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

Many severe, centralized pain patients have to take a drug from the 3 classes and do it safely and effectively. In other words, they take the drugs “as prescribed.”

Additionally the “Holy Trinity,” originally called the “Houston Cocktail,” is a term coined by law enforcement. Addicts tend to use monosyllabic terms to refer to their poison of choice; “Holy Trinity” has too many syllables.

Forest Tennant is a pioneer in pain management who operates a pain clinic for intractable pain patients in West Covina, CA. His clinic was recently raided by DEA agents.

Ryle Holder is a Georgia pharmacist and patient of Dr. Tennant. Scott Guess operates an independent pharmacy  and clinic in Atascadero, CA that specializes in pain management.

This column was distributed by Families for Intractable Pain Relief, a project of the Tennant Foundation.

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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 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.”

“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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In October my doctor at the cancer hospital called CVS Caremark PBM for a prior authorization and was told until I am denied coverage for the rx one can not be requested. On 12/5  I was informed by my local pharmacy that I was formally denied coverage for my doctor’s rx by CVS Caremark PBM . I asked for the price difference and the pharmacist totally flipped out on me. I was told with venom based negative affect that he would not dispense any rx for me that was not consistent  with the CVS Caremark PBM rx for me. I told him that CVS Caremark PBM is not my doctor has never even seen me and that their rx for me was an unauthorized reduction in my rx. He became even more angry reiterated that he will not dispense any rx that differs from what CVS Caremark would cover and that what I was trying to do was have him fill two different rx and he was not filling two different rx like that for me that he would only dispense the CVS Caremark PBM rx or  I would need to find another pharmacy and hung up on me.

Steve, I don’t think I have ever been treated like such garbage in my life and for sure the entire pharmacy staff and customer base in that small apothcary heard it the entire tirade. Big issue too is that I no longer even have physical access to my rx bc it is e-scripted to the pharmacy.  I also had a very bad reaction to fillers in varied pharmco brands of my liquid medication so can only tolerate vistapharm liquid bc I become deathly ill from  Edetate Disodium. So my rx even reads vistaapharm brand only which is a special order.

I am being denied legitimate access to pharmaceutical care and benefits for valid medical needs and I doubt anyone cares or will help even if it is illegal. The ADA is no help. I am not on medicaid and although I sent an email complaint to CT Commission of Pharmacy Drug Control regarding CVS Caremark PBM over reach,patient profiling,practicing medicine without a license and making unauthorized reductions to my medication resulting in a denial of access to needed care I do not hold high hopes of any regulatory response. It is now acceptable to treat anyone on pain medication like a third class citizen with no rights in this country. This situation has become very out of control and very abusive. The cancer hospital will again try to obtain an authorization however this entire situation is egregious and they said unless patients are receiving direct chemo or radiation they are frequently being denied access to prescription pain medication on a daily basis now since CVS Caremark PBM has been allowed to operate this way with immunity. According to them none of the regulatory oversight is commenting or wanting to be involved.  I am very concerned that significant medical issues and pain management related issues that are now somewhat controlled allowing me some semblance of quality of life are at grave risk to resurface and do not think that I should become a victim to a “Customer Care” Team that is unlicensed to practice medicine, patient profiling and allowed to remain anonymous. Its all pretty awful…

Just imagine if this is how CVS Health is functioning as JUST a Pharmacy/PBM… just imagine what is to come if the FEDS approve them to buy Aetna and they also become the HEALTH INSURER..

Is it just me… or has CVS quietly dropped their tag line “Where HEALTH is EVERYTHING”… maybe they need to start using the tag line “It is OUR WAY or the HIGHWAY “

One thing that any pt having a C-II prescribed is to INSIST on getting a paper prescription.. because if the pharmacy receiving the electronic order can’t/won’t fill it .. it becomes DOA.

The DEA now allows the receiving pharmacy to transfer the C-II to a different pharmacy… states have to change their state laws to conform to what the DEA allows and all the pharmacy’s Rx dept software has to be modified to conform… the last time that such a DEA change was made – allowing C-II to be electronically submitted… it took YEARS for states and software companies to “get in line” and it became legal to do.

The same is in limbo right now with DEA allowing pts to get less that the full quantity prescribed and are now entitled – by the DEA – to get “refills” up to the total quantity originally prescribed…  but until the states and software companies get their act together… many pharmacies will not be able to do it.

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SOS here in WA state. A WA state pain clinic closure is coming soon – need to get all WA peeps into new WA group. DOH has told ALL other pain clinics NOT to accept these patients and send them ALL to rehab

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I-Team: Nevada doctors will have to comply with new opioid regulations on Jan. 1

http://www.lasvegasnow.com/news/i-team-nevada-doctors-will-have-to-comply-with-new-opioid-regulations-on-jan-1/876634765

LAS VEGAS – As of New Year’s day, Nevada doctors who prescribe opioid medication will have to comply with new regulations. On Tuesday night, physicians received a crash course on how the rules will work.

The new law, Assembly Bill 474, was initiated because of concerns about an opioid epidemic. As 8 News NOW has been reporting over the last several weeks, there is another side to the opioid issue, so what happens to legitimate pain patients?

The news release which announced the event declared that Nevada has the fourth highest overdose mortality rate in the country that is, the state did back in 2010. However, a lot has changed in the last seven years.

Opioid prescriptions in Nevada have dropped every year since 2011 while overdoses and hospitalizations have gone up, so how can that make sense?

At city hall Tuesday night, the medical society helped prepare local physicians for the impact of Assembly Bill 474. The law is not as draconian as some opioid crackdowns enacted elsewhere, but it means any doctor prescribing opioid medication must provide a detailed medical history so that pharmacists can decide if the prescription should be filled.

State officials say Nevadans are dying from prescription opioids, even though about 90 percent of overdose deaths involve illicit drugs including heroin, meth, fentanyl, alcohol and other substances. Chronic pain patients in Nevada already sign contracts which require urine screening and other conditions.

Patients were not part of the panel Tuesday night but were in the audience because they worry the new requirements will turn a bad situation worse.

“It’s very burdensome for prescribing physicians, and I’m really afraid what’s going to happen is that a lot of doctors are just going to quit prescribing these opioid pain medications altogether because they don’t want to be bothered with it,” said Rick Martin, chronic pain patient. “They don’t have enough time to deal with patients as it is, and there are not enough pain management doctors in town or elsewhere to handle the patients thrown under the bus by primary care physicians who don’t want to treat them anymore.”

Martin, a retired pharmacist, says millions of legitimate pain patients are being punished because of the actions of addicts who overdose, mostly on illicit drugs. Under Nevada law, pharmacists can already decline to fill prescriptions, though they are supposed to consult with the doctor first.

As reported in our recent series, the other side of opioids, Nevada pharmacists already use patient profiling to decide if they will fill opioid prescriptions. They also have an unofficial blacklist containing the names of doctors.

   This report stated that they had previously reported that Nevada Pharmacists are “profiling” pts as to who is “worthy”, in their opinion, to have a controlled substance filled. Has the Nevada legislature put responsibilities on Pharmacists that exceeds both their training and legal authority under the state’s Pharmacy Practice Act ?

Since we are dealing with subjective diseases… will pharmacists be held to a higher liability when they fail to “get it right” and refuse to fill prescription(s) written by a legal prescriber ?

There was a couple of physicians in the early 90’s that got sued for refusing to treat the pain of end of life cancer pts. The survivors in the families sued … not for malpractice… but for pt/senior ABUSE.. and each lawsuit the plaintiffs were awarded ONE MILLION + for pt/senior abuse..

Normally filling a C-II prescription takes the pharmacist 2-3 times everything else because of administrative tasks that only the pharmacist can do. Asking a Pharmacist to take on the added time consuming task of “evaluating the pt’s needs” for the controlled substance could cause a lot of pharmacists to “just say no” or more commonly stated phrase “I’m not comfortable”…

But this state mandate on pharmacist could come back to haunt their employer by not providing enough staffing hours for the pharmacist to do this mandatory task(s) and/or the pt’s PBM/insurance by not providing proper funding that allows the employer to provide proper staffing.

Since we are talking about a state mandate and potential profiling, and if the board of pharmacy (BOP) can find their “balls and backbone” they should be able to act on consumer complaints of unprofessional conduct  against both the permit holder (employer) and the PIC ( Pharmacist in Charge) and the dispensing pharmacist – if not the PIC.

The primary charge of the BOP is to protect the public’s health and safety… if they fail to act on obvious and gross harm to a specific segment of the population, could those individual members of the BOP be sued for failing to “do their job” ?

Since those pts who are suffering from subjective disease… – in theory – they should be covered by the Americans with Disability Act and Civil Rights Act and if it can be proven that all involved (PBM/insurance, employers, pharmacists) put policies and procedures in place that cause profiling to happen and legit/on time/medically necessary medication was denied … which could be considered a civil rights violation of all those pts covered under those two laws.

There are so many moving parts to this whole issue…This could keep a lot of personal injury and civil rights attorneys very busy for a long time.

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