Tricare to reduce number of network pharmacies for its beneficiaries this month

https://www.stripes.com/theaters/us/2022-10-11/tricare-prescriptions-pharmacy-express-scripts-7659239.html

A new contract from prescription-drug benefit manager Express Scripts will force nearly 15,000 pharmacies out of the Tricare network by the end of this month, according to a spokeswoman for a small pharmacies’ association.

The new contract will remove 14,963 pharmacies from the network by Oct. 24, leaving approximately 41,000 pharmacies.

A proposed contract Express Scripts sent to participating pharmacies in August lowered their reimbursement rates below even their own costs, Anne Cassity, vice president of federal and state government affairs at the National Community Pharmacists Association, told Stars and Stripes by phone Sept. 22. She said association members had never before seen anything like it.

“We saw a massive reduction in reimbursements to the tune of far below even acquisition price for our pharmacies,” Cassity said. “So, they would be underwater on every prescription that they dispense for a Tricare beneficiary.”

Many small, local pharmacies had to refuse the new contract, she said.

“This is going to have a huge effect, especially in rural areas where it’s generally independent pharmacies,” Cassity said.

Express Scripts, a pharmacy benefit management company based in St. Louis, handles annual pharmacy contract negotiations on behalf of Tricare. It also provides a mail order prescription service for Tricare beneficiaries. The company has 27,000 employees and annual revenue of over $100 billion, according to job-search website Zippia.

In August 2021 the Department of Defense awarded a $4.3 billion contract to Express Scripts that incentivized the company to reduce the size of the Tricare retail pharmacy network, according to email and phone conversations with National Community Pharmacists Association spokeswoman Andie Pivarunas.

“Express Scripts began notifying impacted beneficiaries in mid-September 2022,” Tricare spokesman Peter Graves told Stars and Stripes by email Sept. 30.

“Anyone with a prescription at a pharmacy that is transitioning out of the network should transfer it to a new network pharmacy to avoid paying the full cost of the prescription up front or having to file a claim for reimbursement,” Graves said.

Doris Parker, 66, of Alexandria, Va., the wife of a retired service member, used to receive Kisqali, a cancer medication, through the Express Scripts mail-order service, she told Stars and Stripes by phone on Sept. 26.

“About three or four months after I started taking it, they decided they aren’t going to send it to me anymore,” she said.

Parker turned instead to a local pharmacy, but in September was told by Express Scripts that the pharmacy would be dropped from the Tricare network, she said.

Tricare denies its new contract will have a huge, negative impact on beneficiaries living in rural areas.

“The Tricare retail network will continue to meet or exceed Tricare’s standard for pharmacy access,” Graves said. “[Defense Health Agency] expects nearly 95% of beneficiaries will maintain access to at least two network pharmacies within 15 minutes from their home, and over 99% will have access within 30 minutes.”

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This kind of reminds me of when Medicare started  Diagnosis Related Group reimbursement in the early 80’s https://www.medicareadvantage.com/coverage/diagnosis-related-group  basically what it was… that Medicare decided to reimburse hospitals a fix $$$ on a pt when they were admitted to a hospital.  What it meant was that when a pt was admitted to a hospital the  medical reason for admission had a $$$ figure attached to that health issue and if the hospital was able to treat the pt and spend less than the $$$ allowed – they made money – and if they spent more than the $$ allowed – they LOST MONEY…  It was claimed that pts were being DISCHARGED QUICKER AND SICKER before the DRG reimbursement system was implemented.

Medicare Advantage Fraud Cases Pile Up; COVID Origins Settled? Nurse’s Murder Trial

https://www.medpagetoday.com/special-reports/features/101184

Welcome to the latest edition of Investigative Roundup, highlighting some of the best investigative reporting on healthcare each week.

Medicare Advantage Is Being Exploited for Big Profits

Major health insurers are exploiting the Medicare Advantage program to “inflate their profits by billions of dollars,” the New York Times reported, citing their review of dozens of fraud lawsuits, inspector general audits, and investigations by watchdogs.

By 2023, more than half of Medicare beneficiaries are expected to have a private Medicare Advantage plan, according to the Times. Although Medicare Advantage was meant to encourage better care at lower costs and to improve upon the traditional program, it has become more costly.

“The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients,” the Times reporters wrote. “And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.”

In response, most of the largest Medicare Advantage insurers contested the allegations, and have said that federal audits have been subpar. They have also said their goal has been to improve care by accurately describing patients’ health.

“Medicare Advantage is an important option for America’s seniors, but as Medicare Advantage adds more patients and spends billions of dollars of taxpayer money, aggressive oversight is needed,” Sen. Charles Grassley (R-Iowa), who has investigated the industry, said, according to the Times. He added that abuses of the program, such as making patients look sicker than they are, have “resulted in billions of dollars in improper payments.”

Many of the fraud lawsuits have been brought by former health insurers’ employees, and most have been joined by the Department of Justice. However, regulators at CMS have been more lax.

“Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care,” the Times reporters noted.

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Bain: 25% of clinicians want out of healthcare

https://www.beckershospitalreview.com/workforce/bain-25-of-clinicians-want-out-of-healthcare.html

One quarter of U.S. physicians, advanced practice providers and nurses are considering switching careers and one third are considering switching employers, according to newly released results from a survey conducted by Bain & Company.

Below are some key takeaways from the survey and brief, which was released Oct. 11 and can be found in full here. 

1. Of the 25 percent of clinicians who are thinking about exiting healthcare entirely, 89 percent cite burnout as the main driver.

2. Nearly 60 percent of physician, advanced practice provider and nurse respondents say their teams are not adequately staffed; 40 percent feel there is a lack of resources to operate at full potential.

3. Physicians’ net promoter score dropped from 36 points in 2020 to 19 points today.

4. Clinicians at physician-led practices gave a net promoter score of 40 points compared to the 6 points from clinicians at non-physician-led practices, such as those operated by hospitals, health systems, parent companies or private equity funds. 

5. The top three things clinicians care about most in their profession are compensation, quality of patient care and workload, according to the survey. Of those three, they are least satisfied with compensation (59 percent expressed satisfaction) and workload (60 percent). Eighty percent said they are satisfied with the quality of patient care. 

6. Burnout shows up throughout clinicians’ days, with 63 percent saying they feel worn out at the end of the workday, 51 percent saying they feel they don’t have time and energy for family and friends during leisure time, and 38 percent feeling exhausted in the morning at the thought of another workday. 

The Bain U.S. Frontline of Healthcare Survey was conducted in July 2022 with 573 U.S. clinicians.

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Other than the “primary parts of our voice ” – volume, pitch, tone, volume … I do not claim to be a expert on the human voice. It is unfortunate that this study is not being done on how the parts of  a person’s voice is changed/compromised by under/untreated pain. While there is no definitive lab test that will conclude what the pt’s pain intensity is, there are a number of other health issues that can be measured and when certain health issues. Here is a chart that indicates that under/untreated pain can complicate a pt’s comorbidity issues and in some incidents cause some comorbidity issues for a pt.

Issues like:

severe hypertension even when the pt is taking up to four different categories of high blood pressure medicines.

Being Diagnosed with Addison’s disease after long term under/untreated pain and the adrenals tend to fail for trying to increase cortisol output,  when the body tries to compensate for all the stress the pt is dealing with from under/untreated pain

Some pain pts often are dealing with some sort of auto immune disease and because of that they tend to suffer from hypothyroidism and/or a very low thyroid level – but just within the “acceptable range”

Just imagine if we could get a basic voice recording during school physical or other such points with a  interaction with a health care practitioner.  Or any other time frame that could be from a reliable point in a person’s life

I suspect that most chronic pain pts’ vocalizations change … sometimes dramatically with break thru pain.  With sort of basic vocal test with a pt… that can be compared at some point later in life if/when the pt becomes a chronic pain pt and/or dealing some acute pain from a surgical intervention.  Could be utilized to treat the pt’s pain and optimize their pain management and quality of life.

This sort of data could also put a prescriber’s mind at ease that the pt is not faking the pain and/or the intensity of the pain.  Also could give the prescriber more documentation that the pt has a valid medical necessity for pain management.

Artificial intelligence could soon diagnose illness based on the sound of your voice

https://www.npr.org/2022/10/10/1127181418/ai-app-voice-diagnose-disease

Voices offer lots of information. Turns out, they can even help diagnose an illness — and researchers are working on an app for that.

The National Institutes of Health is funding a massive research project to collect voice data and develop an AI that could diagnose people based on their speech.

Everything from your vocal cord vibrations to breathing patterns when you speak offers potential information about your health, says laryngologist Dr. Yael Bensoussan, the director of the University of South Florida’s Health Voice Center and a leader on the study.

Dr. Olivier Elemento of Weill Cornell Medicine is the other co-principal investigator on the project.

Travis Curry /Olivier Element

“We asked experts: Well, if you close your eyes when a patient comes in, just by listening to their voice, can you have an idea of the diagnosis they have?” Bensoussan says. “And that’s where we got all our information.”

Someone who speaks low and slowly might have Parkinson’s disease. Slurring is a sign of a stroke. Scientists could even diagnose depression or cancer. The team will start by collecting the voices of people with conditions in five areas: neurological disorders, voice disorders, mood disorders, respiratory disorders and pediatric disorders like autism and speech delays.

The project is part of the NIH’s Bridge to AI program, which launched over a year ago with more than $100 million in funding from the federal government, with the goal of creating large-scale health care databases for precision medicine.

“We were really lacking large what we call open source databases,” Bensoussan says. “Every institution kind of has their own database of data. But to create these networks and these infrastructures was really important to then allow researchers from other generations to use this data.”

This isn’t the first time researchers have used AI to study human voices, but it’s the first time data will be collected on this level — the project is a collaboration between USF, Cornell and 10 other institutions.

“We saw that everybody was kind of doing very similar work but always at a smaller level,” Bensoussan says. “We needed to do something as a team and build a network.”

The ultimate goal is an app that could help bridge access to rural or under served communities, by helping general practitioners refer patients to specialists. Long term, iPhones or Alexa could detect changes in your voice, such as a cough, and advise you to seek medical attention.

To get there, researchers have to start by amassing data, since the AI can only get as good as the database it’s learning from. By the end of the four years, they hope to collect about 30,000 voices, with data on other biomarkers — like clinical data and genetic information — to match.

“We really want to build something scalable,” Bensoussan says, “because if we can only collect data in our acoustic laboratories and people have to come to an academic institution to do that, then it kind of defeats the purpose.”

There are a few roadblocks. HIPAA — the law that regulates medical privacy — isn’t really clear on whether researchers can share voices.

“Let’s say you donate your voice to our project,” says Yael Bensoussan. “Who does the voice belong to? What are we allowed to do with it? What are researchers allowed to do with it? Can it be commercialized?”

While other health data can be separated from a patient’s identity and used for research, voices are often identifiable. Every institution has different rules on what can be shared, and that opens all sorts of ethical and legal questions a team of bioethicists will explore.

In the meantime, here are three voice samples that can be shared:

Credit to SpeechVive, via YouTube.

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It is included in both the Americans with Disability Act and The Civil Rights Act that discrimination under those laws …both racism/disability are in the same sentence.  I guess that race or skin color is perhaps a lot more rational and identifiable as a possibility of the pt being discriminated against. While validating that a pt is dealing with acute pain than chronic pain… but there is no lab test that will determine the pt’s intensity of their pain. and perhaps what healthcare personnel rely on to validate their reasoning for failing to treat the pt’s pain without any justification for failing to treat ? 

Nurse Protests Her Firing Over Refusal to Take Implicit Bias Training

https://www.medpagetoday.com/special-reports/features/101127

A Texas nurse said she was fired for refusing to take implicit bias training, claiming that states across the U.S. are forcing healthcare professionals to “make false confessions of racism,” and that she “refused to go along.”

Laura Morgan, RN, said that she was let go from Dallas-based Baylor Scott & White Health in February, months after the organization put forth its annual training modules for clinical educators. She said that she had expressed concern about the required implicit bias training, and requested meetings with her employer’s chief nursing officer and human resources director so she could be exempt.

“After 39 years of providing equal care to all my patients without regard to their race, I objected to a mandatory course grounded in the idea that I’m racist because I’m white,” Morgan wrote in an opinion piece published in the Wall Street Journal. “The idea of implicit bias is grounded in the belief that white people treat those who aren’t white worse than those who are. It’s part of the woke assumption that society, including healthcare, suffers from ‘systemic racism.'”

“Policy makers don’t seem to be considering the unintended consequences of these mandates,” she continued. “Accusing my peers and me of racism will contribute to soaring levels of burnout, causing many to leave the medical profession. Some, like me, will surely be forced out. Patients, especially minorities, will experience the most harm.”

Ultimately, Morgan said that she knew her termination was looming after it became evident she would not be exempt from the implicit bias training at Baylor Scott & White. However, she said that she was still “devastated” when she was fired and could not find a new healthcare job.

Morgan expressed concern about the growing number of her peers who may be forced out of the field for sharing her view, citing a continuing-education course on implicit bias through the Kentucky Board of Nursing and requirements for such training in states like Michigan and Massachusetts. She also wrote that more state mandates are likely on the way, “including in red states,” and that implicit bias training has garnered support from powerful medical associations.

There is not “sufficient evidence to support the claim that all white people are implicitly biased,” and there is research that indicates “implicit bias testing is flawed,” she said.

However, many other organizations and experts flatly disagree with Morgan’s stance.

They continue to hold that implicit bias is what is in fact harming patients, and that such findings have been behind a nationwide push for training — supported by many on both sides of the political aisle — to help chip away at the issue.

Groups including the Federation of State Medical Boards have highlighted how COVID-19 has shed further light on longstanding healthcare disparities across the country, and they have taken new measures to understand and address systemic racism, implicit bias, and inequity in medical regulation and care.

Morgan’s former employer told MedPage Today in a statement: “Baylor Scott & White Health believes in the importance of, and is committed to Diversity, Equity and Inclusion initiatives; and it believes in providing its team members resources for continual development.”

Morgan is now a program manager at an organization called Do No Harm, which states that its mission is to “protect healthcare from a radical, divisive, and discriminatory ideology.”

Morgan told MedPage Today in an email that it was important for her to write and publish the opinion piece “because requirements to complete this type of ‘education’ in order to start or keep a career or obtain a license in the healthcare industry are increasing across the country.”

“There has been a substantial outpouring of support for my position on this issue from healthcare providers and the public since its publication in the Wall Street Journal,” she said.

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Motrin/Ibuprofen came to market in 1975 and those suffering from pain perceived it as a “miracle med”… The Pharma that brought it to the market – UpJohn – grossly under estimated the demand there would be for this medication..  It almost instantaneously went into a BACK ORDER STATUS.. The Pharmacy I was working at the time was able to purchase this med directly from UpJohn and we would order 12 bottles of 500 tabs of Motrin 400 mg… every couple of days… when we did get a order… it would all be GONE….  UpJohn had to build a new manufacturing facility to meet demand..  It was in a BACK ORDER STATUS for what seemed like FOREVER.  Motrin was the first new addition to the class of meds we now know as NSAID.  Prior to this, pain pts only had Aspirin, Tylenol and a Rx med Indocin.

Hopefully, sooner rather than later… “they” will come to the conclusion that no matter what methodology is used to treat a pt’s pain… each has their own problems, possible pain management, complications, adverse side effects and/or possible harm to various parts of the human body. “they” have been searching for the “perfect pain management protocol” since I was in pharmacy school in the 60’s.

Any every few years, “they” make a new press release of  “new promising, non addicting pain management medication” in early development.

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Will Narcan being available – for free – in vending machines, will this encourage other to “try street fentanyl” because they believe that they have someone with them that can “save their ass “… and not knowing that Narcan has a fairly short half life and someone ODing on illegal street fentanyl… may return to a status of fatal respiratory suppression within 15 minutes and even if a second dose is administered – there is two doses in one of these boxes provided by these vending machines – doesn’t mean that the pt who has OD’d.. will survive after getting two separate doses of Narcan.  Could “we” see an increase in the abuse of illegal street fentanyl and/or the number of OD’s/poisoning because the people trying illegal street fentanyl for the first time… doesn’t understand all the possible complications and outcomes, because they have Narcan on hand and falsely believe that it can “save their ass” when taking illegal street Fentanyl

Narcan vending machine in Kentucky empty within one day of being installed

https://www.wcvb.com/article/narcan-vending-machine-kentucky-empty-within-day/41519040

VINE GROVE, Ky. —

Kentucky’s first Narcan vending machine, the brand name for the opioid-reversal drug naloxone, is completely empty just one day after it was installed.

Vine Grove Police Chief Kenny Mattingly said the machine was empty by 6 p.m. last Friday. The machine was just announced and unveiled the day before.

“I thought it would go quick, but not that fast,” Mattingly said.

The vending machine was installed outside of the Vine Grove Police Department last Friday.

Mattingly had the idea for it after he saw a young woman save a friend’s life earlier this year when he overdosed in her bathroom.

 That got me to thinking about making it available to the general public, versus law enforcement and first responders,” Mattingly said.

The biggest perk of the machine is that it’s completely free. All people have to do is punch in a number and it dispenses a two-dose box of Narcan and literature about treatment and recovery.

Mattingly said the department has ordered more and the machine will be restocked this week.

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FDA announces recall of 2 cardiovascular medications due to labeling mix-up

https://cardiovascularbusiness.com/topics/clinical/pharmaceutics/fda-announces-recall-2-cardiovascular-medications-due-labeling-mix

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