It would seem that our healthcare system is consolidating geographically, in doing so “they” are creating “healthcare deserts” and “healthcare oases” and it also seems that chain pharmacies are at the forefront of creating a “pharmacy desert”.. Since there is a mention in their article of chains “pulling back” because DOJ/DEA fines. Could one or more of the chain pharmacies elect to stop stocking certain controlled meds? It use to be that pharmacies were required – by the state pharmacy practice act – to stock medications that are routinely prescribed in their market area. Most pts prescribed controlled meds are considered disabled or would be disabled without their medications.  If a pt, who patronizes a chain pharmacy and all of a sudden they are told that their med is on back order or unavailable.  The pt may want to lookup/read the state’s pharmacy practice act and see it they can find that requirement to stock meds routinely prescribed in their market. Federal & state law requires each pharmacy to maintain a perpetual inventory of all C-II meds.

Could pts get the inspector from the state pharmacy board to do a “check-in” with one or more chain pharmacies to verify that they are not stocking one or more C-II’s.  Getting the Board of Pharmacy (BOP) take actions against the Pharmacist in Charge (PIC) and the permit holder, for failing to stock/inventory most/many/all C-II’s. 

This could go several ways… BOP could decline to send out a pharmacy inspector, pharmacy could be found to be stocking C-II, but the BOP has no concerns that the pharmacy has stopped dispensing C-II’s or it was discovered that the pharmacy stopped stocking C-II’s and the BOP failed to take any action against the PIC and permit holder for violating the practice act.

In this article, the chains are admitting that some of the reason for attempting to reduce overhead costs and mentions the fines imposed by the lawsuit and fines imposed by 50 state Attorney Generals and others.  There is an agreement with those 50 state AG’s that the 3 major chains (CVS, Walgreen, Walmart) that they would reduce the number of controls they dispense to pts.  I have a copy of the agreement between those 50 AG’s and the three major drug wholesalers who agreed to reduce the controls that they sell to ALL PHARMACIES. 

There is a growing “pile” of evidence that these corporations are INTENTIONALLY denying pts – mostly disabled pts – of their medically necessary and legally prescribed controlled substances. 

It’s not just CVS. Other big pharmacy chains cut hours, close stores

https://ohiocapitaljournal.com/2023/09/01/its-not-just-cvs-other-big-pharmacy-chains-cut-hours-close-stores/

Walmart is cutting hours at its busy pharmacies, while Rite Aid — which is already selling off stores — is expected to file for bankruptcy protection, news organizations have reported over the past week.

The news comes after inspectors have found that CVS’s understaffed stores in Ohio have in some instances lacked controls to protect patients. And it raises the prospect that after buying up independent and small-chain competitors, cost-cutting large chains might not be able to adequately protect patients — when they can provide service at all.

One Tuesday, Reuters reported that Walmart was trying to reduce costs by asking 16,000 pharmacists to work fewer hours. Earlier this year, the company reduced the hours at 4,500 of its 5,000 pharmacies by two a day, the story said.

Reasons cited for the need for cuts include the $3.1 billion Walmart has to pay to settle a national opioid lawsuit, a lack of pharmacy technicians, and losses from sales of a weight-loss drug, the story said.

Meanwhile, Rite Aid is reportedly planning to file for Chapter 11 bankruptcy protection — a move that would likely involve the company closing 400 of its roughly 2,000 stores, Yahoo News reported. It also cited mounting costs from opioid settlements as part of the reason.

Also bedeviling the companies might be difficulty competing with e-commerce retailers for front-of-store sales of items such as cosmetics and shampoo. 

The outlet Digital Commerce 360 reports that online retailers sold more than $1 trillion worth of merchandise in 2022. And while its 8% growth that year was off from the 12% to 14% growth that typified the years from 2013 to 2019, it still was robust.

In 2021, CVS announced that it was closing 900 of its stores over the next three years, citing declining sales due to online competition as part of the reason.

The declines come after the big pharmacy chains in the 1990s and 2000s made a big bet that they could make money if they “sold everything, seemingly everywhere, at all hours,” as Slate put it last year.

But as the retail bet seems to be coming up lemons, it comes with a real cost to pharmacy patients.

For example, CVS bought and closed numerous smaller competitors and moved their prescriptions to its stores. Now it’s been closing its own stores and moving those scripts into its remaining stores, seemingly without adding staff to accommodate the new patients.

The Ohio Board of Pharmacy is proposing sweeping new rules after finding serious problems due to understaffing and high turnover. They include weeks-long waits for medicine, incorrectly filled prescriptions and a lack of controls over narcotics and other dangerous drugs.

In addition to those problems, the closure of smaller competitors — especially in rural areas — has made it much more difficult for some patients to get to the pharmacy, which for some is their only regular encounter with a medical professional. In other words, the closures have created pharmacy deserts.

In at least some cases, the problem isn’t that the companies owning big chains are losing money, it’s that they’re not making enough to keep Wall Street happy. For example, CVS Health made almost $2 billion in profit in the second quarter of this year, but that was 37% less than a year earlier, CNBC reported. 

But the corporation owns not only the biggest pharmacy retailer. It also owns Aetna, a top-ten health insurer, and CVS Caremark, the nation’s largest drug middleman. And not all of the slump was due to pharmacy operations.

In the CVS’s second-quarter earnings call, CEO Karen Lynch said, “We grew (pharmacy) revenue to $28.8 billion, an increase of nearly 8% versus the prior year. We generated $1.4 billion of adjusted operating income in the quarter, a decrease of 17% from the prior year, largely due to lower COVID-related volumes.”

Meanwhile, Walmart didn’t break out revenue from its pharmacy operation. But overall net income for the second quarter was up 53% over a year earlier, at $7.89 billion.

So at least some of the big chains are slashing stores or staffing — or both — even though their owners are making billions.

As it proposed new patient protections, the Ohio Board of Pharmacy cited numerous surveys indicating that safety is much less of a concern at the independent pharmacies and small chains that the big chains have been pushing out of business.

One was a 2021 survey asking Ohio pharmacists whether they agreed with the statement, “I feel that the workload-to-staff ratio allows me to provide for patients in a safe manner.” 

Almost 90% of those working for large chains responded that they didn’t have enough staff to keep patients safe. By contrast, almost three quarters of small-chain and independent pharmacists said they were adequately staffed to protect patients.

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Is this law from 1935 in conflict with the proposed bill list below ?

42 USC 1395: Prohibition against any Federal interference Nothing in this subchapter shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.

If You Need Pain Pills, Politicians Want To Monitor Your Body Chemistry

https://reason.com/2023/09/04/if-you-need-pain-pills-politicians-want-to-monitor-your-body-chemistry/

Our political leaders envision a future in which high-tech implants snitch about our use of painkillers.

What if your medical conditions could be monitored from a distance to assess your health and adjust treatment plans based on real-time information? What if the same technology could be used to track your use of medications, such as opioids, to make sure you’re not using them in frequencies and dosages frowned upon by bureaucrats who’ve never met you? You might already have guessed that it’s that second implementation of the technology that interests politicians, who want to remotely monitor our body chemistry to stop us from getting high.

Big Brother Will See You Now

“Not later than 18 months after the date of enactment of this Act, the Comptroller General of the United States shall conduct a study and submit to the Committee on Energy and Commerce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions and the Committee on Finance of the Senate a report on the use of remote monitoring with respect to individuals who are prescribed opioids,” reads a small section inserted into the Support for Patients and Communities Reauthorization Act, which has 63 cosponsors in the House of Representatives. The program includes “identification of cohorts of individuals who stand to benefit the most from remote monitoring when prescribed opioids.”

What a future our political leaders envision, in which high-tech snitches tell unblinking overlords about our use of painkillers—or any other health data they desire.

“A government‐​sanctioned study like the proposed one by GAO will no doubt show that, given current or projected technologies, it is possible to remotely monitor how patients use opioids through their physiological responses,” warn the Cato Institute’s Jeffrey A. Singer, a senior fellow and general surgeon, and Patrick G. Eddington, a senior fellow in homeland security and civil liberties. “With such data in hand, misinformed anti‐​opioid crusaders in Congress will then take the next ‘logical’ step — legislation requiring all patients prescribed opioids for any reason to be remotely monitored (another example of ‘cops practicing medicine.’)”

“This will intimidate health care practitioners into further curtailing opioid prescribing to their patients in pain,” they add. “This simply exacerbates the misery that state and federal opioid prescribing policies have already inflicted on them that is driving many to suicide and some to homicide.”

That pain is undertreated is beyond question. Last year, the Centers for Disease Control and Prevention (CDC) acknowledged that opioid guidelines have been inflexibly interpreted. The CDC emphasized that “some policies purportedly drawn from the 2016 CDC Opioid Prescribing Guideline have been notably inconsistent with it and have gone well beyond its clinical recommendations” resulting in “untreated and undertreated pain.”

Physicians are leery of prescribing opioids for fear the DEA will target them and deprive them of their livelihoods and their freedom. Patients fear being labeled as drug-seekers and cut off from medication that lets them function. Remote real-time monitoring of body chemistry won’t calm anybody’s concerns about being second-guessed by bureaucrats. Resentment of and resistance to such intrusive surveillance is guaranteed given that diabetics have already told researchers that such monitoring is unwelcome.

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A CRIMINAL ENTERPRISE OF THE UNITED STATES GOVERNMENT THAT MUST BE DISBANDED:
According to Leo Beletsky and Jeremy Goulka’s September 2018 article, “The Federal Agency That Fuels the Opioid Crisis,”
in the New York Times:
“The Drug Enforcement Administration, the agency that most directly oversees access to opioids, deserves much of the blame for these deaths. Because of its incompetence, the opioid crisis has gone from bad to worse. The solution: overhauling the agency, or even getting rid of it entirely.”

STUDY BY RICHARD LAWHERN, PH.D DEBUNKS BOTH 2022 CDC, ALL DOJ ENFORCEMENT GUIDELINES: “PRESCRIPTION OPIOID CRISIS IN AMERICA HAS BEEN ONE MAGNIFICENT HOAX”

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This ~ 40 minute video showed up in my email inbox and very informative information provided by two attorneys. Describing how they “track down” – per their criteria that is all about “numbers” and “data mining”.. your basic data “fishing expedition” in the state’s PDMP.

According to the first attorney in the video,  “they” were using the MME system as absolute to level the playing field of various opioids being prescribed. It would appear that prescribing a pt > 90 MME/day appeared to be a “pretty hard line” as being a huge red flag of prescribing “too much” & opioids without a valid medical necessity.

Of course, no mention of the pt’s pharmacogenomic metabolism tests, consideration if the pt had multiple disease issues, that were each a pain generator. It also appeared that a pt being prescribed  concurrently a opioid, benzodiazepine & muscle relaxant was a “do not cross line”.  \

The attorney reviewing what is considered suspicious activities of a pharmacy. One being when a pt is dealing with palliative care and/or cancer and PICK THEIR OWN PRESCRIPTION UP!

Maybe what these two attorney put forth about “illegal controlled meds prescribing/dispensing” might suggest why the SCOTUS in June ,2022 ruled ( 9-0 vote) in the Ruan/Kahn case that the DEA could not use objective criteria when evaluating a prescribing when treating pts dealing with subjective disease(s).

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In my life time, it was believed that physicians PRACTICED MEDICINE. Since computers have invaded all of our lives, medicine has been sliding or evolving towards the science of medicine. Artificial Intelligence (AI) as it interfaces with medicine, the window on the “practice of medicine” may close to some degree, maybe at least try to totally close that window and fully open the “science of medicine” when it comes to treat pts dealing with subjective diseases ( pain, anxiety, depression, ADD/ADHD and multiple mental health issues).  These are diseases that have few/no medical tests to confirm that the pt is dealing with a specific disease and/or the intensity of the impact of the disease on the pt’s QOL ( Quality Of Life).  AI functions – makes decisions based on FACTS and they can be coded to have biases.

How slow or fast that this may happen, is anyone’s guess, but the pain community may be one of the first to find out!

Artificial Intelligence May Influence Whether You Can Get Pain Medication

https://kffhealthnews.org/news/article/artificial-intelligence-pain-medication-narx-score/

Elizabeth Amirault had never heard of a Narx Score. But she said she learned last year the tool had been used to track her medication use.

During an August 2022 visit to a Hospital in Fort Wayne, Indiana, Amirault told a nurse practitioner she was in severe pain, she said. She received a puzzling response.

“Your Narx Score is so high, I can’t give you any narcotics,” she recalled the man saying, as she waited for an MRI before a hip replacement.

Tools like Narx Scores are used to help medical providers review controlled substance prescriptions. They influence, and can limit, the prescribing of painkillers, similar to a credit score influencing the terms of a loan. Narx Scores and an algorithm-generated overdose risk rating are produced by health care technology company Bamboo Health (formerly Appriss Health) in its NarxCare platform.

Such systems are designed to fight the nation’s opioid epidemic, which has led to an alarming number of overdose deaths. The platforms draw on data about prescriptions for controlled substances that states collect to identify patterns of potential problems involving patients and physicians. State and federal health agencies, law enforcement officials, and health care providers have enlisted these tools, but the mechanics behind the formulas used are generally not shared with the public.

Artificial intelligence is working its way into more parts of American life. As AI spreads within the health care landscape, it brings familiar concerns of bias and accuracy and whether government regulation can keep up with rapidly advancing technology.

The use of systems to analyze opioid-prescribing data has sparked questions over whether they have undergone enough independent testing outside of the companies that developed them, making it hard to know how they work.

Lacking the ability to see inside these systems leaves only clues to their potential impact. Some patients say they have been cut off from needed care. Some doctors say their ability to practice medicine has been unfairly threatened. Researchers warn that such technology — despite its benefits — can have unforeseen consequences if it improperly flags patients or doctors.

“We need to see what’s going on to make sure we’re not doing more harm than good,” said Jason Gibbons, a health economist at the Colorado School of Public Health at the University of Colorado’s Anschutz Medical Campus. “We’re concerned that it’s not working as intended, and it’s harming patients.”

Amirault, 34, said she has dealt for years with chronic pain from health conditions such as sciatica, degenerative disc disease, and avascular necrosis, which results from restricted blood supply to the bones.

The opioid Percocet offers her some relief. She’d been denied the medication before, but never had been told anything about a Narx Score, she said.

In a chronic pain support group on Facebook, she found others posting about NarxCare, which scores patients based on their supposed risk of prescription drug misuse. She’s convinced her ratings negatively influenced her care.

“Apparently being sick and having a bunch of surgeries and different doctors, all of that goes against me,” Amirault said.

Database-driven tracking has been linked to a decline in opioid prescriptions, but evidence is mixed on its impact on curbing the epidemic. Overdose deaths continue to plague the country, and patients like Amirault have said the monitoring systems leave them feeling stigmatized as well as cut off from pain relief.

The Centers for Disease Control and Prevention estimated that in 2021 about 52 million American adults suffered from chronic pain, and about 17 million people lived with pain so severe it limited their daily activities. To manage the pain, many use prescription opioids, which are tracked in nearly every state through electronic databases known as prescription drug monitoring programs (PDMPs).

The last state to adopt a program, Missouri, is still getting it up and running.

More than 40 states and territories use the technology from Bamboo Health to run PDMPs. That data can be fed into NarxCare, a separate suite of tools to help medical professionals make decisions. Hundreds of health care facilities and five of the top six major pharmacy retailers also use NarxCare, the company said.

The platform generates three Narx Scores based on a patient’s prescription activity involving narcotics, sedatives, and stimulants. A peer-reviewed study showed the “Narx Score metric could serve as a useful initial universal prescription opioid-risk screener.”

NarxCare’s algorithm-generated “Overdose Risk Score” draws on a patient’s medication information from PDMPs — such as the number of doctors writing prescriptions, the number of pharmacies used, and drug dosage — to help medical providers assess a patient’s risk of opioid overdose.

Bamboo Health did not share the specific formula behind the algorithm or address questions about the accuracy of its Overdose Risk Score but said it continues to review and validate the algorithm behind it, based on current overdose trends.

Guidance from the CDC advised clinicians to consult PDMP data before prescribing pain medications. But the agency warned that “special attention should be paid to ensure that PDMP information is not used in a way that is harmful to patients.”

This prescription-drug data has led patients to be dismissed from clinician practices, the CDC said, which could leave patients at risk of being untreated or undertreated for pain. The agency further warned that risk scores may be generated by “proprietary algorithms that are not publicly available” and could lead to biased results.

Bamboo Health said that NarxCare can show providers all of a patient’s scores on one screen, but that these tools should never replace decisions made by physicians.

Some patients say the tools have had an outsize impact on their treatment.

Bev Schechtman, 47, who lives in North Carolina, said she has occasionally used opioids to manage pain flare-ups from Crohn’s disease. As vice president of the Doctor Patient Forum, a chronic pain patient advocacy group, she said she has heard from others reporting medication access problems, many of which she worries are caused by red flags from databases.

“There’s a lot of patients cut off without medication,” according to Schechtman, who said some have turned to illicit sources when they can’t get their prescriptions. “Some patients say to us, ‘It’s either suicide or the streets.’”

The stakes are high for pain patients. Research shows rapid dose changes can increase the risk of withdrawal, depression, anxiety, and even suicide.

Some doctors who treat chronic pain patients say they, too, have been flagged by data systems and then lost their license to practice and were prosecuted.

Lesly Pompy, a pain medicine and addiction specialist in Monroe, Michigan, believes such systems were involved in a legal case against him.

His medical office was raided by a mix of local and federal law enforcement agencies in 2016 because of his patterns in prescribing pain medicine. A year after the raid, Pompy’s medical license was suspended. In 2018, he was indicted on charges of illegally distributing opioid pain medication and health care fraud.

“I knew I was taking care of patients in good faith,” he said. A federal jury in January acquitted him of all charges. He said he’s working to have his license restored.

One firm, Qlarant, a Maryland-based technology company, said it has developed algorithms “to identify questionable behavior patterns and interactions for controlled substances, and for opioids in particular,” involving medical providers.

The company, in an online brochure, said its “extensive government work” includes partnerships with state and federal enforcement entities such as the Department of Health and Human Services’ Office of Inspector General, the FBI, and the Drug Enforcement Administration.

In a promotional video, the company said its algorithms can “analyze a wide variety of data sources,” including court records, insurance claims, drug monitoring data, property records, and incarceration data to flag providers.

William Mapp, the company’s chief technology officer, stressed the final decision about what to do with that information is left up to people — not the algorithms.

Mapp said that “Qlarant’s algorithms are considered proprietary and our intellectual property” and that they have not been independently peer-reviewed.

“We do know that there’s going to be some percentage of error, and we try to let our customers know,” Mapp said. “It sucks when we get it wrong. But we’re constantly trying to get to that point where there are fewer things that are wrong.”

Prosecutions against doctors through the use of prescribing data have attracted the attention of the American Medical Association.

“These unknown and unreviewed algorithms have resulted in physicians having their prescribing privileges immediately suspended without due process or review by a state licensing board — often harming patients in pain because of delays and denials of care,” said Bobby Mukkamala, chair of the AMA’s Substance Use and Pain Care Task Force.

Even critics of drug-tracking systems and algorithms say there is a place for data and artificial intelligence systems in reducing the harms of the opioid crisis.

“It’s just a matter of making sure that the technology is working as intended,” said health economist Gibbons.

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This is what is happening in Colorado …

I’m looking for help with having a PBM trying to deny
coverage because of a MME. My state (Colorado) has 
passes a law that says these pbm cannot deny coverage
because of a predetermined mme. The pbm doesn’t feel
that they are under that same law. I am denied
getting coverage because of this. 
For the record the name of he law for my state is called
The act senate bill 23-144 in case you would
like to see what Colorado has done for its
chronic pain patients. Here is a hyperlink to the text of the Colorado law 
https://pluralpolicy.com/app/legislative-tracking/bill/details/state-co-2023a-sb23144/1266204
Here is an excerpt from the law:The act also prohibits a pharmacy,
health insurance carrier, or pharmacy benefit manager from
having a policy in place that requires a pharmacist to refuse
to fill a prescription for an opiate issued by a
health-care provider solely because the prescription 
is for an opiate or because the prescription order
exceeds a predetermined morphine milligram equivalent
dosage recommendation or threshold. 

Apparently this particular PBM believes that they are exempt from state law, even though most all PBM’s are licensed insurance companies and would have to have a state license to furnish product/services within states they are operating in.

Under this law, any/all PBM’s would be under the over sight of the state Insurance Commissioner and since this state has a state law that in particular denotes that PBM’s are covered under the law, the state Attorney General may come into play on enforcing the law.

Some times state legislators, are not happy when they pass laws that none of the state agencies will enforce the law. A lot of tax dollars going to waste, first on the legislators passing the bill and then all the state agencies failing to do their job.

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If you are a pt that has been on what has been called the “pharmacy crawl” going from pharmacy to pharmacy to find one that has in stock the controlled med that you have been prescribed. I would recommend that don’t get too excited, expecting to see this new DEA rule to be in place with all the various pharmacy software companies and the “switch” Sure Scripts where all E-Rx data goes thru and it was brought on line abt 20 yrs ago and I don’t know if they provided for pharmacies to pharmacy communications. I know when the DEA first granted the ability for prescribers to be able to send controlled Rxs electronically, all the mandatory protocol that was required by the DEA to get a pharmacy software certified was really a challenge to software programmers. As I remember, many pharmacy software companies, it took months to get their software certified. If we take a recent example of DEA waiting until about 4-6 weeks before prescribers were told to renew their DEA licenses to created the mandate for them to complete the 8-12 hr training program to meet the old X-wavier exemption to be able to prescribe SUD meds in treating addiction to be able to renew their DEA license.

In effect: DEA final rule on transfer of EPCS in schedules II–V between pharmacies for initial filling

https://ncpa.org/newsroom/qam/2023/08/30/effect-dea-final-rule-transfer-epcs-schedules-ii-v-between-pharmacies

A new DEA final rule, which became effective August 28, states that an electronic prescription for a controlled substance (EPCS) in schedule II–V may be transferred between retail pharmacies for initial filling on a one-time basis only, upon request from the patient. The DEA also clarified that any authorized refills included on a prescription for a schedule III, IV, or V controlled substance are transferred with the original prescription.

The final rule requires that the transfer of EPCS in schedule II-V must be communicated directly between two licensed pharmacists, the prescription must remain in its electronic form, and the contents of the prescription must be unaltered during the transmission. The final rule also stipulates that the transfer of EPCS in schedule II–V for initial dispensing is permissible only if allowable under existing state or other applicable law. In addition, the final rule describes the information that must be recorded to document transfer of EPCS in schedule II–V between pharmacies for initial dispensing. The electronic records documenting EPCS transfers must be maintained by both pharmacies for two years from the date of the transfer

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Pharmacist Advocate: Renee Blare RPh

CRIES OF THE USELESS EATERS: NEO-EUGENICS, SUB-HUMANIZATION, AMA- “CRIMINALIZATION OF MEDICINE MUST STOP,” MICHIGAN BLUE CROSS-DOJ-DEA, TARGETTING PAIN CENTER OF WARREN MI., (SZYMAN, BOTHRA, POMPY et al. TRIALS)

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