Medical marijuana could ease Wyoming opioid crisis

www.wydispensaries.com/medical-marijuana-could-ease-wyoming-opioid-crisis/

The biggest controversy over medical marijuana in Wyoming should be why legislators haven’t already legalized it.

Here’s the reason: many of our lawmakers don’t understand the issue. They remain blinded by the rhetoric of long ago when marijuana was thought of as a “gateway drug” as harmful as heroin. Those arguments are still made today by Wyoming legislators who rely on thoroughly outdated propaganda and incorrect information to keep medical marijuana illegal.

Opponents of marijuana use in the 1960s and 1970s maintained that it did not have any medical benefits, but now we know from scores of scientific studies that their claims were wrong. Medical marijuana is legal in 29 states and the District of Columbia, improving the lives of patients with a host of diseases and conditions.

But not in the Cowboy State.

Inexplicably the vast majority of Wyoming legislators fail to grasp what is at the heart of the matter — pain relief and how to obtain it without becoming addicted to the opiates that are killing thousands of Americans each year.

We all experience pain. I can’t accept that we allow elected officials — not doctors, pharmacists or researchers mind-you — to dictate how we deal with it. Some argue that it is a morality issue. What’s moral about refusing aid to the suffering?

Others may argue that prohibition is the will of the people. Representatives taking that stance either don’t know, or don’t care, that an October 2016 University of Wyoming poll showed that an overwhelming 81 percent of state residents support the legal use of medical marijuana.

Despite its opposition to medical marijuana, the Legislature did show during the recent budget session that it is concerned about the sweeping opioid epi­demic. Senate President Eli Bebout (R-Riverton) sponsored a bill to create an opioid addiction task force that will include lawmakers, physicians, pharmacists, law enforcement and others.

Medical marijuana deserves to be a priority consideration of the task force’s agenda and not rejected out-of-hand because some believe it is hazardous to their political and professional health.

Currently our lawmakers have left those with chronic suffering with three unacceptable options: choose to live with pain, risk addiction and overdose with prescription or street opiates, or break the law by smuggling marijuana into Wyoming that was legally purchased in Colorado, Montana or other states.

Two new studies published last week by the JAMA Internal Medicine journal corroborate what other research projects have shown — the availability of legal marijuana reduces reliance on legal opiates like oxycodone, hydrocodone and codeine, and illegal street drugs like heroin.

Since 1999, according to Scientific American magazine, opiate overdoses have killed more than 165,000 Americans. The publication estimates the social costs of abusing these drugs at $55 billion per year.

If there is a way to provide effective pain relief for Wyomingites that will not end in tragedy for the victims, their families, friends and communities, we should jump on it. That’s especially true when the alternative already has widespread public support. About the only thing standing in the way of this readily available solution is the hide-bound ideology of the unwinnable “war on drugs.”

News flash, we lost that “war” decades ago. But the casualty count keeps climbing.

Peter Grinspoon, M.D., of Harvard Medical School says the most common use of medical marijuana is the relief from chronic pain and diseases such as cancer and multiple sclerosis.

“Marijuana is said to be a fantastic muscle relaxant, and people swear by its ability to lessen tremors in Parkinson’s disease,” Grinspoon wrote in the Harvard Health Blog. The Harvard physician noted it has also been successfully used for fibromyalgia, endometriosis, interstitial cystitis “and most other conditions where the final common pathway is chronic pain.”

We already know that marijuana can be used to help patients with cancer, multiple sclerosis, glaucoma and to manage nausea and weight loss associated with HIV, irritable bowel syndrome and Chron’s disease. Scientists are now researching how the drug can be used to help veterans returning from combat zones with PTSD. Early results are promising.

The number of diseases and medical conditions alone that can be successfully treated with medical marijuana is reason enough for state lawmakers to approve its use. But the new studies show medical marijuana also significantly decreases opioid use.

Researchers at the University of Georgia, in the most comprehensive study of the subject to date, found that states with medical marijuana dispensaries saw a nearly 15 percent decline in the number of daily opioid doses filled under Medicare Part D. In other words, in states where people have legal access to marijuana, pharmacies issue fewer, people consume fewer and the federal government pays for fewer dangerous opioids.

A University of Kentucky study came at the question from a slightly different angle but showed similar results. In their experiment, the Kentucky researchers found that in states with medical marijuana laws doctors wrote 5.88 percent fewer opiate prescriptions on average. In recreational pot states like Colorado the reduction jumped to 6.38 percent.  

If the remaining 21 states, including Wyoming, approved medical marijuana, it’s logical to conclude that number could be even higher.

Over the years a limited number of Wyoming legislators have shown they understand the benefits of medical marijuana. Former Sen. Keith Goodenough (D-Casper) sponsored a bill in 2003 that passed the Senate Judiciary Committee but died when Republican leaders refused to allow the measure to get to the Senate floor.

One of the senators who voted for the bill in committee 15 years ago was current Sen. Bruce Burns (R-Sheridan), who explained at the time that he brought marijuana from Colorado to New York to help ease the pain of a relative who was dying of cancer. That experience three decades ago convinced Burns that Wyoming should allow a physician to prescribe marijuana to patients, and pharmacies to fill those prescriptions just like painkillers, penicillin and other drugs.

Rep. Sue Wallis (R-Recluse), who saw her husband’s pain ease from medical marijuana as he was dying of lung cancer in a Colorado hospital, had planned to introduce a medical marijuana bill but she died in January 2014 before it could happen.

Burns and Wallis learned first-hand from their relatives how beneficial medical marijuana can be. But at this stage lawmakers shouldn’t need personal experience to buy in. The mountains of medical evidence and the enormous social benefits experienced in other states should be enough.

In the campaign to combat the widespread problem of opioid addiction that now claims the lives of an estimated 42,000 Americans per year, Trump has challenged researchers to “come up with a painkiller that’s not so addictive.”

But what the president wants is already available. Medical marijuana is one vital component in the battle against the opioid epidemic and it needs to be in the comprehensive packages of ways the state and federal governments save lives.

It doesn’t have to be difficult. Other states already have dispensary systems in place and laws covering growing and taxing cannabis. As many legislators like to say, there’s no need to “reinvent the wheel.” To combat opioid use — which the Legislature is already on record as supporting — legalizing medical marijuana makes sense and could be accomplished in the next general session.

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https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/72206

Can a film help shift the conversation on reducing deadly errors in medicine?

The documentary To Err Is Human, which is currently in previews and opens to wide release in the fall, attempts to answer that question, highlighting the obstacles, consequences, and attempts to address the myriad factors on both the institutional and individual level responsible for errors in medicine.

“It’s a massive topic to address,” said director Mike Eisenberg, following a recent screening of his film. “We really wanted to maintain a singular focus — what would my dad have done if he made this movie?”

His late father, John Eisenberg, MD, MBA, was one of the early directors for what is now the Agency for Healthcare Research and Quality (AHRQ). He launched AHRQ’s evidence-based practice centers and was viewed as a pioneer for his work in healthcare research. In 2002 he died from a brain tumor, at the age of 55.

To Err Is Human gets its title from the landmark 1999 report on deaths from medical error from the Institute of Medicine, which estimated that between 44,000 and 98,000 hospitalized Americans die from medical errors each year.

Medical error isn’t currently a CDC-approved option when listing cause on death certificates — only diseases, morbid conditions, and accidents can be listed.

In 2016 an open letter from Martin A. Makary, MD, MPH, of Johns Hopkins Medicine in Baltimore, and colleagues urged the CDC to change this policy.

The authors of the letter — who defined death from medical errors as “1) errors in judgment or skill, coordination of care, 2) a diagnostic error, 3) a system defect resulting in death or a failure to rescue a patient from death, and 4) a preventable adverse event” — pointed to the fact that funding for medical research is often based on mortality figures. As such, patient safety gets a short shrift, and little public awareness.

The CDC says its methodology is in keeping with international standards of reporting on the causes of death.

More recent (though controversial) estimates put the number of deaths due to medical error at 400,000 per year or higher, but even conservative estimates would still make it the third leading cause of death in the U.S. following heart disease and cancer.

Sally Roumanis, RN, telling the story of the medical error that cost her husband’s life

“In 2006, I had my own medical error and became part of that statistic,” said Sally Roumanis, RN, a patient-safety specialist at Yale, who shared her experience during a panel discussion that followed the screening.

Her husband Dean ended up in the ER at Yale following a cardiac event while cycling. A stent was put in and everything had seemingly gone well. It was late at night and Dean urged Roumanis and their daughter to head home for rest. “I can’t stand you hovering,” he joked, Roumanis recounted.

But at 5 a.m. Roumanis received a call saying her husband’s condition had drastically worsened. She arrived back at Yale to see a team rushing toward the cath lab, then doctors performing chest compressions on her husband.

A couple of days later she was told her husband’s death was a result of medical error.

A coronary artery had been perforated during the stent procedure resulting in bleeding and pericardial collection. “That wasn’t the error — it was a complication,” explained moderator Harlan Krumholz, MD, of Yale’s Institute for Social and Policy Studies. “But throughout the night, as Dean began to struggle, the junior doctors failed to escalate the problem to a higher level and didn’t appreciate the seriousness.”

It was early in the morning and the doctors handling the situation were early in their careers. “Nurses were advocating for escalation,” Krumholz continued, “but didn’t feel empowered to override the situation.”

The inexperienced doctors were treating the symptoms without understanding the cause. Dean’s condition continued to spiral downward until 5 a.m. when he went into cardiac arrest. “His pressure drops dramatically — they realize it needs to be escalated,” Krumholz said. “They rush him to the lab, but it’s too late.”

“This can’t be happening,” Roumanis told herself. “You just think, ‘no, he’s in a hospital, he’s in a safe place.'”

Talking About Medical Errors

In the past, doctors were trained not to talk about mistakes, but that attitude has shifted. The film features one institution that uses actors to train physicians delivering news of a medical error made during care.

Marna P. Borgstrom, MPH, left, discussing Yale’s approach to patient safety

Marna P. Borgstrom, MPH, president and CEO of Yale New Haven Health System, said that nothing has changed in the way of medical malpractice litigation, but that organizations — and individuals within organizations — have made the decision that it’s the right thing to do. “Now, whenever there is an error made, whether or not there is identifiable harm to the patient, we encourage the responsible clinicians to talk with the patients about that,” she said.

“Patients still sue us when that happens,” she added, “and that’s not wrong, because in some cases people are entitled to damages.”

Borgstrom, who spoke during the panel portion, recalled that when Yale first started tracking medical errors in an internal patient safety-reporting database there were about 14,000 events the first year, across the network of providers. “That sounds like a lot,” she said. Three years later it was 24,000 and growing.

“We viewed that as a good sign,” she said. “Rather than being afraid of telling people we made a mistake, people are talking about it.”

AHRQ

AHRQ, which has been under constant threat of defunding by Congress, is still in trouble and could possibly be rolled into the National Institutes of Health (NIH). “If AHRQ is dissolved into the NIH, there will still be some form of patient safety effort going on in NIH, where people who worked at AHRQ will hopefully be able to continue their work, but the budgets will be decreased, their efforts will be pared down,” Eisenberg said. “The way it is right now will no longer exist if that happens.”

However, as part of the omnibus bill, Congress passed a 3% increase to AHRQ’s budget for the next fiscal year ($334 million total), the first increase in 10 years. “So this is good news. There are caveats — I’m sure that those increases come with responsibilities that are not only focused on patient safety,” Eisenberg said. “The entire budget is never only about patient safety anyway.”

He said there are still people in very powerful positions who don’t think AHRQ’s work is important.

In 2012 AHRQ released a report detailing that a combination of best practices, improved safety culture, and a bigger focus on teamwork could cut central-line-associated bloodstream infections (CLABSIs) in hospitals by 40%. Borrowed from lessons learned in the aviation industry, one of the components included use of a procedure checklist, and during the film and panel discussion — countless comparisons were made to the Federal Aviation Administration’s ability to improve safety.

“A lot of these problems are engineering problems,” said Kevin M. Johnson, MD, of the Department of Radiology & Biomedical Imaging at Yale School of Medicine, chiming in from the audience. “And we have almost no engineers around.”

The Film

Between interviews with experts in the field of patient safety, To Err Is Human weaves in the story of Susan Sheridan, whose family’s intersection with the healthcare system was met with two medical errors.

First, jaundice (a sign of too-high bilirubin) in her newborn son, Cal, was ignored and led to brain damage and development of cerebral palsy. Sheridan’s experience led her to become a patient-safety advocate. Today hospitals routinely tests for elevated bilirubin.

Years later her husband Patrick was diagnosed with and treated for a benign brain tumor. Additional tests from pathology had revealed a malignant tumor, yet this was never communicated to Patrick’s physician. Left untreated, the disease aggressively spread until it was too late. He died in 2002.

While the plan is for wide release in the fall, the trailer is now available online and various upcoming screenings have been scheduled in select cities — including Cleveland on Monday, Tuesday and Wednesday next week, and Philadelphia on April 20. The latter will include a panel discussion.

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https://www.painmedicinenews.com/Web-Only/Article/04-18/Medicare-Announces-New-Guidelines-on-High-Dose-Opioids/48469

New limits for high-dose opioid prescriptions will be enacted next year for Medicare Part D users, the Centers for Medicare & Medicaid Services (CMS) announced on April 2. Prescriptions will be held to a standard of 90 morphine equivalent milligrams (MME) per day, which follows the CDC prescribing guidelines for primary care physicians released last year.

The Medicare announcement—part of the 2019 Medicare Advantage and Part D Rate Announcement and Call Letter—also sets limits for opioid-naive patients on seven-day prescriptions, and notes the expansion and combination of the Overutilization Monitoring System and other government facets to identify “high-risk” opioid users, defined as using high levels of opioids from multiple sources, and “potentiator” users, who are using other medications (e.g., benzodiazepines) that increase the risk for adverse effects from opioids. CMS also plans to increase education on overdose risk and prevention.

With around 42.8 million people enrolled in Medicare Part D as of 2017, and a precedent for setting industry example, the agency hopes to “address the opioid epidemic” with these limits, aiming for an “overall reduction in opioid overuse and overdoses.”

The limits will not affect patients in long-term care facilities, hospice, palliative care or those effected by cancer-related pain. It also excludes patients seeking medication-assisted treatment for opioid addiction, such as those on buprenorphine. 

Some research has shown higher doses can be correlated with overdose. A Veterans Health Administration sample of chronic pain showed overdose patients had an average dosage of 98 MME per day, compared with other patients who had an average of 48 MME per day. The CDC also said an opioid dosage at or above 50 MME per day doubles the overdose risk, compared with dosages less than 20 MME per day. The standard of  90 MME per day now set by Medicare is equivalent to 90 mg of hydrocodone per day, 60 mg of oxycodone or about 20 mg of methadone. 

But the average number of daily MME per prescription has been declining, from 60 to 50 MME per day between 2006 and 2015, according to numbers from the CDC. Those with high-dose prescriptions (≥90 MME per day) also have declined, to an average 6.7 per 100 people in 2015. And overall prescriptions are down, at around 70 per 100 persons that same year, although that number is still three times higher than in 1999.

we know that opiate prescriptions have been declining annually since 2012 and they are using TWO YEAR OLD DATA – 2015 and using generally accepted national averages upward to 10% of the population could be classified as suffering from incurable intractable chronic pain – requiring 24/7 opiate therapy.  With the CMS quoted numbers – using 2015 data – they believe that with 30% of that group of pts being untreated properly is STILL TOO HIGH..

CMS is also using opiate conversion ratios that are stated as.. FACTS … where are in fact… “HIGHLY CRUDE ESTIMATES”… and apparently there is no pt accommodation for the pt being fast/ultra fast opiate metabolizer.

Here is four quotes from the CDC opiates guidelines:

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function.”

“Clinicians should consider the circumstances and unique needs of each patient when providing care.”

“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”

“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”

It would also appear that CMS’ recommendation COMPLETELY IGNORES the above parts of the CDC opiate dosing guidelines.

It would also appear that CMS is dead set on discriminating against a segment of our society that is consider a “protect class” under the Americans with Disability Act and the Civil Rights Act.  Since the federal agency that is in charge with enforcing the ADA  https://www.ada.gov/filing_complaint.htm   is under the same agency as the DEA – Dept of Justice.  AND… since CMS and CDC are part of HHS… 

Is it just me… or does there seem to be a great deal of collusion and cross protection of the actions of various Federal agencies by other Federal agencies ?

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www.hightimes.com/news/senators-take-jeff-sessions-marijuana-research-restrictions/

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www.medcitynews.com/2018/04/cvs-pharmacists/

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http://www.modernhealthcare.com/article/20180413/NEWS/180419954

The lawsuit was unsealed after the federal government declined to intervene in the case on April 2.

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www.bolenreport.com/not-just-us-opioid-crisis-something-far-worse-happening/

There is NOT Just a US “Opioid Crisis” – There is Something Far Worse Happening…

Here it is…

Note from Tim Bolen – Our newest writer, Jonelle Elgeway, is, due to personal experience (major injuries), an EXPERT on US Pain Management issues.  Jonelle was on the 1996 Olympic Field Hockey Team. With the Opioid Crisis sweeping the nation I recruited Jonelle to give us an “Insiders View” of what’s happening.  When I first read her draft article (below) I was astounded to find out how bad the OFFICIAL US Pain Management system really is.  Jonelle is addressing Congress April 25th, 2018 on pain issues- Below is why she is doing that.

By Jonelle Elgaway

There is no playbook on what to do when your life is turned upside down and inside out from a life altering car accident or major health issue. YOU’RE SCARED!

And you would expect that living in the United States the healthcare system would be there to not only save your life, but give you effective treatments and medications.

The United States healthcare system STINKS! And WE need to change it!

One of the biggest current U.S. healthcare FAILS is the so called “Opioid Crisis.”

First off, the United States isn’t dealing with a prescription opioid crisis.

It’s not even a heroin crisis.

The United States is currently in an Illicitly Manufactured Fentanyl Crisis.

In 2016 the Centers For Disease Control (CDC) created guidelines for primary care physicians prescribing for patients that are first time prescription pain medication users. The group of panelists were primarily made up of the Physicians for Responsible Opioid Prescribing (PROP) specializing in substance abuse.

Somehow these guidelines were taken as law and have created an out of control brush fire that’s turned into a forest fire, focusing on patients needing pain medication to have any quality of life.

How the “Opioid Epidemic” all started and the SCARY TRUTH about Illicit Manufactured Fentanyl (IMF)

1996 OxyContin was marketed as a low habit forming pain medication.

In 2010 the reformulation of OxyContin forced illegal pill users to turn to heroin, due to the tamper resistant pills.

In 2011-2012 the CDC states that heroin use took off. Debra Dowel from the CDC testified that we are now in an era of synthetic drugs.

China and Mexico now creates and illegally exports carfentanyl, which is an analog of the synthetic analgesic fentanyl. A unit of carfentanyl is 100 times as potent as the same amount of fentanyl, 5,000 times as potent as a unit of heroin and 10,000 times as potent as a unit of morphine. They have changed the molecules of heroin just enough that illegal drug users are able to get that “original high” that they always chase. We need to let the public know how dangerous this is.

All street drugs are showing up with IMF and essentially are POISONED!

To Main Stream Media and the White House… IMF IS YOUR PROBLEM! We must warn the public that they are playing Russian Roulette when buying anything from the streets. Recently one county in Ohio stated that 99% of the overdoses were different types of carfentanyl. Only 3 cases were plain heroin.

Who is being affected?

There are 116 million chronic pain patients in the U.S.

There are 25-26 million intractable pain patients, which are noncancerous rare and painful diseases like Complex Regional Pain Syndrome (CRPS), Arachnoiditis and Rheumatoid Arthritis to name a few.

Out of these intractable pain patients, 5-6 million patients have been stripped of their pain medications due to forced tapers or forced reductions because of the CDC Guidelines. This was supposed to be about overdoses and addiction wasn’t it?

Instead this is causing entirely new issues.

Three things will happen to these patients… 1) They will commit suicide 2) They will turn to street drugs, which they won’t know what they are getting, leading to possibly more overdoses 3) More health issues will be created from having high levels of out of control pain for long periods of time such as; heart attacks, stroke, high blood pressure, cancers and auto immune issues.

How do we fix this issue?

(1)  Lawmakers should start by NOT creating any new laws or policies with data used from the CDC, because we now know that the CDC data is flawed and manipulated. The CDC recently admitted that they inflated the overdose numbers.

(2) The CDC guidelines should be revoked and instead use the Federation of State Medical Boards (FSMB) written by doctors and medical boards specializing in pain management. When chronic pain patients use their medication properly, they rarely become addicted. Within the US there are less than 2% of the population that become addicts. This number hasn’t changed in the last 60 years.

(3)  Many states now accept and doctors need to use a Palliative Care Certificate and Exceptions. This will allow doctors to prescribe pain medication over the CDC guidelines of 90 mme. Centers for Medicare and Medicaid Services (CMS) plan to use the CDC guidelines, which have NO scientific studies supporting that CDC’s 90 mme or CMS’s 200 mme levels are dangerous and will cause overdose or addiction for intractable pain patients. Again, there are no studies! In fact, FDA scientists did a study finding that there is no difference between pain from cancer and noncancerous pain.

(4)  Doctors should be given reimbursements as a palliative care visit instead of an office visit.

(5)  Fund programs to help build institutions like what the VA or other countries are setting up all over the world to take care of patients properly through multidisciplinary programs. Let’s be real about the limitations on alternative therapies within the US, if doctors provide them, health insurance doesn’t cover them.

(6)  Fund education for physicians on how to properly use pain medication and deal with patients having rare and painful diseases and chronic health issues.

(7)  Create harm reduction strategies for people with substance abuse issues.

(8)  Stop trade with Mexico and China until they deal with their illegal trade of IMF.

There is no “One Size Fits All” approach to pain management…

The is a really SIMPLE issue with a SIMPLE solution. Allow patients to have access to the correct medications and treatments that they need to have any quality of life.

Intractable pain patients dealing with severe and painful diseases are not a one-size-fits-all. They are not going to become addicts or overdose on the pain medication that they safely have taken for many years.

We need to let doctors treat their patients how they deem fit. The government needs to realize the real battle is with IMF coming in from Mexico and China!

By Jonelle Elgaway

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Failure to provide adequate pain medication to people with disabilities violates our civil rights under the U. S. Supreme Court’s OLMSTEAD (1999) and the Americans with Disabilities Act by preventing us from becoming “integrated into the community to the fullest extent possible”, owning homes, working, enjoying family and friends and interacting with non-disabled people. Segregation of us in assisted living, nursing homes or institutions is forbidden by this Supreme Court that is the Law of the Land.

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http://www.wlox.com/story/37924468/the-opioid-crises-hurts-those-in-pain-even-more

BILOXI, MS (WLOX) –

We’ve all heard about the opioid epidemic and the efforts of law enforcement to crack down on abuse. 

However, there’s another side of the debate that often gets overlooked: the thousands of people who depend on controlled narcotics to remedy their chronic pain. Dottie Lyons is one of those people.  

Lyons can barely walk these days. The medicine that helps is getting harder to get. “My pain is horrendous. On the lower dosage of medicine, it maybe takes it from a 10 to a 5 or 6 if I’m lucky. It just hurts to move,” she said. 

She was badly hurt in an offshore accident years ago. She explained, “I’ve got metal plates and screws holding my spine together.” 

Her son Marc Hurley, helps as much as he can. He sees the change. “Before she got cut back on her pain medication, she could do a lot more for herself. She was more self-sufficient. She could drive, she could walk,” Hurley said. 

Dottie knows about the opioid crises but has not become an addict. She stated, “When I hear about this epidemic and I’m in this pain constantly, I just am very careful with how I do take the medicine.” 

Getting her medicines has become so difficult at times for Dottie, she now resorts to the practice called pill splitting. She cuts her dosages in half to make them last longer.

Marc says visiting the doctor these days is a challenge. ”Just about every physician you talk to these days, they’re scared. They have every right to be. They’re scared to prescribe more because they don’t want the DEA to go put them in jail,” Marc noted. 

This is not the life that Dottie wanted. She said, “I don’t want to take meds, but I don’t want to be in pain either.” 

When Marc sees that pain, he hurts too. He stated, “People that don’t abuse these drugs are the ones that suffer the most.” 

For those in the medical profession, Dottie has a message. “They’ve got to wake up. They can’t make people suffer like this all the time,” she said. 

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http://www.healthcarefinancenews.com/news/aetna-whistleblower-accuses-cvs-healths-caremark-fraud-medicare-part-d-drug-prices

An unsealed 2014 lawsuit by an Aetna actuary whistleblower against CVS Caremark, the insurer’s pharmacy benefit manager, accuses the PBM of billing the government for prescription drugs at a greater price than it pays to pharmacies.

The PBM did not disclose to Aetna how much it was being paid by the pharmacies, nor that it was pocketing the difference, a practice known as spread-pricing, according to the complaint brought by Sarah Behnke against CVS Caremark, Caremark Rx, CaremarkPCS Health and SilverScript Insurance Company.

[Also: Congressman blasts CVS Health, Aetna merger, asks for deeper investigation]

The lawsuit claims that Caremark and its affiliate SilverScripts submitted fraudulent Medicare Part D actual drug costs to CMS since at least 2007.

At the time of the lawsuit Behnke was a senior actuary/head actuary for Medicare Part D for Aetna.

CMS’s payments are required to be based on the actual cost of a drug, meaning the drug price received by the pharmacy.

In September, 2012, Caremark notified Aetna of an increase in the maximum allowable price of 229 generic drugs. These drugs represented 59 percent of the utilization by Aetna’s Part D beneficiaries. 

On average, the increase was 13 percent for a 30-day supply. 

Behnke did an investigation and discovered that the prices Caremark had been charging, as well as those they proposed to charge, were significantly higher than prices being charged by other Part D plan sponsors to their beneficiaries for the same drugs. For example, Aetna competitors had prices for lisinoprol l 0 mg tablets that ranged from $1.54 to $3.02, but Aetna’s price was $4.69, the lawsuit said. 

Aetna determined that its prices were as much as 25- to 40-percent higher than its competitors’ prices. 

In 2013, Aetna brought its findings about the drug prices to Caremark and asked if this information could be used to negotiate lower pricing with pharmacies or if Caremark had already negotiated discounts similar to what Aetna’s competitors had negotiated, but were not passing them through to Aetna. 

In a virtual admission of liability under the Medicare statute and Part D regulations, the lawsuit said, Caremark responded that it had negotiated lower prices on Aetna’s behalf but was not required under the contract to provide these prices to Aetna. 

Any increase in Aetna’s discounts would have only been achievable by getting greater discounts from the pharmacies and should not have impacted the Caremark defendant’s bottom line since the prices were merely pass-throughs, the lawsuit said. That is, Caremark’s profit for the PBM services was covered through administrative fees, not a mark-up on drug prices, the lawsuit said. 

But Caremark is also the PBM for Aetna’s commercial line of business.

“This arrangement benefits the Caremark defendants because in commercial contracts, they keep the difference, or the spread between the price Caremark has negotiated with the pharmacy and the price they charge their PBM customers, particularly under lock-in PBM agreements,” the lawsuit said.

CVS Health denied any allegations of wrongdoing.

“We believe this complaint is without merit and we intend to vigorously defend ourselves against these allegations,” CVS Health said by statement on Tuesday. “CVS Health complies with all applicable laws and CMS regulations related to the Medicare Part D program, and the government filed a notice of declination with regard to this complaint. Also, contrary to these false allegations, CVS Health is committed to helping both patients and payers with solutions to lower their prescription drug costs.”

Caremark said it recently announced that drug price growth remained flat for its PBM clients in 2017.

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com

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