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When healthcare providers end up really being healthcare deniers
Posted on January 13, 2024 by Pharmaciststeve
I got the email below on Jan 1, 2024. This pt’s story is not a unique issue. Another example of bureaucrats and politicians attempting to “solve” our fabricated opioid crisis by creating a “one size fits all” on pain management.
After having this blog for 12-13 yrs, I have developed a fairly sizeable network of chronic pain pts, chronic pain advocates, and numerous healthcare practitioners. I shared this woman’s email with a couple of select people that I believed might be able to STEP UP. And one did:
When a pt’s long term medical records mean nothing when seeing a new practitioner
When everything seemed to start to fall into place for this young lady. This young lady’s pharmacist and the mid-level practitioner who was forcing her to reduce her pain meds had to step in to make sure that things were not going to change the way that this mid-level practitioner wanted things to happen. Here is a video this young lady sent that she personally explains what has happened.
Hi Steve,
I have sent you my story before. I am a single disabled palliative care sick patient in Maine. In September of 2021, my doctor and I were targeted by the assistant attorney general, Michael Miller. We think it was for 2 reasons-he was very effective at getting patients disability, testings, procedures, equipment, etc and because I require a high dose of opiates to physically and mentally function. Dr. Lommler believes Michael Miller made a deal with the insurance companies and profited somehow for taking him out. Michael Miller used at least 2 agencies to target, harass, and destroy us. They suspended Dr. Lommler’s license for going over the 100 MME limit on my prescription. However, Maine has a palliative care exemption that allows people (like me) to have access to opiates for pain control and disease treatment options. It also allows us to go over the 100 MME limit. They refused to lift the suspension unless he transferred to a “board approved” facility. He chose to retire because he wanted to stay at his independent office with his 200 complicated and unique patients. They gave neither one of us any due-process! They used backdoor methods and I believe they were illegal! There was a covering LNP seeing me for a year. We tried to find a doctor everywhere in Maine to see me but because of the Opiate Task Force and doctors getting red-flagged for going over the 100 MME limit and being dragged in front of the board, no one would see me. I was forced to transition to the hospital where all of my specialists are. You see, Maine and New Hampshire were the 2 states prescribing the most Opiates so they created a New England Opiate Task Force and sent them to work with the Governor Mill’s administration to red-flag doctors prescribing over the 100 MME limit and drag them in front of the board of medicine! They have forced independent providers to either retire or transfer to a “board approved” facility. These “board approved” facilities all have anti-opiate one-size-fits-all policies. The hospital that I am at has an anti-opiate provider masquerading as a “pain specialist.” She believes Opiates are life threatening and dangerous to everyone. She is force tapering me off all my pain medication! I am complicated and unique-I have multiple health conditions. I had an original medical nightmare that left me with life altering physical deformities and severe debilitating pain. I have Crohn’s disease, vitamin and bone deficiencies, and neuropathy-all of these cause malabsorption so I have to take double doses of all of my medication! I cannot have the conventional pain management treatments because I am allergic to everything and sensitive to anything and I have a prosthetic heart valve. I have Scoliosis and severe Osteoporosis with dangerously low Scores. I am 46 in an 86 year old’s body.
They are stereotyping anyone on opiates as addicts and forcing them off pain medication. The only option they give you is Suboxone-I cannot take this because the side effects would be catastrophic to my body. I had nothing but recovery and progress with my 8 1/2 year stable pain regimen. I was able to semi function independently with a decent quality of life. Since this provider has been force tapering me, I can no longer function independently at all and I have zero quality of life! According to Maine’s own definition and standards, what this facility and provider are doing to me is disability abuse! I tried to contact patient services for an advocate but was told there wasn’t one. The woman I spoke with for 2 minutes, asked me what my concerns were. I explained to her what was happening to me. 2 days later I received a letter stating my concerns were forwarded to the Medical Director and Operations Manager and they agree with the provider force tapering me. They also said there was no medical justification for my pain medication. I filed a public accommodation discrimination complaint with the Maine’s Human Rights Commission but haven’t heard a word since intake months ago! The letter gave an 800 number to call if you disagreed with their decision. It was the board of licensure telling you to submit a complaint. I already filed a complaint with the board of medicine and nurses months ago. So, you have to go to the same people that are red-flagging and harassing doctors going over the 100 MME limit. I won’t hold my breath! These are the same people that asked Dr. Lommler how he didn’t know that I was taking half of my pain medication and selling the other half! Dr. Lommler provided them with 7 1/2 years worth of passed urine screens and passed frequent random pill counts! I wasn’t even allowed to attend or participate into the investigation into my opiate use-I could’ve answered that question myself-I have never misused my pain medication! In fact, I did everything that I was supposed to do! How in the world can I trust they will help me!
Since this provider has been forcing me off my pain medication, I have had sky high blood pressures-202/129, severe bloody noses, I have been discharged from aquatic therapy-which I needed to get into my Crow Walker boot, I am completely dependent on my sons, I have had to quit tutoring for supplemental income, I can no longer walk on my crutches so I am trapped in my wheelchair, and I cannot mentally or physically function! My counselor and former providers have tried talking with this provider but she refuses to listen because she knows best. I had to spend my Christmas in the ER and I am now watching my right leg and foot do exactly what my left leg and foot did in my original medical nightmare. When my body is in severe stress, my multiple conditions play off of one another and wreak havoc on my body. Last time, the severe stress was an allergic reaction to hardware (we didn’t know why at the time, it took years to figure it out). This time, it is force tapering my pain medication! This time, it’s the providers choice to force taper me because of her personal feelings about a medication! Medical providers are supposed to do what is in the best interest of the patient, not what is in the best interest of their personal feelings! I have cellulitis in my right leg and foot with ulcers everywhere! I maintain my left leg and foot with Cuban for compression. I tried to wrap my right leg and foot but it’s not used to being wrapped, and I get continuous Charley Horses. They are intolerable with all of my pain medication being taken away! I have severe PTSD and zero trust in doctors from my original medical nightmare! I never ever wanted to go back to that sick person trapped in a wheelchair, I thought I left it behind for ever! This time, I don’t have a heart valve to lose! I am petrified and profoundly devastated because I worked so hard for 8 1/2 years to recover and progress and now that has been destroyed! I see people helping doctors that have been arrested but what about people, like me, who have been targeted, harassed, discriminated against, and literally going through disability abuse-who tells our story and helps us?
My counselor gave me a brochure for adult protective services and she told me to call because what they are doing to me is discrimination and disability abuse. I called and the lady said there is no process for this situation. She told me that it does qualify but the only thing I can do is file a complaint with the board of medicine and nurses because they are the only entities that have authority and jurisdiction over medical providers. I told her that I already filed complaints but it will take months because they only meet one day a month! I told her my body won’t make it that long and I asked her, “what if I die in the meantime?” She said, “let’s hope it doesn’t come to that but good luck!” WHAT? It’s like a nightmare that I cannot wake up from! I have contacted every politician in Maine and asked for their help. Crickets…I requested assistance from Governor Mills but she doesn’t even think she has to answer to her constituents. I have reached out to every volunteer lawyer’s projects and disability rights groups but they all claim no to have the resources to help me. I have documented, taken pictures, recorded videos, screenshot messages from my portal between her and I, audio recorded my video appointments exposing her discrimination and disability abuse! I cannot find an attorney in Maine to help me. This provider only saw me one time in person! She never looked at any areas causing my pain, she’s not monitoring my vitals or everything that is happening to me, she doesn’t even have the correct MRI’s-she’s going by a 2008 one when I was a normal person and could walk on my own, and she’s retaliating against me for filing a complaint! I need help and I don’t know where or who to go to! I even have an appointment with cancer care, January 23rd. I have MGUS and the blood work markers and symptoms all point to it turning into Multiple Myeloma. I asked her to please pause the force taper until I can get into my appointment. She said, “Oxycodone will not cure Multiple Myeloma so the force taper will continue!” How cruel is that!
I was hoping that you may have some direction or advice to help me. If I knew how to file a civil lawsuit against the hospital and provider, I would do it myself. Since September of 2021, I have had to be my own advocate, case manager, and attorney!
I already missed about 6 years of my sons’ lives because of my original medical nightmare! I can do no physical activity without my pain medication! I really don’t think my body will make it through this force taper! Opiates are literally life saving for me! They knew that I wouldn’t be able to find another doctor to see me and Michael Miller and the board of medicine took 2 doctors from me! The provider force tapering me filed a complaint against the LNP that saw me for a year. In it, she said that she felt compelled because Kaye endangered my life by prescribing these life threatening and dangerous medications. She also accused me of bribing Kaye in her complaint. That is ludicrous-I have never bribed anyone! Kaye made it very clear in her response that no one forced or bribed her. She also made it clear that I was the only patient she ever prescribed narcotics for in her entire medical career! I have been accused of selling half of my pain medication and bribing doctors! I am a law abiding Mainer and American just trying to live my life!
Thank you for taking your time to read my email. You can reach me any time at xxx.xxx.xxxx
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most societies/communities have 1 or more agitators, disruptors, false prophets, scammers, traitors, saboteurs and cult leaders
Posted on September 11, 2022 by Pharmaciststeve
Some believe our country is on the verge of a Civil War, they may be right, but it won’t be a bilateral war like our last Civil War.. Our society has voluntarily divided itself in – for lack of a better description – TRIBES.
The chronic pain community is not all that different from our country of as a whole.
Recently a fellow chronic pain pt who had been advocating for end stage pediatric pts in a large hospital system that has a “no opiate” policy. All of a sudden the advocated was told that he was no longer permitted to advocate for these end of life pediatric cancer pts. I suppose that this major hospital system will return to treating these pediatric pts with NSAIDS and Acetaminophen and let them live the rest of their lives in a torturous level of pain.
There are rumors as to who said what and to whom… I am not going to elaborate. However, they know who they are and what was said to cause this to happen. One can only imagine the deprived mental status of those who have been involved in this.
Some have told me that this tribe of malcontents have monetized chronic pain pts’- personal information and several other covert processes. I started my blog in 2012 and have tried to motivate and educate chronic pain pts in some ways that they can navigate their way to getting their pain management back. Some chronic painers have told me that I should charge for my advice. My Pharmacy degree, license and career has provided for Barb and myself a comfortable retirement.
After this issue with these end of life pediatric pts, Going forward… I am going to ASK of people that want my advice to make a contribution to one of the four national charities listed below, these are all about THE KIDS… and charities we support. Maybe in some small way, my advice can help more than just one person/family.
https://www.stjude.org/ St. Jude Children’s Research Hospital – deals with kids dealing with cancer and/or life threatening health issues
https://lovetotherescue.org/ Shriners Hospital – deals with kids, born with “broken bodies” and birth defects
https://rmhc-kentuckiana.org/ Ronald Mc Donald House – this is near us and just a few blocks from a very large regional pediatric hospital ,3 other major hospitals within blocks, one being a teaching hospital and having the only LEVEL ONE TRAUMA CENTERS for 100 miles and part of a medical university and helps provide housing for families with kids in the hospital
https://t2t.org/ Tunnel to Towers Foundation – helps get handicapable housing for veterans, first responders with “broken bodies” , families with spouse/parent killed in the line of duty and Gold Star Families
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Lobbyists for PBMs come to a legislature bringing LIES and $$$ for re-election campaign funding
Posted on May 13, 2024 by Pharmaciststeve
Pharmacy benefit managers or PBMs for short, now wield nearly limitless power and influence over the prescription drug market owning at least 85% of pharmaceutical industry. Their tight grip on the market has allowed them to engage in unfair pricing practices with very little oversight. They can raise the price you and your insurance company pay for medications, and instead of passing that revenue along to pharmacies, they keep it for themselves. Without having to answer to anyone, they rake in the cash off consumers backs and hurt patients in the process.
Which leaves the question, what is being done about it and how are they not being regulated? Well, let’s dive in …shall we.
A bill was presented at the state level during last session to demand PBM reform, unfortunately it didn’t even get called to vote.
“Why it didn’t get voted upon is something that will anger me forever, because it has everything to do with politics and money and had nothing to do with the right thing,” said Dan Strause former CEO of Hometown Pharmacy.
Wisconsin Representative Micheal Schraa, shares some insight.
“The general public has no clue. I spoke at a Republican Lincoln day dinner about three weeks ago. And I said how many people in this room, and there were about 140 people, how many in this room know what a PBM is, pharmacy benefit manager, six hands went up,” said Schraa.
Yet the negative Impact PBMs have on the nation’s healthcare system is growing daily. As more and more small pharmacies are getting smothered out of the equation.
Schraa said his drive to push PBM Reform legislation started about 10 years go when his pharmacist Ken brought it to his attention.
“I walked in one day and Ken just said, you got to sit down with me, and I got to tell you what’s going on. Were getting killed by these things, by these PBMs, and I’m like what’s a PBM, I never heard of it before,” said Schraa.
Micheal said he started doing his own research and asking questions, the more he learned the more eye opening it was to him. That something needed to be done.
“There we a lot of powerful statements and a powerful testimony from people that had personal experiences with how the PBMs have negatively affected them. So, it’s just been my mission. I knew I would be coming again this session with another bill. Senator Felzkowski and I worked on it and it was really frustrating at the end, not having it go anywhere.
Bill 737 had 104 co-sponsors on it out of 132 legislators. Schraa personally went to every single democrat and republican office in efforts to get as much bipartisan support on the bill as possible. But it never even got called to the floor to be voted upon during the last legislative session. There were 13 separate asks in the bill and there were even efforts made to amend a single one of these asks into a separate bill, pertaining to hospitals, that would demand some transparency from PBMs regarding formularies. (Called MAC Pricing Language which is a spread showing the average cost of a drug across all companies that manufacture that drug.) In hopes that it would be the most beneficial piece to independent pharmacies.
“So, we had this amendment and we added it to another bill that the hospitals really needed. We felt this was a bill that couldn’t be killed and wasn’t going to have an issue in the Senate,” said Schraa.
“The Mac language was kind of watered down a little bit, but we still got a chunk of it in there. I thought this is great. The governor’s office was in they didn’t like a little bit of wording so we changed it to appease them so they would sign the bill, or sign the bill that this amendment went to, and we passed it. And it went over the senate and died,” said Schraa.
There are many speculations as to why the PBM reform bill, has been avoided.
“The ugly part of politics is that campaigns cost a lot of money to run and not everybody can self-finance especially in the assembly or the senate,” said Schraa.
However, Schraa said there are still those willing to fight for the people and what’s right.
“That’s where the heart of this issue comes in. There’s 30-some other states that have passed pretty significant PBM reform. The decision makers in those states have made a decision, we’re going to stand up for the people,” said Schraa.
Schraa has a plan for the next legislative session to break down this complex bill and get it passed.
“It’s a complicated issue,” said Schraa. Unless you’re a pharmacist or someone who works with this everyday it can be really hard to focus on the several different things this bill highlights. Schraa plans to break it down to have a legislator for each section.
“That way I think the health plans and PBMs that are against this, its going to be a lot harder for them to come in and trash 12 or 13 different legislators. They were going around lobbying in each office saying, you know Schraa’s PBM bill is going to raise prescription drug costs, out right lying,” said Schraa.
Schraa said he understand lobbyists and their job is to protect their clients.
“There’s so much money in this game for them and they’re so powerful and the lobbying core is so well paid,” said Schraa.
Schraa said it’s frustrating because he sees the net effect that PBMs are having on so many people including his own family, who have fallen victim to adverse medical reactions due to wrongful practices. Schraa said, he and fellow supporters will continue to bang their fists on the desk until PBM reform is accomplished.
“The education process is huge, and I think this patient protector will be a game changer. It’s going to be super hard for them to continue to shovel this underneath the table and try to hide it. When you have so many different avenues bringing the light out and exposing, you know light is the best disinfected and that’s starting to happen,” said Schraa.
That’s why patientprotector.us was created, if you or a loved one are being affected, share your stories on the online portal so they can be heard by legislators and a difference can be made.
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A Philadelphia pharmacy’s closure after 26 years highlights the industry’s growing challenges
Posted on May 12, 2024 by Pharmaciststeve
A Philadelphia pharmacy’s closure after 26 years highlights the industry’s growing challenges
Last Monday, Friendly Pharmacy filled 318 prescriptions. For about 100 of them, insurance companies paid the pharmacy less than $3.
In 22 instances that day, the reimbursement was less than the cost of the medication. And that’s just among the prescriptions that were actually filled. Managing pharmacist Brad Tabaac said he has to turn away some patients because their prescriptions will cause too much of a loss for his business.
One recent patient, for instance, came in hoping to transfer his inhaler prescription to Friendly after his local Rite Aid closed. Filling the medication would have cost Friendly $22 more than the insurance reimbursement.
“I just can’t afford to serve him,” Tabaac said.
And now he can no longer afford to serve anyone.
Tabaac plans to close his doors on May 31 after 26 years in business. As a second-generation pharmacist, he said, he’s been working in drug stores since he was 11 years old. Making money on medicine wasn’t a question back then, but now it’s a string of “exhausting” calculations on a daily basis.
“Years ago, you would just fill prescriptions, and you would concentrate on patient care,” Tabaac said. “Now you have to look at each and every prescription you fill and say, ‘Am I losing money?’”
Why pharmacy benefit managers are challenging small pharmacies
Independent pharmacies like Friendly, as well as some chains, have been pinched by pricing and fees set by pharmacy benefit managers — the companies that handle prescription drug plans for health insurance.
The three biggest pharmacy benefit managers are CVS Health, Optum Rx and Express Scripts. They control nearly 90% of the market, according to the National Community Pharmacists Association (NCPA), and some of their parent companies also own pharmacies. In other words, NCPA has said, “what community pharmacies charge patients and are reimbursed is often determined by a competitor.”
This challenge has caused more than 80 community pharmacies in Pennsylvania to close just in 2024, said Rob Frankil, executive director of the Philadelphia Association of Retail Druggists (PARD). Contracts with pharmacy benefit managers are “take it or leave it,” he said, giving individual business owners little to no room for negotiating reimbursement rates that will allow them to stay in business.
PARD has been lobbying lawmakers for changes.
The Federal Trade Commission is conducting an inquiry into the system. Chair Lina M. Khan said at a White House Roundtable in March that complaints to the commission suggest pharmacy benefit managers “hike the price of drugs, deprive patients of access to certain medicines, and drive community pharmacies out of business.”
As pharmacy benefit managers “have consolidated and vertically integrated, we hear of a system where corporate red tape and bureaucracy obstruct patients from getting their medications, sometimes with devastating results,” Khan said.
Khan noted that the pharmacy benefit managers haven’t fully complied with FTC orders seeking documents and data.
“We are undertaking this work with enormous urgency and focus. And if we find evidence of illegal practices, we will not hesitate to act,” Khan said.
Tabaac acknowledges that effort but said it’s coming too late for his business.
“Pharmacists knew they were going to lose money on branded drugs,” he said. “But they were signing these contracts because they were thinking, ‘What else am I going to do?’”
Other costs rising
While Tabaac can’t control the revenue he brings in from prescriptions, despite having plenty of customers, he also can’t control certain costs that have risen in recent years. One of them is business insurance, he said, which has become more expensive in part due to his pharmacy’s location in the Kensington neighborhood. Friendly was dropped by its business insurer in recent years because of incidences of vandalism in the community, he said, and had to find a new policy.
“The insurance companies do not want to insure us,” Tabaac said. “We’re too much of a risk.”
Once Friendly closes, the closest chain pharmacy is a Rite Aid about three-quarters of a mile away. A few other independents remain open closer to Friendly’s location, according to city records, but pharmacy density here is lower than in other sections of the city.
Not long ago, Tabaac absorbed the patients from another independent pharmacy nearby that closed because of finances.
Tabaac is concerned about the patients who have accessed prescriptions through Friendly’s delivery services or relationships with doctors who do house calls, as well as those who don’t drive and will have to take public transit to a new location.
“Will they find an advocate? Some of them will,” he said. “I fear that many of them won’t.”
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FDA issues ‘most serious type of recall’ for insulin pump-related iOS app
Posted on May 12, 2024 by Pharmaciststeve
FDA issues ‘most serious type of recall’ for insulin pump-related iOS app
The U.S. Food and Drug Administration has issued a Class I “most serious type of recall” for an iOS app used in conjunction with an insulin pump.
The “correction” as referred to by the FDA on Wednesday, rather than a product removal, relates to the t:connect Mobile App iOS v2.7. It was confirmed by Tandem Diabetes Care the following day, which stated that Android app users are not included in the recall.
“The t:connect mobile app works with the t:slim X2 insulin pump with Control-IQ technology,” the FDA states. The pump delivers insulin under the skin at set and variable rates for the management of diabetes.
The app recall is due to a software issue that may cause the app to crash and be automatically relaunched which “may result in pump battery drain and may lead to the pump shutting down sooner than typically expected.”
The FDA says pump shutdown “could lead to an under-delivery of insulin and may result in hyperglycemia or even diabetic ketoacidosis, which can be a life-threatening condition due to high blood sugars and lack of insulin,” and encourages those with diabetes who use insulin pumps to carry backup supplies in case of pump failure.
“The correction highlighted in the recall notice was addressed in the t:connect app update for the Apple iOS platform (v2.7.1) released on March 18th,” Tandem Diabetes Care said in a press release. “Affected customers were notified by Tandem on March 26th, and more than 98% of affected customers had already updated their devices as of April 15th. We continue to make every effort to contact everyone who has not yet updated their iOS app to the new version.”
Tandem Diabetes Care gives detailed instructions to customers who wish to check their mobile app versions here.
“Ensuring the safety of our patients is our top priority, and we take any safety concerns with our products very seriously,” Tandem Diabetes Care said in its release. “No deaths have been reported, and we will continue monitoring the new version of the t:connect app released in March to ensure the concerns described in the recent recall notice from the FDA have been addressed.”
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bye-bye so sad
Posted on May 9, 2024 by Pharmaciststeve
Be careful what you post in titles. I have a post concerning a chronic pain pt Robert Charles Foster who had lost his pain meds and ended up getting cops to end his pain FOR GOOD.
Apparently, there was a couple of words in the title that did not meet FB’s “community standards” and they deleted them.
They seem to have a problem with intractable chronic pain pts resolving their untreated torturous level of pain via some sort of self-inflicted means.
The hyperlink above points to the one post on FB, they have not found yet. See how far they go to see if the community standards are met!
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PBMs are now often more profitable than the drug manufacturers and insurance companies they work with
Posted on May 9, 2024 by Pharmaciststeve
Editorial: To save local pharmacies, state must rein in the middlemen
Pharmacies in Western Pennsylvania are closing at an alarming clip, pushed out of business by a complex, opaque and utterly broken medication reimbursement system. The state legislature, following the recommendation of Gov. Josh Shapiro, must act to bring transparency and accountability to the important, but little-known, health care middlemen called pharmacy benefit managers, or PBMs.
PBMs are corporations — sometimes associated with major pharmacy chains, like CVS subsidiary Caremark, but more often independent — who manage the relationships between the makers of prescription drugs, the insurance companies who pay for them (including Medicaid and Medicare), the pharmacies that distribute them, and the people who need them. In particular, PBMs set terms and pricing.
The original purpose of PBMs was simply to process claims for prescription medicines, but over time they evolved, and now they negotiate prices at every stage of the process. In theory, this give patients and their insurers bargaining power against drug manufacturers. In practice, PBMs cut deals with manufacturers and insurers, including steering patients toward preferred drugs, and have near-total power to set the terms of their contracts with pharmacies.
For many everyday drugs, pharmacists are forced to accept a loss, sometimes in the hundreds of dollars, on each prescription they fill. The result: reimbursement rates that are ruinous for pharmacies, especially independent businesses in underserved areas, leading to closures and reducing vulnerable people’s access to life-enriching, -sustaining and -saving medicines.
Against the spread
PBMs originally made money by charging insurers to process claims and manage prescription benefits. But now they make money from all parts of the process, most notably through a practice known as “spread pricing.” To understand spread pricing, you have to understand how prescriptions are priced. The problem is that PBMs consider this a trade secret.
Even if we can’t know how they do it, we can know what they do: PBMs negotiate the price insurance companies pay for prescriptions, the price pharmacies are reimbursed for prescriptions and the copays charged to patients. The pharmacy has essentially no control over any aspect of the pricing for the products most important to its own bottom line (and in many cases their survival): When the pharmacist plugs prescription information into the computer, the PBM spits out the dollar amounts.
The “spread” in “spread pricing” is the difference between the amount PBMs charge insurers — including Medicaid and Medicare — and the amount they reimburse pharmacies. PBMs pocket the difference without even handling the drugs in question.
Spread pricing is why PBMs are now often more profitable than the drug manufacturers and insurance companies they work with. In 2017, the largest PBM in the nation, Express Scripts, made over $100 billion; the drug manufacturer Pfizer, only $52 billion.
When Ohio investigated the PBMs handling the state’s Medicaid program in 2018, they found that spread pricing was costing taxpayers a cool $223 million per year. When the state banned spread pricing and contracted with a single PBM, it charged only $25 million for its services. The PBMs had been skimming $200 million of pure profit off medications for the state’s poorest patients.
Banning spread pricing in Ohio also resulted in reimbursements for pharmacists rising by $38 million — reflecting better pay for pharmacies and huge net savings for everyday people.
No other choice
PBMs hold all the cards against pharmacies, including chains, because they gatekeep access to major insurers and drug manufacturers in their exclusive networks. It’s even worse in the Pittsburgh region, where healthcare giants UPMC and Highmark both use the same PBM, Express Scripts.
If a Pittsburgh pharmacy doesn’t like the terms Express Scripts offers, it’s free to turn them down — and lose access to about two-thirds of local patients.
This means pharmacies often sign on to unfair pricing structures, controlling everything from reimbursement rates to preferred medications. When pharmacists are forced to accept a loss on so many prescriptions they fill, they must choose between dropping patients whose prescriptions are draining the company and risking the viability of the entire business. In either case, the people they serve lose.
Last month, at least 12 pharmacies closed their doors across Western Pennsylvania alone. There’s no reason to believe we won’t keep losing more. Advocates say that the U.S. loses one pharmacy branch per day. This results in prescription deserts, usually in already underserved urban and rural communities.
No incentive to change
The fact is a shuttered pharmacy isn’t a threat to business for PBMs. Patients will always need their medications. Some PBMs even argue they are providing the remaining pharmacies with a boost in business.
But if a pharmacy closes, it’s likely because the patients it served needed medicines for which PBMs reimbursed unfairly. They’ll have to go somewhere, and the financial contagion will spread. One of the pillars of the health care system — one that seems simple compared to hospitals and other providers — is slowly collapsing.
The state can do something about it. Pennsylvania should follow Ohio’s example and ban spread pricing. Companion bills HB 1993 and SB 1000 would do just that, while forcing PBMs to submit details of their pricing schemes to the state Insurance Department. The bills would also ban PBMs from “patient steering” by creating exclusive networks of contracted pharmacies or charging higher co-pays at pharmacies they don’t contract with.
PBMs claim that their aggressive tactics translate to big savings for their clients, and that spread pricing covers the cost of their services. If that’s true, they should have no issues opening up their books for the public to take a look. The future of access to essential medicines depends on it. People’s health, even their lives, depend upon it.
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Who are you being referred to for additional care or services
Posted on May 9, 2024 by Pharmaciststeve
you may have to click on graphic to properly enlarge it
Vertical integration visualized
https://ncpa.org/newsroom/qam/2024/05/08/vertical-integration-visualized
We all know what it means, but what does it look like? Each year Drug Channels updates its chart of vertically integrated insurers, PBMs, specialty pharmacies, and providers—all of which, Drug Channels editors point out, face renewed scrutiny from the Federal Trade Commission, the Office of Inspector General, and members of Congress. As the FTC, in particular, takes strides to hold insurer-PBMs accountable, and we’re finding more and more evidence of PBM greed, study this chart so you can help your patients understand the health care world they live in (and one that profoundly affects all of us).
If a practitioner refers you to another healthcare organization or practitioner, this chart may explain why you are being referred! This chart will show everyone where the referral is to another healthcare organization owned by the same corporation. It is called SELF-REFERRAL and most likely the practitioner that you are seeing is an employee of that same corporation.
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Protest Express Scripts May 17th 9AM – 1PM
Posted on May 8, 2024 by Pharmaciststeve
Filed under: General Problems | 2 Comments »
When a chronic pain pt becomes over verbally abusive not liking my free advice
Posted on May 8, 2024 by Pharmaciststeve
the 1+ minute audio file below is from a chronic pain pt who reached out to me for assistance. Apparently, a Wags Pharmacist refused to fill this pt’s controlled Rx. This pt reached out to me via FB chat. It took me ~ 90 minutes just for the pt to tell me who the pt’s insurance company was. Finally abt 80 minutes in the back/forth in FB chat, the pt shared a copy of their medication insurance card. The card said Prime Therapeutics, and doing a little research online. I discovered that Walgreens and Prime Therapeutics had jointly created a new company https://www.alliancerxwp.com/ that is a PBM, mail-order pharmacy, and specialty pharmacy. At that point, it seem obvious to me that her PBM was owned by Wags and it was Wags that was refusing to fill her controlled Rx. I spent another 30-45 minutes talking to this pt on the phone about her issue, and another 30-45 minutes giving her a detailed suggestion that might get her controlled Rx filled.
Maybe I should have just told the pt that the letter could not be changed in any way to get that Wags Pharmacist to fill her controlled med.
This pt’s phone number was from the East Coast, but claimed they were living on the West Coast. The pt was also wants to have someone to find her a new doctor. I referred to a couple of people within APDF https://americanpaindisabilityfoundation.org/ who could possibly know more about doctors around the country who will possibly properly treat chronic pain pts and are pain refugees. The advocates were not aware of any prescriber in the pt’s area who the pt could be referred.
Then various verbal abuse started coming. I see ~ 20 emails sent from this pt. The APDF advocate that I referred to, has told me an untold number of calls to his home by this pt. Below is a voicemail that this pt left me. BE WARNED, the language used could be offensive to some.
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5 people arrested after surge of suspected drug overdoses in Austin: Police
Posted on May 8, 2024 by Pharmaciststeve
Here is a example of how our judicial system in VERY INCONSISTENT Pain Management Physician Convicted of Unlawfully Distributing Opioids
The Physician looks at the potential of 480 yrs in prison over prescribing 9 pts three different controlled meds over 6 yrs, BUT NO OVERDOSE DEATHS!
In the below article NINE OD DEATHS, Five people were arrested and charged with possession or delivery of a controlled substance! NO involuntary manslaughter or some degree of MURDER!
5 people arrested after surge of suspected drug overdoses in Austin: Police
Nine people are suspected to have died in connection with the overdoses.
Five people have been arrested after dozens of people overdosed in Austin last week, leading to nine suspected deaths.
The Austin Police Department said Marcellus Barron, 30; Denise Horton, 47; Gary Lewis, 50; Ronnie Mims, 45; and Kanady Rimjo, 32, were arrested and charged with possession or delivery of a controlled substance, according to local ABC News affiliate KVUE.
Police said they located the suspects by investigating the source of the narcotics used in the recent overdoses, KVUE reported. The drugs included marijuana and crack cocaine laced with fentanyl.
Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine, according to the Centers for Disease Control and Prevention.
Most cases involving fentanyl-related harm, overdose and death in the U.S. have been associated with illegally made fentanyl, the CDC said. It is often sold through illegal drug markets and mixed with other drugs, such as cocaine or heroin, to increase its effects.
STOCK PHOTO/Getty Images
Starting around 9 a.m. ET on Monday, April 29, Austin-Travis County Emergency Medical Services (ATCEMS) said it received a surge of calls concentrated in the downtown area.
ATCEMS said it usually receives two or three overdose calls per day, but the number of calls equated to a 1,000% increase in call volume, Dr. Heidi Abraham, deputy medical director for ATCEMS, said last week during a press conference.
As of Monday, there were 79 reported overdoses and ATCEMS distributed 438 Narcan rescue kits. Narcan is given as a nasal spray and the active ingredient in the medication — naloxone — can quickly restore breathing if someone is experiencing an opioid overdose.
Police say a sixth person, 55-year-old Johnny Lee Wright, was arrested after surveillance video captured him delivering narcotics to Austin residents, KVUE reported. According to the APD, Wright has several previous felony convictions, including some related to narcotics.
APD did not immediately return ABC News’ request for comment.
A record number of Americans have died from drug overdoses. In 2022, there were nearly 108,000 drug overdose deaths, according to provisional data from the CDC.
In Texas, drug poisoning-related deaths for 2022 sit at 15.4 per 100,000 people, which is the highest rate since at least 2011, according to provisional data from the Texas Department of State Health Services.
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Medicare Hospital Trust Fund to Stay Solvent Until 2036, Trustees’ Report Says
Posted on May 7, 2024 by Pharmaciststeve
Medicare Hospital Trust Fund to Stay Solvent Until 2036, Trustees’ Report Says
https://www.medpagetoday.com/publichealthpolicy/medicare/109997
Projection is 5 years longer than last year’s prediction
The Medicare Hospital Insurance Trust Fund is expected to remain solvent until 2036, 5 years longer than projected last year, the Medicare trustees said Monday in their annual report to Congressopens in a new tab or window, but they also expressed concern about low payment rates to physicians.
The longer hospital trust fund solvency is “largely due to greater income and lower expenditures than was projected last year,” a senior administration official said on a call with reporters. “Income was projected to be higher because the number of covered workers and average wages per worker were both projected to be higher than last year’s estimate.”
On the other hand, “expenditures were projected to be lower in the short-range period mainly as a result of a policy change to reduce Medicare Advantage spending,” the official said.
The long range actuarial deficit of the hospital trust fund is 0.35% of taxable payroll, “lower than last year’s estimate of 0.62%,” he said. “Two ways to reduce the deficit are to decrease outlays by 8% or increase the standard payroll tax rate” from 2.9% to 3.25%.
The trustees’ report covers two separate funds. The Medicare Hospital Insurance Trust Fund — also known as the Part A Trust Fund — pays for inpatient hospital care as well as hospice care and skilled nursing facility and home health services following hospital stays. The Supplemental Medical Insurance (SMI) Trust Fund pays for benefits under Medicare Part B — which includes physician services — and Medicare Part D, which is the prescription drug benefit.
The SMI Trust Fund is adequately financed into the indefinite future because it is financed by beneficiary premiums and federal funds that are automatically adjusted each year to cover costs for the upcoming year. In contrast, the Part A Trust Fund is financed by a variety of sources, including payroll taxes, a portion of the taxes on Social Security benefits, Part D state payments, Part B drug fees, and beneficiary premiums.
The Medicare board of trustees has six members: the secretaries of Labor, HHS, and Treasury; the Commissioner of Social Security; and two public trustees, although the public trustee positions have been vacant since 2015. The CMS administrator serves as the board’s secretary.
The Medicare trustees also found that Part B expenditures were $502.9 billion in 2023 and are expected to grow annually at an average of 7.7% for the next 5 years under current law. In 2024, the monthly Part B premium rate is $174.70 and is projected to increase to $185 in 2025, although that amount won’t be finalized until later this fall.
As for the Part D drug program, expenditures there stood at $131.1 billion in 2023 and are projected to grow at an average annual rate of 8.2% over the next 5 years, according to the report.
In comparison to the rosy overall forecast for the Hospital Insurance Trust Fund, the official warned that “uncertainty remains about adherence to current law payment updates, particularly in the long range,” adding that the concern “is more immediate for physician services, for which a negative payment rate update is projected in 2025, and updates are projected to be below the rate of inflation in all future years.”
In particular, the official told MedPage Today on the call, with a negative payment update anticipated for 2025 and 0.25% or 0.75% updates specified after that, which are “considerably lower than projected rates of inflation…, there’s a recognition that those updates are not going to meet up with expectations for provider costs, and that’s the concern that is raised.”
The trustees’ report includes an alternative scenario in which physician payment rates are raised in conjunction with the rate of increase in the Medicare Economic Index (MEI), a measure of healthcare inflation. Under that alternative — which likely would ease concerns about beneficiary access to physicians — “total Medicare expenditures would increase to 8.4% of GDP [gross domestic product] at the end of the long-range [75-year] projection period, as opposed to 6.2%” if current law doesn’t change, the official said. He noted that without changes to current law, “should payment rates prove to be inadequate for any service, beneficiary access to and quality of Medicare benefits would deteriorate over time.”
Raising physician payment rates in line with the MEI was also discussed by the Medicare Payment Advisory Commission (MedPAC) in its March report to Congressopens in a new tab or window. “Given recent high inflation, cost increases could be difficult for clinicians to continue to absorb,” the reportopens in a new tab or window said. “Yet current payments to clinicians appear to be adequate, based on many of our indicators. Given these mixed findings, for calendar year 2025, the commission recommends that the Congress update the 2024 Medicare base payment rate for physician and other health professional services by the amount specified in current law plus 50% of the projected increase in the MEI.”
“Based on CMS’s MEI projections at the time of this publication, the recommended update for 2025 would be equivalent to 1.3% above current law,” the report continued. “Our recommendation would be a permanent update that would be built into subsequent years’ payment rates, in contrast to the temporary updates specified in current law for 2021 through 2024, which have each increased payment rates for one year only and then expired.”
American Medical Association president Jesse Ehrenfeld, MD, MPH, said in a statementopens in a new tab or window Monday that “This report continues the drumbeat of recommendations that all point out that the payment system is failing patients and physicians. When physicians face a set of facts, we respond to improve the situation. It would be political malpractice for Congress to sit on its hands and not respond to this report.”
“Medicare trustees and MedPAC have teed up the issue for members of Congress who, no doubt, have heard from constituents about problems accessing healthcare under Medicare,” he added. “The AMA has plenty of reform ideas to permanently solve the problem and end this annual cycle of payment cuts and patches.”
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