CVS upper echelon Disney World Bash: John Legend entertainment – costs up to ONE MILLION DOLLARS

CVS/Aetna’s $9 billion in profits paid for a lavish party and stock buybacks. Not patients’ medical claims.
CVS/Aetna’s spending included trips to Disney and a John Legend concert for employees.

A few days after executives of CVS/Aetna won a resounding thumbs up from Wall Street last week, they headed south (many undoubtedly on private jets) to Disney World for a lavish “leadership” party they threw themselves.

Thanks to videos posted on social media by some of the partiers, we know the company hired John Legend to entertain them.

John Legend doesn’t come cheap. Back in 2015, he reportedly was paid $300,000 to sing two songs at a Beverly Hills wedding. Luxury wedding planner Scarlet tells clients it will now cost them $1 million (plus travel and production costs) to snag Legend for their big events. We don’t know what his corporate rate is, but I doubt he would charge the country’s fourth largest corporation anything less than that.

Meanwhile, a few miles southwest of Orlando, friends of cancer patient Jasen Garrity are trying to raise $10,000 on GoFundMe to cover the out-of-pockets Aetna made Garrity pay before his treatment could begin. As the fundraiser’s organizer wrote:

Jay currently requires an insertion of a tracheotomy to allow him increased ability to breathe. It is difficult for him to sleep. Robin (his wife) is awake most nights worrying over Jay. To get the trach inserted Jay will need to be admitted to the hospital for 6 days and the hospital requires $2600.00 to even schedule the surgery because Aetna’s family deductible has reset.

Garrity’s story is by no means unique. While CVS CEO Karen Lynch and other executives were swag surfin’ in Florida, thousands of American patients have had to turn to GoFundMe because they can’t afford the deductibles, copays, and other out-of-pockets insurers demand they pay. In fact, 100 million Americans–most of them insured by Aetna and other big insurers–are mired in medical debt. As Kaiser Health News reported in June:

In the past five years, more than half of U.S. adults report they’ve gone into debt because of medical or dental bills…A quarter of adults with health care debt owe more than $5,000. And about 1 in 5 with any amount of debt said they don’t expect to pay it off…The burden is forcing families to cut spending on food and other essentials. Millions are being driven from their homes or into bankruptcy.

While Jasen Garrity and millions of other insured Americans with serious health issues were begging for money to stay alive last year, Lynch hauled in more than $20 million, 458 times the average pay of other CVS employees. Also know that Aetna is spending considerably less paying patients’ medical claims as a percentage of revenues this year than last year, despite the fact that CVS collected billions more from its customers during the first six months of this year than in the same period in 2021 ($157.5 billion and $141.7 billion respectively).

That enabled the company to report making $9.3 billion in profits during the first half of 2022, $200 million more than during the first half of 2021. This year is off to such a good start for CVS that Lynch and her fellow executives told investors last Wednesday that they believe profits will be higher this year than they previously had expected.

Wall Street loved that news. By the time the New York Stock Exchange closed Wednesday afternoon, investors had bid the company’s stock up 6%, according to CNBC. 

CVS execs gave no indication they’ll use any of the extra billions to help customers like Jasen Garrity stay out of bankruptcy. They did say a few months ago, however, that they will spend up to $10 billion this year buying back shares of CVS stock, a gimmick that will increase the value of the millions of shares of CVS stock that Lynch and other company executives own.

By the way, most of the company’s revenues are now coming from the pharmacy benefit manager (PBM) it owns, not from its health plans and retail stores. During the first half of 2022, its PBM revenues totaled $82.3 billion, far more than the $45.9 billion from Aetna’s health plans and the $51.7 billion from CVS stores.

As patient advocate Beth Joyner Waldron tweeted about the company’s leadership bash in Orlando:


I encourage you to read Waldron’s thread, which along with the pics and videos she found of CVS’ partying leaders, went viral. (If you have time, you might also consider reading a piece I wrote several years ago about the lavish parties insurers throw every year–using customers’ money–to reward their top sales executives. And take a look at the thread I wrote in March about the role Karen Lynch and Cigna CEO David Cordani played in creating America’s growing out-of-pocket debt crisis.)

I also encourage John Legend to donate whatever CVS paid him to help cover the outrageously high out-of-pocket expenses millions of insured Americans are desperately trying to cover.

I doubt he knew the enormous pain and suffering Aetna’s high out-of-pocket requirements are causing for so many. And based on this Twitter thread from 2020, I believe his heart is in the right place:

He went on to say:

John Legend, the work I do now is an attempt to make amends for the years I helped big insurers make Wall Street happy and for all the leadership junkets I attended. I call on you to make amends for your ill-advised private CVS concert by supporting the important work of the Lower Out of Pockets NOW Coalition. We won’t rest until we make Aetna and the rest of Big Insurance change so their customers can stay out of bankruptcy and away from GoFundMe.  You can make an enormous difference if you’ll join us.

Life saving & liver sparing therapy given to few insured pts on a timely basis ?

CDC: Few Insured Patients With Hepatitis C Get Timely Treatment

— Not even one-third received curative drugs within a year of diagnosis

Although hepatitis C infection is a highly curable disease, few insured patients diagnosed received direct-acting antiviral (DAA) treatment during 2019-2020, while disparities contributed to treatment delays, according to new CDC data appearing in an early edition of the Morbidity and Mortality Weekly Report.

Adjusted multivariable regression analysis showed Medicaid recipients were least likely to initiate DAA treatment within 360 days of testing positive for hepatitis C infection (23%). Medicare recipients fared somewhat better (28%), as did individuals with private insurance (35%).

Adjusted odds ratios relative to private insurance for receiving DAA therapy were:

  • Medicaid: 0.54, 95% CI 0.51–0.57
  • Medicare: 0.62, 95% CI 0.56–0.68

And among those treated at some point, more with private insurance received it within 180 days of initial diagnosis (84%) compared with those on Medicaid (75%) or Medicare (77%), reported Carolyn Wester, MD, MPH, director of the Division of Viral Hepatitis at the CDC, and colleagues.

Medicaid is the least likely insurer to cover DAA treatment, so it was no surprise that residents of states with Medicaid treatment restrictions were less likely to initiate treatment, versus those in states without them (aOR 0.77, 95% CI 0.74–0.81).

Hepatitis C viral infection impacts over 2 million Americans with incidence on the rise — especially among young individuals with injection drug use — and leads to 14,000 annual deaths nationally. Eight to 12 weeks of DAA treatment is recommended to effectively cure 95% or more hepatitis C cases. Despite this, only about 1.2 million individuals initiated DAA treatment from 2014 to 2020, which remains far below the national elimination goal as fewer seek treatment.

“Everyone with hepatitis C should have access to lifesaving treatment, regardless of race, ethnicity, age or insurance status,” said CDC Acting Principal Deputy Director Debra Houry, MD, MPH, in a press release. “What these data tell us is that at best, only one in three people are treated within a year of being diagnosed and we must reduce the barriers and get more people treated for hepatitis C in our country. This is critical to stop preventable deaths and prevent new infections.”

For this report, CDC researchers retrospectively examined Health Verity data on over 2 million patients with hepatitis C across all 50 states and the District of Columbia from Jan. 30, 2019, to Oct. 31, 2020. Those included were adults ages 18-69, who were continuously insured for at least 60 days before and at least 360 days after their diagnosis. The analysis adjusted for demographics, insurance payor, and Medicaid restrictions.

Younger people – ages 18-39 – on Medicaid or private insurance had the lowest rates of treatment initiation, versus those ages 50-59. Across all insurance plans, men had consistently lower odds of initiating treatment than did women.

Among Medicaid recipients, odds of treatment initiation were lower for Black individuals (aOR, 0.93, 95% CI 0.88–0.99) or those coded as “other” for race (aOR 0.73, 95% CI 0.62–0.88), versus whites.

To increase treatment access, researchers suggested removing eligibility restrictions/preauthorization requirements, providing treatment where patients already receive services in as few visits as possible, and expanding primary care providers who can treat hepatitis C.

“People shouldn’t have to jump over hurdles to access lifesaving, cost-effective treatment,” said Wester in the CDC’s press release. “Removing barriers to treatment is a critical step, as is increasing screening for hepatitis C. We estimate about 40% of people with hepatitis C in the U.S. are unaware of their infection — testing is the first step to accessing curative treatment.”

Wester and colleagues acknowledged that the findings may not be generalizable to all hepatitis C patients, since those incarcerated or uninsured were excluded. Treatment initiation rates could have been overestimated, while data on ethnicity were missing for 61% of people included in the analysis.

Zoom meeting: 08/11/22 12PM (noon) EDT Attorneys discussing using ADA to help addicts get harm reduction drugs & paraphernalia

Advancing Syringe Services in the US: The Untapped Role of the ADA

Please join us to discuss “Advancing Syringe Services in the United States: The Untapped Role of the Americans with Disabilities Act”.

About this event


The United States is facing an unprecedented set of public health challenges. Now killing nearly 1000 people daily, the COVID-19 pandemic is also compounding the ongoing crisis of addiction and risky substance use. Disruption in treatment and support services, economic shocks, despair and social isolation wrought by coronavirus have all impeded efforts to bend the overdose curve—now surging again after a momentary deceleration prior to the onset of the pandemic. By the same token, there is evidence that people with substance use disorder are more susceptible to COVID-19 infection and its deadly sequelae.

Now more than ever, prevention and supportive services are vital to safeguarding the health of people with substance use disorder. Although access to substance use treatment has received substantial attention and support, harm reduction services are being left behind. These vital programs include syringe service programs (SSPs), naloxone distribution, drug checking, and supervised consumption facilities. Intended to address the needs of highly-stigmatized, criminalized people who use illicit drugs, SSPs have been shown especially effective as platforms for stemming bloodborne infections, preventing overdose, and facilitating access to a broad range of assistance, including COVID-19 testing, substance use treatment, housing, and other essential support.

Please join the Health in Justice Action Lab for a virtual networking and strategy session to improve and expand access to syringe services in the US, featuring authors Leo Beletsky, JD, MPH, Valarie Blake, JD, MA, and Abigail Fletes, JD.

See the article here.

Join Zoom Meeting:       

Thu, August 11, 2022

12:00 PM – 1:30 PM EDT

Meeting ID: 389 588 8990

Here’s who Democrats’ drug pricing bill will actually help

Here’s who Democrats’ drug pricing bill will actually help

WASHINGTON — Millions of patients in the Medicare program could eventually see lower prescription drug costs if Democrats pass their latest drug pricing plan into law.

The plan, which cleared a major hurdle Sunday when the Senate very narrowly approved it, has four major policies — it would allow Medicare to negotiate prices for some costly drugs, penalize drugmakers for hiking prices faster than inflation, redesign Medicare’s prescription drug benefit and cap annual costs at $2,000, and cap Medicare patients’ insulin costs at $35 per month.

Those changes won’t take effect right away. Most wouldn’t take effect until 2024; negotiated drug prices won’t be in place till 2026. The cap on insulin costs comes a little sooner, in 2023. And drugmakers that hike their prices would face penalties starting in October.

Democrats’ drug pricing reforms also won’t help as many people as they had originally hoped, as two major provisions that would have affected people who get insurance through their jobs ran afoul of Senate rules.

That means most of the patients who will directly benefit from the policy are adults 65 and older who are in the Medicare program. STAT has compiled a list of the categories of patients who are most likely to see benefits at the pharmacy counter.

There’s one big variable to keep in mind — insurance premiums. At least for a little while, as Medicare’s benefits get more generous and more patients can afford drugs, spending may go up.

“The premium effect is really difficult to predict, almost more difficult than the effect on drug prices,” said Juliette Cubanski, the deputy director of Medicare at the Kaiser Family Foundation.

The legislation would cap premium increases at 6% per year through 2029 to help decrease the impact, but it’s possible in the short-term that some beneficiaries could pay more for premiums than they would save.

None of the policies in Democrats’ package would directly affect people who get insurance through their jobs, or through Affordable Care Act marketplaces. There’s a raging debate over whether the pharmaceutical industry will charge these patients more to make up for lost money, or whether cost controls in Medicare could set a precedent for other insurers to demand lower prices, as well.

It seems counterintuitive, but Medicaid programs could actually have higher costs too if drugmakers raise their prices more slowly, according to congressional budget analysts. If that trend continues, it will cause states to have to make choices to work around the financial hit.

Medicare patients who pay a lot for drugs

The most obvious benefit is in the part of Medicare that covers drugs sold in pharmacies, Part D, where the reform package would cap patients’ annual out-of-pocket costs at $2,000 and spread them throughout the year, starting in 2024.

There are differing estimates of how many people could benefit from the cap.

Kaiser Family Foundation analysts found that 1.4 million people with traditional Medicare benefits spent $2,000 or more in 2020. An estimate co-authored by Sean Dickson, director of health policy at the West Health Policy Center, found that if a $2,000 out-of-pocket cap had been instituted in 2021, at least 3.1 million patients would have seen savings.

While many older adults may not spend more than $2,000 per year on their drugs right now, the new annual cost protections ensure financial protections for the future, said Vanderbilt University associate professor of health policy Stacie Dusetzina.

“People should be really excited. Medicare Part D has been an incredibly beneficial program for older adults, [and it] does not work for people who need expensive drugs,” Dusetzina said.

It’s unclear whether patients who take drugs that Medicare ultimately negotiates starting in 2026 will save money simply because of the negotiation.

They’re likely to be expensive, so it’s possible folks will still hit that $2,000 cap anyway. But if not, patients would likely end up paying a percentage of the lower price, which could save them money on each prescription fill.

Low-income patients on Medicare

The package also includes a change to Medicare’s low-income benefits for pharmacy drugs — a provision that has flown a bit under the radar.

Right now, Medicare enrollees who make between 135% and 150% of the federal poverty level get some help from the federal government for their drug costs, but they still have to pay 15% of the prices of their drugs. For 2022, 150% of the federal poverty level is $20,385 for a single person.

Starting in 2024, Democrats’ plan would allow people making up to 150% of the federal poverty level to get full benefits. That means they would have a set, low cost for each prescription instead of paying a percentage of the full price.

Around 400,000 people fell into that category in 2020, per a Kaiser Family Foundation analysis, but Dusetzina said there may be more patients out there who are eligible, but not enrolled.

“This is a really big deal because by definition, these patients are near poor but still have high cost-sharing,” Dusetzina said.

Medicare patients who use insulin

Democrats’ drug pricing plan would also force all plans in Medicare to offer insulin at a maximum of $35 per month for patients starting next year.

Medicare beneficiaries already have options to buy a plan that caps insulin costs at $35 per month, but about a quarter of Medicare patients still paid more than that in 2021, per data compiled by the the life science analytics firm IQVIA.

It’s a quick turnaround, as plans have already submitted their premium estimates for next year, but insurers have factored in that this policy could become law, West Health’s Dickson said.

Medicare patients taking drugs on the market now

It wouldn’t necessarily lower drug prices, but Democrats’ proposal to penalize drugmakers that hike prices faster than inflation would provide more predictable prices for Medicare patients.

This policy is the first scheduled to go into effect. The penalties would start in October for pharmacy drugs, and in January for drugs that are administered in doctors’ offices.

It’s hard to predict the future of which drugs would have seen dramatic price spikes, but similar to the annual cost protections, it allows more predictability for Medicare patients. However, half of drugs covered by Medicare took price hikes steeper than inflation in 2020, according to a Kaiser Family Foundation analysis.


While pts can’t get their Rxs in a timely manner at CVS ..this is how they help upper management unwind at DISNEY WORLD

The most recent quarter CVS reported abt a 3 BILLION net profit (pretax)… the above apparently is from a recent “upper echelon management” is REWARDED for helping CVS generate all those $$ in profits…

from the twitter post  The private John Legend concert CVS Health hosted (despite restrictive formularies, non-medical switching & denying patients medication access due to cost) was just the icing on the cake CVS leaders enjoyed this week in Orlando. Let’s take a peek at good times on patient dime…

study provided a clear picture of pain medication: to assist pharmacists in targeting deprescribing efforts geared at both patients and providers

Pain Management in Breast Cancer Outpatients

Pain is reported by 25% to 89% of breast cancer (BC) patients during the disease process. This pain, which may be due to disease progression, surgery, or drug treatment, can range from mild to severe and can be of short or long duration. Little is known about how this pain is managed in the outpatient setting.

A retrospective, administrative claims data study utilizing information from the National Ambulatory Medical Care Survey (NAMCS), which is a national probability cross-sectional sample survey of office-based medical care services, was conducted to examine pain management practices and the factors associated with the prescription of pain medications, especially opioids, in women with BC. The study analyzed NAMCS data obtained between 2011 to 2016.

Women aged 18 and older years were included in the study if—based on either International Classification of Disease-9 (ICD-9) or ICD-10 codes—BC was their primary diagnosis. The medications were classified using the American Hospital Formulary Service (AHFS) classification and included opioids, nonopioids (e.g., nonsteroidal anti-inflammatory agents, acetaminophen, salicylates), and combinations of both drug classes. Adjuvant analgesics included the anticonvulsants (e.g., barbiturates), antidepressants (e.g., selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants), and corticosteroids.

Between 2011 and 2016, 23.95 million office visits were made by women with a primary diagnosis of BC. Of this group, over one-half (50.81%) were aged 40 to 64 years. One-third (32.81%) of visits occurred in the Northeast region, with almost all (95.65%) occurring in metropolitan areas. The vast majority of patients (83.7%) were identified as White. Most of these patients (84.93%) were seen in general and family practice settings. Depression and diabetes were the most common comorbidities.

During these visits, over one-quarter (27.12%, or about 6.5 million women) received pain medications. Among the total study population, 15.16% received opioids, 17.13% were prescribed nonopioid analgesics, and 22.7% received adjuvant therapies. Over one-tenth (10.27%) of patients received combination analgesics. Tramadol and oxycodone were the most prescribed opioids (3.75% and 1.57%, respectively). Ibuprofen, followed by naproxen, were the most prescribed nonsteroidal anti-inflammatory agents (3.73% and 1.27%, respectively). Benzodiazepines, followed by glucocorticoids, were the frequently prescribed adjunctive therapies (7.61% and 6.98%, respectively).

Factors significantly associated with the decreased prescribing of analgesics included residing in the Northeast as opposed to the West (odds ratio [OR] = 0.31, 95% CI -0.10 to 0.99), being White as opposed to Black (OR = 0.5, 95% CI 0.3-0.85) and being seen by nonprimary care physicians rather than primary care physicians (OR = 0.37, 95% CI 0.15-0.94). Being on Medicaid or other state-based payment programs as opposed to having private insurance (OR = 2.38, 95% CI 1.15-4.93), being prescribed adjuvant medications versus not receiving these agents (OR = 4.74, 95% CI 3.10-7.24), and visiting general or family practice specialties compared with other specialties (OR = 3.18, 95% CI 1.22-8.29) were associated with increased prescribing of pain medications.

The only two factors that were significantly associated with opioid prescribing were geography and medical specialty. Women living in the Northeast, Midwest, and South were 94-fold (OR = 0.06, 95% CI 0.01-0.29), 85-fold (OR = 0.15, 95% CI -0.04 to 0.62) and 76-fold (OR = 0.24, 95% CI 0.06-0.92) less likely to receive opioids than those residing in the West. General and family practice clinicians were significantly more likely to prescribe opioids compared with other disciplines (OR = 6.76, 95% CI 1.71-26.70).

This study provided a clear picture of pain medication usage among women with BC and can assist pharmacists in targeting deprescribing efforts geared at both patients and providers.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

HHS, DOJ Issue Guidance to Eliminate Telehealth Discrimination

HHS, DOJ Issue Guidance to Eliminate Telehealth Discrimination

The federal agencies’ guidance provides examples of discrimination during telehealth visits and actions to ensure virtual care remains accessible to all.

 In honor of the Americans with Disabilities Act (ADA) anniversary, the US Department of Health and Human Services (HHS) worked with the US Department of Justice (DOJ) to publish new guidance that seeks to eliminate discrimination in the telehealth arena.

The COVID-19 pandemic has been accompanied by rapid expansions in healthcare access, particularly through the use of telehealth. Although telehealth is a valuable resource, discrimination does exist, leading to barriers to care. For example, research has shown that racial minorities, older age groups, and those living in rural areas use telehealth less frequently than their counterparts, and the digital divide further exacerbates disparities in virtual care access.

As 2022 marks 32 years since the introduction of the ADA, HHS and DOJ released guidance focused on federal nondiscrimination laws, including the ADA Section 504 of the Rehabilitation Act of 1973, Title VI of the Civil Rights Act of 1964, and Section 1557 of the Patient Protection and Affordable Care Act, and actions healthcare providers can take to ensure they are in compliance with these laws.

The guidance aims to ensure equitable care for those with disabilities, including people who are blind, deaf, or do not speak English proficiently. Blind people who seek out telehealth solutions may find that the modality does not contain screen reader software, and deaf people may have trouble engaging with an interpreter over telehealth. Those who are not fluent in English may struggle to seek and schedule an appointment. 

To curb discrimination, providers can take several actions, including making changes to their policies and practices to provide additional support for disabled people who wish to have a virtual visit, such as implementing sign language interpretation and language assistance services.

“It is critical to ensure that telehealth care is accessible to all, including patients with disabilities, those with limited English proficiency, and people of all races and national origins,” said Assistant Attorney General Kristen Clarke of the Justice Department’s Civil Rights Division, in a press release. “Federal civil rights laws protect patients from discrimination whether they receive health care online or at the doctor’s office. The Department of Justice will vigorously enforce the ADA and other civil rights laws to ensure that health care providers offering telehealth services are doing so free from discrimination.”

HHS and DOJ also said that people can file complaints if they feel they are a victim of telehealth discrimination.

Complaints related to ADA violations are common and can occur when treating various conditions.

In May, AIDS Alabama and CHLPI claimed that Alabama Medicaid did not provide hepatitis C treatment for those struggling with substance use disorders. While filing the complaint, the organizations defended their argument by pointing out that Alabama Medicaid is in violation of the ADA.

7 healthcare takeaways from Senate Democrats’ newly passed $739B landmark bill

7 healthcare takeaways from Senate Democrats’ newly passed $739B landmark bill

With a 51-50 vote, Senate Democrats passed a sweeping $739 billion bill Aug. 7 that furthers some of the largest changes to healthcare in years.

Titled the Inflation Reduction Act, the bill touches energy, tax reform and healthcare. The House is expected to take it up Aug. 12, with Democrats aiming to approve it and send it to President Joe Biden’s desk.  

Here are seven healthcare takeaways from the 755-page bill

Drug pricing

1. For the first time, Medicare would be allowed to negotiate the price of prescription medicines with manufacturers. Negotiation powers will apply to the price of a limited number of drugs that incrementally increases over the next seven years. Ten drugs will be eligible for negotiations beginning in 2026; eligibility expands to 15 drugs in 2027 and 20 by 2029. 

2. The HHS secretary will provide manufacturers of selected drugs with a written initial offer that contains HHS’ proposal for the maximum fair price of the drug and reasoning used to calculate that offer. Manufacturers will have 30 days to either accept HHS’ offer or propose a counteroffer.  

3. Members of Medicare Part D prescription drug plan would see their out-of-pocket costs for prescription drugs capped at $2,000 per year, with the option to break that amount into monthly payments, beginning in 2025.

4. Democrats lost on a provision to place a $35 cap on insulin for Americans covered by private health plans. The provision to cap insulin at $35 dollars for Medicare enrollees passed by a of 57-43. 

5. Drug companies will be required to rebate back price differences to Medicare if they raise prices higher than the rate of inflation, coined an “inflation rebate.”

6. The legislation makes all vaccines covered under Medicare Part D free to beneficiaries with no deductibles, co-insurance or cost-sharing, starting in 2023. 

Tax subsidies 

7. The legislation extends the Affordable Care Act’s federal health insurance subsidies, now set to expire at the end of the year, through 2025. Democrats say the extension will prevent an estimated 3.4 million Americans from losing health coverage.

This can be a slippery slope to what Congress can control… Did they only mandate $35/month price limit ONLY ON INSULIN PAID FOR BY Medicare Part D and part  C, maybe because it would be a bad political move – and possibly unconstitutional – to tell private insurance companies and the three pharmas that produce insulin… in what they can charge for a product.

The PBM industry claims that they “negotiate” with pharmacies on what they will be paid to fill prescriptions and that industry controls about 90%+ of the FOUR BILLION Rxs that are filled in the USA.  Their action of  “negotiating ” with pharmacies is actually a “take it or leave it” contract. In the end the pharmacy is told to sign/take the contract offered or we will make sure that most of your pts will end up having their Rxs filled at one or more of your competitors.

The play a similar game with the Pharmas,  the pharmas are told if you want your brand name med on their approved formulary, you will pay the PBM a certain percent – claimed to be up to 75% of the AWP (Average Wholesale Price) otherwise the PBM will be require that to get their med paid for will require a PA (prior authorization) and everyone knows that the PBM will suggest to the prescriber a therapeutic alternative that doesn’t require a PA for the pt to get some medication for their health/medical needs.

This year, I ran into a problem with Humana Part D that they would only pay for a particular generic pharma med, even though on their website, they state that the generic is “covered”, HOWEVER, paying CASH for the med was $15.00 LESS than my copay would have been unless a particular pharma’s generic was dispensed.  Where was that extra $15.00 going ?… Probably into Humana’s bottom line, because the rebate/discount/kickback to Humana from the pharma was greater than the generic that my pharmacy stocked and wanted to fill and bill Humana.

If Congress can dictate what a manufacturer can charge for this particular product (Insulin) what will prevent Congress – other than a lot of lawsuits – from telling untold number of manufacturers, retailers and others are allowed to charge for their products and/or how much gross/net profit  a business could legally allowed to make.  Are we on a path for Congress to attempt to nationalize many large businesses…the next step towards socialism ?


Minnesota is among the first states to address the unintended consequence of CDC opioid guidance from 2016


Minnesota is among the first states to address the unintended consequence of CDC opioid guidance from 2016

LAKEVILLE, Minn. — On August 1, a change to a Minnesota state statute regarding opioid prescribing quietly ushered in a change that could be life-saving for people who suffer of severe, chronic pain. 

The change addresses issues that arose from the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain. While the guideline was “intended to improve communication between providers and patients,” it had an unintended consequence for sufferers of intractable pain. It led to dosing restrictions and tapering of the only medication that worked for them.

“This is severe, unrelenting, incurable pain, where other medications have not worked as well or don’t work at all,” said Cammie LaValle, who suffers from complex regional pain syndrome. “It is an incurable, rare disease, rare condition. It is systemic, and at one point I was using a wheelchair, I was begging for amputation of my arm and my leg, because the pain is that severe.”

“It is considered one of the suicide pains,” said Dr. Todd Hess, who has worked in pain management for more than 30 years. “It is very difficult to treat, and it’s what I specialize in.”

Technically, Dr. Todd Hess is recently retired from that specialty, and says it’s a direct result of the impact the CDC guideline had on his ability to treat patients.

 “It felt like I couldn’t do my job any more,” Dr. Hess said. “The 2016 CDC guideline had good intentions, I believe, at the start, but it was not meant to be anything more than a guideline.”

The guideline featured specific numeric thresholds for opioid prescribing, which were later adopted widely and used in regulations and state laws to police opioid prescribing.

“Pain doctors were literally being investigated,” Dr. Hess said. “I mean, I’ve been investigated numerous times and luckily they’ve all come out in my favor because we’ve done the right thing, and that has sent a chilling effect to the medical community.”

And that left Cammie and many other patients out in the cold.

During a hearing in the Minnesota Senate this spring, Laura Johnson, a chronic pain patient, provided emotional testimony of her own struggles.

“I have suffered with chronic pain for over 20 years. I have MS and a deformed spine,” Johnson said. “I can no longer sit, I can’t sleep and I can’t walk. I don’t have a pain doctor anymore. I got dumped because he was so afraid of the fear of the DEA and the guidelines.”

Johnson said she represented just one of many patients who were no longer able to share their stories.

“Many have turned to the streets out of desperation,” she said. “Many more have ended their lives.” 

Both the Minnesota Medical Association and American Medical Association backed up that patient testimony, sending letters in support of the bill.

“For too many years, patients with pain have suffered because of inflexible, numeric thresholds on opioid therapy,” wrote Dr. James Madera, CEO of the AMA.

But thanks to the advocacy, led by Cammie, there is finally hope. The revised statute changes Minnesota law in several ways:

Provides new or updated definitions for intractable pain, drug diversion, palliative care, rare disease and establishes criteria for the evaluation and treatment of intractable pain when treating non-terminal and terminal patients.

  • No physician, advanced practice registered nurse, or physician assistant shall be subject to disciplinary action by the Board of Medical Practice or Board of Nursing for appropriately prescribing or administering a controlled substance in Schedules II to V of section 152.02 in the course of treatment of a patient for intractable pain, provided the physician, advanced practice registered nurse, or physician assistant keeps accurate records of the purpose, use, prescription, and disposal of controlled substances, writes accurate prescriptions, and prescribes medications in conformance with chapter 147 or 148 or in accordance with the current standard of care.
  • No physician, advanced practice registered nurse, or physician assistant, acting in good faith and based on the needs of the patient, shall be subject to disenrollment or termination by the commissioner of health solely for prescribing a dosage that equates to an upward deviation from morphine milligram equivalent dosage recommendations or thresholds specified in state or federal opioid prescribing guidelines or policies, including but not limited to the Guideline for Prescribing Opioids for Chronic Pain issued by the Centers for Disease Control and Prevention and Minnesota Opioid Prescribing Guidelines.
  • Prohibits a prescriber from tapering a patient’s medication dosage solely to meet a predetermined dosage recommendation or threshold if the patient is stable; is experiencing no serious harm from the level of medication prescribed, and is in compliance with treatment plan and patient-provider agreement.
  • No pharmacist, health plan company or pharmacy benefit manager shall refuse to fill a prescription for an opiate issued by a licensed practitioner authorized to prescribe opiates solely based on the prescription exceeding a predetermined morphine milligram equivalent dosage recommendation or threshold.
  • Requires the prescriber and patient to enter into an agreement that includes the patient’s and prescriber’s expectations, responsibilities, and rights according to the best practices and current standard of care with agreement to be signed by the patient and the prescriber, and a copy of the agreement included with the patient’s medical record and a copy to the patient, to be reviewed at least annually and when there are any changes to treatment plan.
  • Absent clear evidence of drug diversion, nonadherence with the agreement must not be used as the sole reason to stop a patient’s treatment with scheduled drugs.

“Opioids are not for everybody, and this is not a pro-opioid bill at all,” Dr. Hess said. “It’s a doctor/patient relationship bill, where patients and doctors and nurse practitioners and PA’s will have a safe zone to do it properly. We know this is dangerous, but we also know not treating pain is dangerous too.”

“It will hopefully protect patients like me, and worse off than me,” Cammie said. “There are people actively dying right now that don’t have access to medications because their oncologist are afraid to prescribe.”

I did a word search of this text for “DEA” and it only appeared ONCE…  “It will hopefully protect patients like me, and worse off than me,” Cammie said. “There are people actively dying right now that don’t have access to medications because their oncologist are afraid to prescribe.”

Does this mean, that if any entity – like the DEA or VA system – decides to impose some daily MME system limit as to a pt’s daily dose.. will this law back the prescriber’s belief as to what the pt’s valid medical needs are. Could a insurance/PBM company does not impose a limit, just refuses to pay for a particular med or category of meds or refuse to pay for any Rx above a certain MME.

DEA Policy Reversal on Allowed Prescription Annotations for Schedule II Prescriptions

here is a post I did recently and I am not sure what the DEA is up to with information contained in the letter in this post,  but I suspect that it has something to do with prescribers sending out controlled med Rxs that is missing a “i” being dotted and/or a “t” being crossed.  Could the DEA start collecting data on such prescribers and could they determine that a particular prescriber is sending out controlled med Rx and track data on such prescribers and could they look to such a prescriber as providing “illegal Rxs” because of those “i’s” not dotted or “t’s” not crossed.  Here is a post : Supreme Court hearing for the Doctors Xiulu Ruan, MD and Shakeel Kahn, MD

Where the SCOTUS with a 9-0 vote decided that the DEA had been using OBJECTIVE CRITERIA to judge prescribers treating pts dealing with SUBJECTIVE DISEASES and it was ILLEGAL for the DEA to do so… Could this be what the DEA is going to use as “go around” to what they have used in the past to “take prescribers down” ?  Only time will tell, but this SCOTUS decision maybe a good example the path the chronic pain community needs take to get some better pain management… and that would mean using law firms.

Insurance denies pt’s therapy: because the insurance company guidelines are out-of-date

AITA for Pointing Out to the Insurance Company That I’m the Expert on My Patient?

I (48, F) had to do one of those “peer-to-peer” calls with an insurance physician (undisclosed-age, M). I know, it’s a commonplace task now, what’s the big deal, etc., but let me explain.

From the start of the conversation, tons of red flags. First of all, he won’t tell me what specialty he is. And I’m like, “Okay, that’s kind of weird, but can you at least tell me if you’re an oncologist?” Then he asks, “Why does that matter?” So I say, “It matters a lot because I’m an oncologist and this is about a person with cancer. It’s literally a matter of life and death because your insurance company denied their cancer treatment.”

He finally says, “No,” he’s not an oncologist.

“So then, what’s your specialty?” I ask.

He clears his throat and says he isn’t allowed to say. Then he reminds me that this call is being recorded for quality assurance purposes.

“Excellent,” I say. “Then it’s being recorded that you’re the one obstructing my patient’s access to lifesaving treatment.”

Then he says there’s no reason to be rude and calls me “Miss.” I ask him to please refer to me by my title of “Dr,” and he drops the “Miss” but instead starts using my first name as if we’re old friends or something.

At this point, I’m not making any progress in getting my patient’s medication approved, so I let the first name/untitling go and ask him to explain why the insurance company denied the medication (let’s call it X).

I hear him shuffling papers, and then he says it’s because we didn’t try medication Y yet.

I tell him it’s correct that medication Y used to be the standard-of-care first-line therapy, but as of 6 months ago, the FDA approved medication X as the more effective therapy. I explain to him the insurance company guidelines are out-of-date. Any board-certified oncologist would know this. Which he, inconveniently, is not.

Then he tells me there’s often a lengthy delay in updates to company guidelines, which he can’t control. To which I respond, “That’s why I, as the patient’s doctor, should be in charge of what treatment is approved,” not him or the insurance company.

He says he doesn’t disagree with me, but it’s not in his power to approve it. Because the company hasn’t updated its guidelines, I’ll have to talk to an oncologist at the insurance company to get an override.

It seems obvious to me it would have made more sense to do that in the first place, but in the interest of time, I keep this comment to myself and tell him, “Fine, please transfer me to their oncologist.”

Then he says, “Oh no, I can’t do that. You’ll have to set up another phone call.”

At this point, I’ve had another patient in an exam room waiting for over 15 minutes so I ask him to please hurry and set that up.

I hear papers shuffling again, and he says they can set me up for that phone call at 4:42 AM the next day.

When I ask for a more reasonable time, he says because they’re in a different time zone, that’s all they can offer, and if I don’t take that time, then my patient’s case will be closed, and I’ll have to start all over with the appeal from the beginning — which means talking to someone like him again.

Because there’s no real choice, I take the offered time. The following morning, the insurance oncologist immediately approves medication X.

So AITA for pointing out that if the insurance company had trusted that I, as a board-certified oncologist, was doing the right thing for my patient from the get-go, we could have saved everyone a lot of time and frustration (and sleep)?

Their response? “This call is being recorded for quality assurance purposes.”

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