Corners are cut to dispense prescriptions, CVS employee tells Ohio Board of Pharmacy

Posted on July 7, 2023 by Pharmaciststeve

Corners are cut to dispense prescriptions,” CVS employee tells Ohio Board of Pharmacy

https://ohiocapitaljournal.com/2023/07/07/corners-are-cut-to-dispense-prescriptions-cvs-employee-tells-ohio-board-of-pharmacy/

At least eight CVS pharmacies in Ohio are so understaffed that they have seen rampant turnover, dirty conditions, lack of controls over dangerous drugs and wait times as long as a month for prescriptions, according to reports by the Ohio Board of Pharmacy. 

The waits have been so long that a harried CVS pharmacist in Wooster said he was “actively triaging prescriptions to ensure lifesaving, life-sustaining medications are filled in a timely manner.” 

In one case, pharmacy workers told inspectors they begged their superiors — unsuccessfully — to close their pharmacies so they could catch up. In another, a pharmacy did intermittently close, making it impossible for patients to get their medicines during the closures.

In another instance, Board of Pharmacy inspectors couldn’t tell if employees were stealing controlled substances. In yet another, they couldn’t tell if CVS was improperly billing insurers for scripts it didn’t fill. 

And in several additional cases, inspectors repeatedly found expired and adulterated drugs on pharmacy shelves and filled prescriptions that gave patients the wrong instructions.

“Corners are cut to dispense prescriptions,” at least one employee at Toledo’s CVS store No. 10246 told investigators last year. Workers there added, “Supervisors/District Managers do not respond to staff calls for help,” the report said.

The accounts come from inspection reports going back to 2020 that the Capital Journal obtained under the Ohio Public Records Act. At least some of the inspections came in response to patient complaints to the board, which licenses Ohio pharmacies.

The inspections come after CVS — already the nation’s largest pharmacy retailer — has for years bought up competitors, closed them and moved the prescriptions of the closed pharmacies to existing CVS stores. Critics raised concerns about the practice, known as “buy and close,” at least as early as 2019.

“Staff at this location was not increased,” a pharmacist at Dayton’s CVS store No. 2528 said last September after the store had absorbed two other closed pharmacies’ prescriptions. She quit the following month.

For its part, CVS didn’t answer questions about specific allegations in the reports, which it referred to as “isolated incidents.”

“We’re working with the Board of Pharmacy to resolve allegations of isolated incidents, most of which date back a year or more,” Amy Thibault, director of communications for CVS Pharmacy said in an email Wednesday. “The health and well-being of our patients is our number one priority.”

Rampant turnover

Pharmacies across the country found themselves under siege as the coronavirus pandemic took hold in the spring of 2020. They were conducting tests and, when they became available, providing COVID vaccines in addition to already administering those for flu and shingles.

At the same time, some pharmacy employees were reluctant to work face-to-face with the public in a health care setting — especially before there were vaccines against a disease that has killed more than 1 million Americans.

But according to the Board of Pharmacy reports, turnover in the CVS stores they investigated seemed particularly bad. And it seemed to be linked to stress from overwork — as well as the parent corporation’s inability or unwillingness to do anything about it.

For example, when an inspector arrived at CVS store No. 2063 in Canton on Sept. 13, 2020, the staff was so harried that it took them 20 minutes to even acknowledge the inspector. The staff said that the store had lost a pharmacist and six technicians “within a short time.”

As workers scrambled, they sweltered in a pharmacy in which the air conditioning unit was broken and an alarm in a drug cooler failed to warn them that it was too warm at 46.4 degrees Fahrenheit. 

“Pharmacy staff and an assistant store manager stated they have asked district leaders to close the store down temporarily to get caught up filling prescriptions as well as clean and organize the pharmacy, but this request was denied,” the report said.

When an inspector returned to the pharmacy on Oct. 29, 2021, things had only gotten worse.

“All pharmacy staff that was present for the September 2021 inspection quit or transferred out of CVS #2063,” the report said.

Even more alarmingly, understaffing there created delays that easily could have harmed patients’ health — despite workers’ best efforts to “triage” which prescriptions to fill first. 

“The pharmacy was over a month behind in filling prescriptions,” the report said.

Especially bad at CVS

During the pandemic, conditions were universally difficult for pharmacies, but CVS might have been a special case.

An owner of an independent pharmacy in Northern Ohio said things were rough for everybody, and that he’s still having trouble keeping enough pharmacy technicians on his staff. But, he said, that never led him to consider temporary closures, or anything like the delays filling prescriptions and other problems seen at some CVS stores.

The pharmacist depends on CVS Caremark — the corporation’s gargantuan pharmacy benefit manager — for his business and asked not to be named. But, he said, he’s talked to CVS pharmacists who have been under pressure so great that it affected their mental health.

The stress appeared to extend even to the upper ranks of CVS’s pharmacy operation.

In July 2021, Ken Sidwell became leader of the district which includes Canton CVS store #2063. When he was interviewed by the Board of Pharmacy, he said the store was short-staffed when he got the job. 

Just three months later, Sidwell was gone. On Oct. 29, 2021, the new district leader, Kenneth Cook, told the Board of Pharmacy that the store “is in the process of hiring new pharmacy staff as well as transferring staff from an overstaffed CVS location.”

CVS spokeswoman Thibault said the company’s policies ensure that its stores are not dangerously short of pharmacy workers.

“Decisions about staffing, labor hours, workflow process, technology enhancements and other operational factors are made to ensure we have appropriate levels of staffing and resources in place at our pharmacies,” she said. “We have comprehensive policies and procedures in place to support prescription safety and we continue to make important strides, including using technology to support our pharmacy teams.”

Buy and close

Not only is CVS the nation’s largest pharmacy retailer, its parent corporation also owns Aetna, a top-10 insurer. It’s also buying up medical centers and physicians practices, helping to make it the nation’s sixth-largest corporation. 

And crucially for pharmacies everywhere, CVS owns the nation’s largest pharmacy benefit manager, CVS Caremark. It and Express Scripts and OptumRx are estimated to control more than 80% of the marketplace and they’re under investigation for possible anti-competitive practices by the Federal Trade Commission. 

Pharmacy benefit managers, or PBMs, act as middlemen for insurers in the drug supply chain. They decide which drugs are covered, so they have great power to negotiate huge, non-transparent rebates and other discounts from drugmakers.

At the same time, they create pharmacy networks. And, because they control access to so many millions of patients, most small-chain and independent pharmacists think they have little choice about contracting with them on whatever terms the big PBMs choose. 

“Take-it-or-leave-it” contracts, the pharmacists call them.

CVS has long said that it maintains strict firewalls between its retail and PBM operations, but small pharmacy operations in Ohio and elsewhere aren’t so sure.

After seeing their reimbursements from CVS Caremark plummet in late 2016, CVS’s “Acquisition Unit” in 2017 sent many of its competitor pharmacies letters saying that it knew times were hard for them and offering to buy them out.

In many instances, CVS didn’t put its sign on the store it had just purchased. CVS instead closed the stores and folded all of their prescriptions into an existing CVS pharmacy. 

Some pharmacists call the practice “buy and close.”

In 2019, when CVS bought 20 stores owned by Medina-based Ritzman Pharmacy and closed all but three, critics said it was classic buy-and-close.

Two of the now-closed pharmacies were in Wooster, one of the cities in which inspectors now find problems in a still-open CVS pharmacy. Three more — in Sugarcreek, Millersburg and Dover — were to the rural south of Canton and Massillon, where CVS stores found themselves seriously stretched in the years since.

Mount Vernon-based Conway’s Pharmacy in 2019 partnered with Knox County to open a pharmacy in Danville on the edge of Amish Country after CVS bought and closed the only pharmacy there a few years earlier. The closure meant that Danville residents — many poor, disabled or both — had to drive 20 minutes or more to get their medicines or to consult with a pharmacist.

Such practices have fueled fears that pharmacy deserts are being created in Ohio and elsewhere.

Lack of accountability

The constant churn in CVS staffing found by Board of Pharmacy investigators led to breakdowns in accounting for dangerous drugs, including opioids, the inspection reports said.

For example, between June 10 and Sept. 22, 2022 Dayton’s CVS store No. 2528 reported 75 oxycodone, 100 hydromorphone and 70 amphetamine pills were missing. In each instance, “CVS Pharmacy was unable to determine a reason for the loss,” the inspection report said.

For most of that period, no “Responsible Person” was in charge. 

The role is as the name implies. The Ohio Administrative Code says, “The Responsible Person shall be responsible for the practice of the profession of pharmacy, including, but not limited to, the supervision and control of dangerous drugs as required…”

That person would normally be the managing pharmacist at a drugstore. But for months after May 26, 2022, there was no such person at the Dayton CVS, according to the report. Inspectors interviewed pharmacist Jean Getter, who said she was asked to serve as temporary manager after the previous Responsible Person, pharmacist Tyler Philo, left.

Getter said that even though she wasn’t the Responsible Person, she asked for help sorting out the safe that contained controlled substances because “it was a mess.”

“She asked the previous Responsible Person and also the District Leader about cleaning up the safe, but it never happened,” the report said.

An inventory of dangerous drugs is supposed to be conducted whenever there is a change of Responsible Person at a pharmacy, but that kept not happening at the Dayton CVS, Getter said.

“No one ever became the permanent Responsible Person, which is why Ms. Getter left CVS in August,” the report said.

Then Pharmacy Board investigators interviewed Philo, the previous Responsible Person and learned something even more confounding.

“He was not aware (four months after he left that) he was still listed as the Responsible Person for CVS Pharmacy #2528,” the report said.

Controlled substances

Board of Pharmacy inspectors also found serious potential problems in CVS stores’ tracking controlled drugs — including the kinds of drugs that have fueled Ohio’s opioid crisis.

Some problems were as simple as leaving deliveries of dangerous drugs at the front of the store for nine hours because pharmacy staffers were too busy to get them. But others might have been more sophisticated.

At Toledo CVS store No. 10246, inspectors conducted, “Multiple audits consisting of 241 controlled substances were conducted by representatives from the Board between on or about November 11, 2021 and on or about April 27, 2022.”

In 42% of cases, they found that too much or too little of the drugs had been provided. They discovered “significant losses” of amphetamines and the painkiller tramadol. 

“Additional losses and overages were discovered, some of which were reported to the board, but many were not reported at all, or not reported in a timely fashion,” report said. It added that auditing what happened to controlled substances was difficult “because CVS records showed multiple significant inventory adjustments and changes in medication counts…”

Counterintuitively, investigators found that on some days when controlled substances were delivered to the Toledo pharmacy, inventories of the drugs actually went down. That might indicate “diversion” — a term used in the industry for stealing drugs.

“It remains questionable if counts were entered as negative numbers in error, or if staff were entering negative numbers to mask the diversion of drugs received on that day,” the report said.

In the same store, inspectors discovered chaotic conditions.

On repeated visits, inspectors found “expired/adulterated” medications on pharmacy shelves and workers told them they hadn’t had time to address the issue. The inspectors also painted a picture of general chaos.

“Shelving for drug storage had collapsed and medications were crushed beneath the shelving units. Drug stock crowded the aisle floors,” the report said, adding, “The counter used for non-sterile compounding was overflowing with (over-the-counter) medications and return-to-stock bottles. Staff food and beverages were also stored in this area. Moldy/rotting food was found on the counter.”

Beyond delays and lacking controls, inspectors found another problem at the store that could endanger patients’ health.

Inspectors on March 3, 2022 reviewed 49 prescriptions filled at the store. They found that seven “had errors in the directions to patients.”

And when inspectors talked to employees, they heard echoes of the complaints at other CVS pharmacies they’d visited.

  • “The pharmacy is always short staffed.”
  • “The workplace was described as hectic. There is no downtime to catch up on tasks.”
  • “Morale among store employees is poor.”

Delays and questions about improper billing

When inspectors visited CVS store No. 8248 in Massillon in late 2021, they found a pharmacy so understaffed that “the pharmacy would close intermittently,” meaning “patients were unable to pick-up/receive their prescriptions.”

They again found confusion over who was legally responsible.

“The Responsible Person, Abbey Yannerella, was listed as the Responsible Person at this location as well as CVS #2063; however, she was no longer working at” the Massillon store, the report said.

They found something else that raised serious questions. 

The store in October 2021 had more than 2,000 prescriptions waiting to be filled, the oldest of which had been waiting for 13 days. A month later, the pharmacist on duty told inspectors that after scripts go unfilled for 14 days, they’re “deleted from the queue.”

The inspectors found one such prescription that was labeled “Print Ready.”

“The prescription’s status indicating ‘Print Ready’ means the prescription was processed through insurance,” the report said. “When a prescription is deleted from the queue, the pharmacy does not reverse the insurance claim.”

CVS didn’t respond directly when asked how often scenarios like this occur — or whether it routinely bills insurers for prescriptions it fails to fill for two weeks and then deletes from its system.

On Nov. 28, 2021 a new Responsible Person, pharmacist Nayan Patel, had been named. He told investigators that the deletion of prescriptions after 14 days was a requirement of the U.S. Centers for Medicare and Medicaid Services. He added that the scripts are placed back into the queue after their deletion.

However, “When asked to explain this process further, he could not elaborate,” the report said.

Then on Feb. 4, 2022, the Board of Pharmacy learned that Patel was Responsible Person for two CVS pharmacies without the special permission required by the board. When the board notified a CVS district leader of that fact, “The district leader notified the board Mr. Patel is no longer the Responsible Person of” Massillon CVS store No. 8248, the report said.

Penalties

The board has notified CVS that it can impose penalties ranging from fines to revoking their licenses as a “Terminal Distributor of Dangerous Drugs” at each of the locations in which it found violations.

So far, CVS store #3613 in Columbus received a $1,000 fine and a written reprimand last August, Board of Pharmacy spokesman Cameron McNamee said in an email Thursday. The violations outlined in that report seem considerably less severe than those found in some other CVS pharmacies.

Violations found at CVS’s Canton store No. 2063 — where staff turnover was particularly rampant — are slated to be considered at the board’s Nov. 7-8 meeting McNamee said.

Hearings for the other stores are yet to be schedule

Filed under: General Problems | Leave a Comment »

How Often Do Health Insurers Say No to Patients? No One Knows

Posted on July 5, 2023 by Pharmaciststeve

How Often Do Health Insurers Say No to Patients? No One Knows

https://www.propublica.org/article/how-often-do-health-insurers-deny-patients-claims

It’s one of the most crucial questions people have when deciding which health plan to choose: If my doctor orders a test or treatment, will my insurer refuse to pay for it?

After all, an insurance company that routinely rejects recommended care could damage both your health and your finances. The question becomes ever more pressing as many working Americans see their premiums rise as their benefits shrink.

The lack of transparency is especially galling because state and federal regulators have the power to fix it, but haven’t.

ProPublica, in collaboration with The Capitol Forum, has been examining the hidden world of insurance denials. A previous story detailed how one of the nation’s largest insurers flagged expensive claims for special scrutiny; a second story showed how a different top insurer used a computer program to bulk-deny claims for some common procedures with little or no review.

The findings revealed how little consumers know about the way their claims are reviewed — and denied — by the insurers they pay to cover their medical costs.

When ProPublica set out to find information on insurers’ denial rates, we hit a confounding series of roadblocks.

In 2010, federal regulators were granted expansive authority through the Affordable Care Act to require that insurers provide information on their denials. This data could have meant a sea change in transparency for consumers. But more than a decade later, the federal government has collected only a fraction of what it’s entitled to. And what information it has released, experts say, is so crude, inconsistent and confusing that it’s essentially meaningless.

The national group for state insurance commissioners gathers a more detailed, reliable trove of information. Yet, even though commissioners’ primary duty is to protect consumers, they withhold nearly all of these details from the public. ProPublica requested the data from every state’s insurance department, but none provided it.

Two states collect their own information on denials and make it public, but their data covers only a tiny subset of health plans serving a small number of people.

The minuscule amount of details available about denials robs consumers of a vital tool for comparing health plans.

“This is life and death for people: If your insurance won’t cover the care you need, you could die,” said Karen Pollitz, a senior fellow at KFF (formerly known as the Kaiser Family Foundation) who has written repeatedly about the issue. “It’s all knowable. It’s known to the insurers, but it is not known to us.”

The main trade groups for health insurance companies, AHIP (formerly known as America’s Health Insurance Plans) and the Blue Cross Blue Shield Association, say the industry supports transparency and complies with government disclosure requirements. Yet the groups have often argued against expanding this reporting, saying the burdens it would impose on insurance companies would outweigh the benefits for consumers.

“Denial rates are not directly comparable from one health plan to another and could lead consumers to make inaccurate conclusions on the robustness of the health plan,” Kelly Parsons, director of media relations for the Blue Cross Blue Shield Association, said in an email.

The trade groups stress that a substantial majority of patient claims are approved and that there can be good reasons — including errors and incomplete information from doctors — for some to be denied.

“More abstract data about percentages of claims that are approved or denied have no context and are not a reliable indicator of quality — it doesn’t address why a claim was or was not approved, what happened after the claim was not approved the first time, or how a patient or their doctor can help ensure a claim will be approved,” AHIP spokesperson Kristine Grow said in a written response to questions from ProPublica. “Americans deserve information and data that has relevance to their own personal health and circumstances.”

The limited government data available suggests that, overall, insurers deny between 10% and 20% of the claims they receive. Aggregate numbers, however, shed no light on how denial rates may vary from plan to plan or across types of medical services.

Some advocates say insurers have a good reason to dodge transparency. Refusing payment for medical care and drugs has become a staple of their business model, in part because they know customers appeal less than 1% of denials, said Wendell Potter, who oversaw Cigna’s communications team for more than a decade before leaving the industry in 2008 to become a consumer advocate.

“That’s money left on the table that the insurers keep,” he said.

At least one insurer disputes this. Potter’s former employer, Cigna, said in an email that his “unsubstantiated opinions” don’t reflect the company’s business model. In a separate written statement, Cigna said it passes on the money it saves “by lowering the cost of health care services and reducing wasteful spending” to the employers who hire it to administer their plans or insure their workers.

The few morsels insurers have served up on denials stand in stark contrast to the avalanche of information they’ve divulged in recent years on other fronts, often in response to government mandates. Starting last year, for example, insurers began disclosing the prices they’ve negotiated to pay medical providers for most services.

Experts say it’ll take similar mandates to make insurers cough up information on denials, in part because they fear plans with low denial rates would be a magnet for people who are already ailing.

“Health plans would never do that voluntarily, would give you what their claim denial rates are, because they don’t want to attract sicker people,” said Mila Kofman, who leads the District of Columbia’s Affordable Care Act exchange and previously served as Maine’s superintendent of insurance.

About 85% of people with insurance who responded to a recent KFF survey said they want regulators to compel insurers to disclose how often they deny claims. Pollitz, who co-authored a report on the survey, is a cancer survivor who vividly recalls her own experiences with insurance denials.

“Sometimes it would just make me cry when insurance would deny a claim,” she said. “It was like, ‘I can’t deal with this now, I’m throwing up, I just can’t deal with this.’”

She should have been able to learn how her plan handled claims for cancer treatment compared with other insurers, she said.

“There could be much more accountability.”

In September 2009, amid a roiling national debate over health care, the California Nurses Association made a startling announcement: Three of the state’s six largest health insurers had each denied 30% or more of the claims submitted to them in the first half of the year.

California insurers instantly said the figures were misleading, inflated by claims submitted in error or for patients ineligible for coverage.

But beyond the unexpectedly high numbers, the real surprise was that the nurses association was able to figure out the plans’ denial rates at all, by using information researchers found on the California Department of Managed Health Care’s website.

At the time, no other state or federal regulatory agency was collecting or publishing details about how often private insurers denied claims, a 2009 report by the Center for American Progress found.

The Affordable Care Act, passed the following year, was a game changer when it came to policing insurers and pushing them to be more transparent.

The law took aim at insurers’ practice of excluding people with preexisting conditions, the most flagrant type of denial, and required companies offering plans on the marketplaces created under the law to disclose their prices and detail their benefits.

A less-noticed section of the law demanded transparency from a much broader group of insurers about how many claims they turned down, and it put the Department of Health and Human Services in charge of making this information public. The disclosure requirements applied not only to health plans sold on the new marketplaces but also to the employer plans that cover most Americans.

The law’s proponents in the Obama administration said they envisioned a flow of accurate, timely information that would empower consumers and help regulators spot problematic insurers or practices.

That’s not what happened.

The federal government didn’t start publishing data until 2017 and thus far has only demanded numbers for plans on the federal marketplace known as Healthcare.gov. About 12 million people get coverage from such plans — less than 10% of those with private insurance. Federal regulators say they eventually intend to compel health plans outside the Obamacare exchanges to release details about denials, but so far have made no move to do so.

Within the limited universe of Healthcare.gov, KFF’s analyses show that insurers, on average, deny almost 1 in 5 claims and that each year some reject more than 1 in 3.

But there are red flags that suggest insurers may not be reporting their figures consistently. Companies’ denial rates vary more than would be expected, ranging from as low as 2% to as high as almost 50%. Plans’ denial rates often fluctuate dramatically from year to year. A gold-level plan from Oscar Insurance Company of Florida rejected 66% of payment requests in 2020, then turned down just 7% in 2021. That insurer’s parent company, Oscar Health, was co-founded by Joshua Kushner, the younger brother of former President Donald Trump’s son-in-law Jared Kushner

An Oscar Health spokesperson said in an email that the 2020 results weren’t a fair reflection of the company’s business “for a variety of reasons,” but wouldn’t say why. “We closely monitor our overall denial rates and they have remained comfortably below 20% over the last few years, including the 2020-2021 time period,” the spokesperson wrote.

Experts say they can’t tell if insurers with higher denial rates are counting differently or are genuinely more likely to leave customers without care or stuck with big bills.

“It’s not standardized, it’s not audited, it’s not really meaningful,” Peter Lee, the founding executive director of California’s state marketplace, said of the federal government’s information. Data, he added, “should be actionable. This is not by any means right now.”

Officials at the Centers for Medicare & Medicaid Services, which collects the denial numbers for the federal government, say they’re doing more to validate them and improve their quality. It’s notable, though, that the agency doesn’t use this data to scrutinize or take action against outliers.

“They’re not using it for anything,” Pollitz said.

Pollitz has co-authored four reports that call out the data’s shortcomings. An upshot of all of them: Much of what consumers would most want to know is missing.

The federal government provides numbers on insurers’ denials of claims for services from what the industry calls “in-network” medical providers, those who have contracts with the insurer. But it doesn’t include claims for care outside those networks. Patients often shoulder more costs for out-of-network services, ramping up the import of these denials.

In recent years, doctors and patients have complained bitterly that insurers are requiring them to get approval in advance for an increasing array of services, causing delays and, in some instances, harm. The government, however, hasn’t compelled insurers to reveal how many requests for prior authorization they get or what percent they deny.

These and other specifics — particularly about which procedures and treatments insurers reject most — would be necessary to turn the government’s data into a viable tool to help consumers choose health plans, said Eric Ellsworth, the director of health data strategy at Consumers’ Checkbook, which designs such tools.

A spokesperson for CMS said that, starting in plan year 2024, the agency will require insurers offering federal marketplace plans to submit a few more numbers, including on out-of-network claims, but there’s no timeline yet for much of what advocates say is necessary.

Another effort, launched by a different set of federal regulators, illustrates the resistance that government officials encounter when they consider demanding more.

The U.S. Department of Labor regulates upwards of 2 million health plans, including many in which employers pay directly for workers’ health care coverage rather than buying it from insurance companies. Roughly two-thirds of American workers with insurance depend on such plans, according to KFF.

In July 2016, an arm of the Labor Department proposed rules requiring these plans to reveal a laundry list of never-before-disclosed information, including how many claims they turned down.

In addition, the agency said it was considering whether to demand the dollar amount of what the denied care cost, as well as a breakdown of the reasons why plans turned down claims or denied behavioral health services.

The disclosures were necessary to “remedy the current failure to collect data about a large sector of the health plan market,” as well as to satisfy mandates in the Affordable Care Act and provide critical information for agency oversight, a Labor Department factsheet said.

Trade groups for employers, including retailers and the construction industry, immediately pushed back.

The U.S. Chamber of Commerce said complying with the proposal would take an amount of work not justified by “the limited gains in transparency and enforcement ability.” The powerful business group made it sound like having to make the disclosures could spark insurance Armageddon: Employers might cut back benefits or “eliminate health and welfare benefits altogether.”

Trade groups for health insurance companies, which often act as administrators for employers that pay directly for workers’ health care, joined with business groups to blast the proposal. The Blue Cross Blue Shield Association called the mandated disclosures “burdensome and expensive.” AHIP questioned whether the Labor Department had the legal authority to collect the data and urged the agency to withdraw the idea “in its entirety.”

The proposal also drew opposition from another, less expected quarter: unions. Under some collective bargaining agreements, unions co-sponsor members’ health plans and would have been on the hook for the new reporting requirements, too. The AFL-CIO argued the requirements created a higher standard of disclosure for plans overseen by the Labor Department. To be fair and avoid confusion, the group said, the Labor Department should put its rules on ice until federal health regulators adopted equivalent ones for plans this proposal didn’t cover.

That left the transparency push without political champions on the left or the right, former Assistant Secretary of Labor Phyllis Borzi, who ran the part of the agency that tried to compel more disclosure, said in a recent interview.

“When you’re up against a united front from the industry, the business community and labor, it’s really hard to make a difference,” she said.

By the time the Labor Department stopped accepting feedback, Donald Trump had been elected president.

One trade association for large employers pointed out that the Affordable Care Act, which partly drove the new rules, was “a law that the incoming Administration and the incoming leadership of the 115th Congress have vowed to repeal, delay, dismantle, and otherwise not enforce.”

The law managed to survive the Trump administration, but the Labor Department’s transparency push didn’t. The agency withdrew its proposal in September 2019.

A Labor Department spokesperson said the Biden administration has no immediate plan to revive it.

Ultimately, it’s the National Association of Insurance Commissioners, a group for the top elected or appointed state insurance regulators, that has assembled the most robust details about insurance denials.

The association’s data encompasses more plans than the federal information, is more consistent and captures more specifics, including numbers of out-of-network denials, information about prior authorizations and denial rates for pharmacy claims. All states except New York and North Dakota participate.

Yet, consumers get almost no access. The commissioners’ association only publishes national aggregate statistics, keeping the rest of its cache secret.

When ProPublica requested the detailed data from each state’s insurance department, none would hand it over. More than 30 states said insurers had submitted the information under the authority commissioners are granted to examine insurers’ conduct. And under their states’ codes, they said, examination materials must be kept confidential.

The commissioners association said state insurance regulators use the information to compare companies, flag outliers and track trends.

Birny Birnbaum, a longtime insurance watchdog who serves on the group’s panel of consumer representatives, said the association’s approach reflects how state insurance regulators have been captured by the insurance industry’s demands for secrecy.

“Many seem to view their roles as protectors of industry information, as opposed to enforcers of public information laws,” Birnbaum said in an email.

Connecticut and Vermont compile their own figures and make them publicly accessible. Connecticut began reporting information on denials first, adding these numbers to its annual insurer report card in 2011.

Vermont demands more details, requiring insurers that cover more than 2,000 Vermonters to publicly release prior authorization and prescription drug information that is similar to what the state insurance commissioners collect. Perhaps most usefully, insurers have to separate claims denied because of administrative problems — many of which will be resubmitted and paid — from denials that have “member impact.” These involve services rejected on medical grounds or because they are contractually excluded.

Mike Fisher, Vermont’s state health care advocate, said there’s little indication consumers or employers are using the state’s information, but he still thinks the prospect of public scrutiny may have affected insurers’ practices. The most recent data shows Vermont plans had denial rates between 7.7% and 10.26%, considerably lower than the average for plans on Healthcare.gov.

“I suspect that’s not a coincidence,” Fisher said. “Shining a light on things helps.”

Despite persistent complaints from insurers that Vermont’s requirements are time-consuming and expensive, no insurers have left the state over it. “Certainly not,” said Sebastian Arduengo, who oversees the reporting for the Vermont Department of Financial Regulation.

In California, once considered the most transparent state, the Department of Managed Health Care in 2011 stopped requiring insurance carriers to specify how many claims they rejected.

A department spokesperson said in an email that the agency follows the requirements in state law, and the law doesn’t require health plans to disclose denials.

Despite the struggles of the last 15 years, Pollitz hasn’t given up hope that one day there will be enough public information to rank insurers by their denial rates and compare how reliably they provide different services, from behavioral health to emergency care.

“There’s a name and shame function that is possible here,” she said. “It holds some real potential for getting plans to clean up their acts.”

Filed under: General Problems | Leave a Comment »

The Patient and the Weather

Posted on July 2, 2023 by Pharmaciststeve

https://thepatientandweather.com/

The weather matters in human health. Pressure is what everyone looks to first, but humidity, temperature,, lightning and the rate of weather change all matter. And, as you body changes, so do the weather impacts. Weather health awareness remains a constant

 

Filed under: General Problems | 1 Comment »

PAIN WARFARE AND PROSECUTORS OF THE DEA: IT HAS COME TIME FOR THE AMA TO PROTECT THE PROFESSION OF MEDICINE

Posted on July 2, 2023 by Norman Clement

Qing McGaha, MD, 55, is the next minority physician to be targeted by the rogue US Department of Justice. Dr. Qing McGaha is a PM&R physician in Clearwater, FL. She received her medical degree from Tianjin Medical University in China, but then came to America for…

 

TAMPA PAIN CLINIC DOCTOR GUILTY OF UNLAWFUL DRUG DISTRIBUTION, OR A CLASSIC CASE OF PROSECUTORS MAKING ILLEGAL THAT WHICH IS LEGAL VOIDING RUAN: TIME FOR AMA INVOLVEMENT!!! (LET’S FILL IN THE BLANKS)

 

Filed under: General Problems | 10 Comments »

Opioid Disparities Shed Light on Potential Implicit Bias in Medicine

Posted on July 1, 2023 by Pharmaciststeve

Opioid Disparities Shed Light on Potential Implicit Bias in Medicine

https://patientengagementhit.com/news/opioid-disparities-shed-light-on-potential-implicit-bias-in-medicine

Researchers posit unequal opioid prescribing habits for Black and White patients in the same hospital are driven in part by implicit bias in medicine.

 – A new study revealing unequal opioid and pain medication prescription access between White and Black patients is calling into question the prevalence of implicit bias in medicine.

The research, published in the New England Journal of Medicine, showed that Black patients are less likely than White patients to get an opioid for pain management, even when receiving care in the same hospital. Although the researchers were careful to call for further investigation into the drivers behind this trend, they suggested inaccurate implicit biases about pain tolerance across racial groups could be at play.
Opioids for pain management are tricky, the team acknowledged in the study. Although opioids can be effective for alleviating acute pain and pain associated with advanced cancer, the medical community has increasingly shied away from over-prescribing opioids for fear of fueling the already raging opioid epidemic.

“Prescribers are challenged to balance these risks with their desire to relieve suffering,” the researchers wrote.

“Historically, this search for balance manifests as more liberal use of opioids for White patients than for Black or Brown patients. Given the complicated trade-offs, we do not yet know which group has fared better overall, but it is hard to imagine that the influence of race in these decisions — given that there is no known physiologic basis — reflects high-quality, equitable care.”

The team noted that limited opioid prescriptions might be protective for Black and Brown people, but that kind of paternalistic approach ignores the very real pain some Black and Brown patients experience.

The team sought to better understand differences in opioid prescriptions by looking at prescribing rates in Medicare patients ages 18 to 64 in and across healthcare organizations. By looking at a population comprised largely of workers with a disability, and by zeroing in on trends within a single institution, the researchers sought to better identify how disparities are playing out.

By and large, those disparities are stark. The team found that White patients were more likely to receive an opioid for pain management than Black patients. And even when Black patients did get an opioid prescription, chances are their White counterparts got a higher dosage. These trends were relevant even among those receiving care within the same hospital.

Across 310 different health systems, 50 percent of Black patients and 52 percent of White patients got any opioid prescription, a statistically significant but small difference, the team said. However, when looking at dosage, there was a bigger discrepancy. The mean annual dose was 36 percent lower for Black people than it was for White people, the team said.

Those findings rang true even when looking at an individual health system. Although the rate of opioid prescription receipt was only slightly lower for Black patients than White patients, 91 percent of health systems prescribed higher doses for White patients than Black.

For three-quarters of health systems, the annual mean dose for Black patients was at least 15 percent lower than for White patients.

The researchers did not investigate the reasons for these disparities, they emphasized as a caveat. That is a critical area for further research.

However, they did posit that implicit bias in medicine could be at play here.

“These opioid-receipt patterns probably reflect both overtreatment of White patients and undertreatment of Black patients,” the researchers wrote. “The findings should prompt systems to explore the causes and consequences of these biased patterns and to develop and test efforts to eliminate the influence of race on the receipt of pain treatment.”

“Could these findings result from something other than racial bias?” they continued. “We do not have the nuanced clinical data necessary to assess the appropriateness of the observed patterns of opioid receipt. Even when clinical data are available, the quality of pain management is hard to assess owing to the complex nature of this care.”

Previous literature about conscious and unconscious bias in medicine suggest to the researchers that those issues could be at play. For example, the medical field has been plagued by common, untrue myths that Black patients experience less pain than White patients, or that they are more likely to misuse opioid drugs. Although proven untrue, these notions could obscure clinicians’ prescribing decisions.

Additionally, poor patient-provider relationships could be erecting barriers. Particularly, patient-provider racial discordance—when the patient and the provider are of difference races—can sometimes lead to poor patient trust, limited empathy, and stunted communication, the researchers said. In turn, that could lead to unequal and potentially ineffective pain management prescribing practices.

And this could move even further beyond the interpersonal patient-provider interaction.

“We expect that systemic structural racism contributes as well,” the researchers posited. “Such systemic factors may include, for example, racially segregated neighborhoods and a lower density of pharmacies and continuity care clinics in predominantly Black neighborhoods than in predominantly White neighborhoods.”

Again, the researchers emphasized the limited evidence they have regarding implicit bias in medicine and the role it might play in opioid prescribing disparities. This is a crucial area for further research, they reiterated.

“We do not know whether or how these differences affect patient outcomes, because both opioid underuse and overuse can cause harm. We do know that skin color should not influence the receipt of pain treatment,” the researchers concluded.

“Our overall observations and system-specific reporting should prompt action by providers, health system administrators, and policymakers to explore root causes, consequences, and effective remediation strategies for racially unequal opioid receipt.”

 

Filed under: General Problems | 3 Comments »

IT AIN’T YOUR DOCTOR

Posted on July 1, 2023 by Norman Clement

 

KABUL, AFGHANISTAN — AUGUST 17, 2021: Zabihullah Mujahid, the Taliban spokesman for nearly 2 decades who worked in the shadows, makes his first-ever public appearance to address concerns about the Taliban’ reputation with women’s education, appearance and rights, television music, and executions, during a press conference in Kabul, Afghanistan, Tuesday, Aug. 17, 2021. (MARCUS YAM / LOS ANGELES TIMES)

YOU ARE WITHIN THE NORMS’ 3rd QUARTER QUICK LIST SYNOPSIS AND SUMMARY OF OUR MOST IMPACTFUL PUBLICATIONS ON DEA CRIMES AGAINST DOCTORS AND THE U.S. TAXPAYERS

Filed under: email box, General dumb-ass problems, Insurance companies | Leave a Comment »

“WHAT WE ARE ENDURING IS TORTURE”

Posted on July 1, 2023 by Norman Clement

” I know professionally and personally that what is being done in the United States to chronic pain patients and now surgery and acute pain patients. This honestly is an example of dictatorship and let me be clear, it is morally wrong. I pray Mr. Clement will find a doctor to treat him. I believe he will find that doctor and he will have to go through physical therapy to get his endurance back.”

MELINDA ROGERS: “I AM SO SORRY THAT THE GOVERNMENT LITERALLY HAS TAKEN OVER MEDICINE,” Part-4

Filed under: General Problems | 2 Comments »

“Congress prohibited a doctor from “knowingly or intentionally” dispensing a controlled substance except as authorized “

Posted on July 1, 2023 by Norman Clement

RUAN, KHAN vs. DOJ-DEA 9-0 RULING BEFORE SUPREME COURT UNITED STATES THE CONTROLLED SUBSTANCES ACT ONLY CRIMINALIZES ACTIVITIES OUTSIDE THE USUAL COURSE OF A DOCTOR’S PROFESSIONAL PRACTICE.

n June 27, 2022, in a separate and related case ruling 9-0 of the United States Supreme Court, Justice Stephen Breyer in summary, wrote for the majority that prosecutors must prove that doctors knew they were illegally prescribing powerful pain drugs in violation of the federal Controlled Substances Act.
When Congress enacted the Controlled Substances Act, it recognized that many drugs and substances regulated under the statute “have a useful and legitimate medical purpose and are necessary to maintain the health and general welfare of the American people.” 21 U.S.C. § 801(1). Congress, therefore, established five schedules to classify drugs and substances based on their accepted medical use for treatment, the relative potential for abuse, and the likelihood of dependence if abused. S e id. § 812.

 

SUPREME COURT SHUTS DOWN DEA FRAUDULENT LAW ENFORCEMENT PURSUITS OF HEALTHCARE PROVIDERS (1000’s OF DOCTORS MUST BE RELEASE FROM PRISON)

Filed under: Dumb politicians, General dumb-ass problems, Insurance companies | 1 Comment »

LAW ENFORCEMENT INTRUSION INTO PERSONNEL PATIENT MEDICAL CARE

Posted on July 1, 2023 by Norman Clement

 

I AM FELIX BRIZUELA, DO.,: I AM A NEUROLOGIST PHYSICIAN, NOT A STREET OR OFFICE DRUG DEALER OR TRAFFICKER

Filed under: General Problems | 1 Comment »

“WE ARE PHYSICIANS, PHARMACISTS, DENTISTS TREATING PATIENTS IN NEED OF PAIN CARE WITH MEDICATIONS, NOT STREET DRUG DEALERS AND TRAFFICKERS”

Posted on July 1, 2023 by Norman Clement

 

PAIN AND THE RULE OF LAW The question here is the Rule of Law. The most fundamental concept of our country, without it our society crumbles. This allows an agency to take anything they want unchecked based on their own manufactured rules and misinterpretation of laws, and medical procedures guidelines, creating their science and facts.
The great fear here is that the United States Drug Enforcement Administration (DEA) has operated unchecked as a rogue sub-agency of government operating outside the rule of law. Creating their own medical science (Auer deference), seizing property using the omnipotent authority of ill-gotten gain over the field of medicine and medical science.

PAIN AND THE RULES OF LAW

Filed under: General Problems, Insurance companies, Medication withdrawal, Mistakes/Errors | Leave a Comment »

« Previous Page — Next Page »