whose BMI is outside of the normal range ?

A pt would be mandated to lose a average of 1-2 lbs/wk until the pt gets their BMI gets into the normal range.

Example: a pt BMI indicates that they are 50 lbs OVER WEIGHT and the pt is provided medication – and paid for by insurance – for the various disease issues they have for ONE YEAR… if they do not reach the 50 lbs loss and get their BMI into the normal range… medication would no longer be paid for by insurance and required hospitalization to treat any health issues related to above recommended BMI would not be paid for by insurance.

If the pt reaches the recommended BMI and still have certain health issues .. then they would be required to participate into mandatory “health club” exercise programs to try and get the health issues to within normal ranges

If the pt is compliant with the mandatory exercise programs and still have some elevated lab values.. then the pt will be required to eat a “proper diet” to get elevated lab values within range.

Only after the pt does/participates all the necessary/mandatory and labs values are outside of normal ranges will the health insurance pay for some medications of the insurance company’s choosing.

If after obtaining all mandatory weight, exercise, diet and stops being compliant and lab values or BMI are out of acceptable range. The pt will be provided a “grace period” to get back to being compliant and if the pt fails to be compliant … coverage for the particular health issues will cease.. and the pt will be required to continue to pay for health insurance premiums so that they have health insurance coverage that are not caused by poor life style factors.

How slippery will this slope get ?

 

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