“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
Last week, the House of Representatives passed the slimmed-down government funding legislation without PBM reform. On Friday, the Senate took up consideration of the funding bill. Senate Democrats threatened to shut down the government, attempting to negotiate potential amendments as well as introducing their own legislation that would fund the government for one month, giving time for additional negotiations regarding President Donald Trump’s spending power. Ultimately, they were unsuccessful. Friday evening, the Senate passed the slimmed-down bill, keeping the government funded, by a vote of 54-46.
While negotiations were occurring, Sens. Ron Wyden (D-Ore.) and Bernie Sanders (I-Vt.) attempted to pass the health care package agreed to in December, which included PBM reform, by unanimous consent, but Sen. Rick Scott (R-Fla.) raised an objection, causing the effort to fail.
For the last 2 years, compounded versions of glucagon-like peptide 1 (GLP-1) medications have been big business. Nearly 137 million American adults are eligible to use these costly drugs to treat diabetes and obesity, or for secondary prevention of cardiovascular disease. That’s more than half of our adult population, so it’s no surprise the drugs have been in short supply. Compounding pharmacies stepped in to fill the gaps, as permitted by law during shortages, and millions of Americans turned to them for affordable, copycat drugs. But the US Food and Drug Administration (FDA) has now declared those shortages over.
Compounding pharmacies will soon have to stop selling their mass-produced versions — at least, in theory.
“There is so much money to be made,” Robert Califf, MD, FDA commissioner under former President Joe Biden, told Reuters.
“There’s just an endless number of tricks that compounders could use. So I don’t think it’s the end of it, but it certainly will bring us into a new era after the time period has passed and all the lawsuits are finished.”
Here’s what you should know.
Concerns About Compounded GLP-1s
As sales of these drugs boomed, problems emerged.
Compounding pharmacies are regulated by the FDA, but the individual drugs they make don’t need to meet the same evidentiary standards as their brand-name counterparts.
The brand-name drug has FDA approval, but the compounded version does not. Advertising for online vendors has walked a fine ethical line in terms of promises made, said Rena Conti, PhD, associate professor of markets, public policy, and law at Questrom School of Business at Boston University, Boston. She’s the co-author of a recent article in JAMA Health Forum that looked at marketing and safety concerns with compounded GLP-1s.
Questionable marketing isn’t the only issue.
“From a medical perspective, one challenge of dealing with the explosion of these products online is that it’s not clear whether your patients are using them,” she said. “Your medical record is not complete, and that creates challenges because these products have side effects and have interactions with other drugs and with the management of other conditions.”
There are risks specific to the way the drugs are dispensed, too. Brand-name GLP-1s generally come in prefilled injection pens. With compounded versions, patients must learn to fill an empty syringe from a vial. User error is common.
“All drugs have side effects, but what we’re documenting is that patient-reported problems with use of these products have exploded,”
Conti said. “We think it has to do with these compounding products being dispensed in a way that patients don’t completely understand how to take them.”
By November 30, 2024, the FDA had received more than 600 reports of adverse events with compounded GLP-1s.
Accessibility and Affordability
As popular as they are, GLP-1 medications aren’t cheap. Brand-name prescriptions cost upward of $1000 per month. According to Becker’s Hospital Review, skyrocketing demand has led several insurers to post operating losses. Coverage was restrictive before, but it’s even more so in 2025.
According to GoodRX, which tracks how insurance companies handle these drugs, almost 5 million people lost coverage for Zepbound this year. And for patients whose insurance does cover some GLP-1s, 83% now must meet some additional requirement, like prior authorization.
This double whammy of limited accessibility and hard-to-swallow pricing helped drive patients to compounding pharmacies, where they’ve been able to get the medications for much less — for instance, telehealth company Hims & Hers has been offering a month’s supply of compounded semaglutide for $165. That company is currently trying to find a legal workaround to the FDA’s deadline.
“Some compounders think maybe they’ll keep producing,” said Jeanne Varner Powell, JD, senior legal risk consultant for the Mutual Insurance Company of Arizona Risk Team.
“They may believe the FDA enforcement manpower is so weak that the FDA won’t be enforcing the prohibition that closely. Maybe they’ll keep producing. Physicians need to be aware of that. From a risk standpoint, I don’t think they’d want to be associated with a compounder that’s in violation of the law.”
Once the ban on large-scale compounding of GLP-1s takes effect, physicians should be on the lookout for — and warn their patients about — counterfeit versions that might fill the gap, Powell said. The FDA has already expressed concern about this.
Meanwhile, the drug companies behind brand-name GLP-1s are getting into the act, selling direct-to-consumers well below list price. Last summer, Eli Lilly began to offer a month’s supply of Zepbound for between $350 and $500 without insurance. The company told NPR that 100,000 people now buy direct each month. Recently, Novo Nordisk announced they’ll be dispensing Wegovy for $499 per month. Even at these lower prices, though, brand-name medications remain out of reach for many.
“It’s about managing expectations,” Powell said. “It’s important to tell patients, while these [compounded] drugs are still available, we expect there’s going to be an end. You have to consider if you can afford the cost of the name brand.”
How to Better Help Your Patients
So while the FDA may say shortages are over, compounded GLP-1s aren’t necessarily going away. They’ll still be permitted on an individual basis. For instance, to create a version of a drug that doesn’t contain a certain ingredient or in a dosage that isn’t readily available.
“That determination is made by the physician who has to write a prescription for a patient-specific drug that, in their opinion, will make a clinical difference for the patient,” Powell said. So if you have patients who need access to a specific kind of compounded GLP-1, you can still prescribe it. Advise your patient on how to find a trustworthy compounding pharmacy, and if necessary, show them how to administer the drugs to themselves.
But use this option judiciously, she cautioned. “I’d hope they wouldn’t get into a routine of copy-pasting, using the same rationale for each patient. If something happens — if an adverse outcome happens — they’re opening themselves to risk.”
Communication is key, Conti said. “If physicians are seeing patients drop weight over time that looks to be in the range of what’s possible with GLP-1s and they haven’t prescribed [the medication], they should educate their patients on the use of these products found online in a compounding format. Ask directly and document it in their medical records.”
Part of that communication calls for empathy and paying attention to each patient’s situation.
“Physicians should anticipate their patients might try to get medications from alternative sources if they can’t get the physician to write an individual compounding prescription, and they can’t afford brand-name prices,” Powell said. “It’s very likely the physician’s duty, as part of their relationship with the patient, to warn them there may be counterfeit drugs out there. Compounded versions should not be available, so they should be very skeptical about anything they see online.”
Do you remember all those wild fires in and around Los Angeles, Calf a few months back. Most of those fires were started from a spark, a camp fire, or other such things. Those fires torched some 90 sq miles. Just look at the CDC opioid dosing guidelines – as a spark – The VA quickly adopted, as did the DEA. Some 30 odd state legislatures condified those guidelines as the law in their state.
It took the CDC THREE YEARS to admit their mistakes, but here we are SIX YEARS later, has anyone seen any significant movement to undo the harm caused by those 2016 guidelines? Does this suggest that those behind the OPIOID PROHIBITION AGENDA have no intention of actually IGNORING THE FACTS that they are causing suffering and harm to untold tens of millions of our citizens.
The CDC did acknowledge that their 2016 opioid prescribing guidelines were misapplied. In April 2019, the CDC stated that its opioid guidelines had been widely misinterpreted and treated as hard and fast rules, rather than as flexible recommendations. The agency recognized that this misapplication led to unintended consequences and patient harm
The CDC acknowledged that the misinterpretation of their guidelines likely contributed to:
Untreated and undertreated pain
Serious withdrawal symptoms
Worsening pain outcomes
Psychological distress
Increased risk of overdose through use of illegal drugs
Suicidal ideation and behavior
The misapplication of the guidelines included:
Extension to patient populations not covered in the original guidelines (e.g., cancer and palliative care patients)
Rapid opioid tapers and abrupt discontinuation without patient collaboration
Rigid application of opioid dosage thresholds
Duration limits imposed by insurers and pharmacies
Patient dismissal and abandonment
In response to these issues, the CDC has since updated its guidelines to emphasize that the recommendations are voluntary and intended to be flexible to support individualized, patient-centered care
. The agency has also clarified that the dosage thresholds provided in the guidelines pertain solely to opioids used to treat chronic pain and are not intended for use in treating substance use disorders
It took CDC THREE YEARS to realize that the 2016 opioid dosing guidelines were a bad idea. I am sure that there are thousands of chronic pain pts that could have told them up front, before the ink had dried on the paper that they were written on, that they were a bad idea.
It took only a couple of weeks for 90 square miles to burn to the ground, but it is estimated that it is going to take 15 to 25 yrs for the whole area to get back to some sort of normalcy.
CDC causes patients to endure needless pain and suffering. Kennedy can help
The Centers for Disease Control and Prevention badly needs an overhaul, especially because of its undue influence on how doctors treat pain patients. Secretary Kennedy has the power to change this.
Not a month goes by without one or both of us receiving emails from desperate people pleading for help finding a physician willing to take new pain patients − a task that has become next to impossible.
Increasingly, these pleas are not just about pain management but about finding ways to end their lives, as years of forced reductions or complete discontinuation of the opioid painkillers that previously allowed them to function have left them bedridden, in constant severe pain or both.
Many have become “pain refugees,” seeking doctors who will accept new pain patients. These are not addicts seeking a fix; they are ordinary people who suffered an accident or serious illness. They once had full, productive lives but now face unimaginable agony.
Patients seek doctors who can help manage pain
Newly confirmed Health and Human Services Secretary Robert F. Kennedy Jr. has rightly called for a top-to-bottom reevaluation of U.S. public health agencies. One agency that badly needs an overhaul is the Centers for Disease Control and Prevention, especially because of its undue influence on how doctors treat pain patients.
In 2016, the CDC published a scientifically flawed opioid guideline built on weak evidence, misrepresented statistics and a fundamental misunderstanding of pain management with “suggested” opioid dosages. The CDC stressed that these guidelines are only recommendations, not “prescriptive.” Even so, when a government agency that people consider the premier authority on health matters makes a recommendation, it amounts to a de facto mandate.
By 2022, 40 states had enshrined the CDC’s 2016 guidelines into law. These state laws dictate the number of pills, their dosage and the duration that doctors can prescribe them. They impose restrictive opioid prescribing practices that undermine patient autonomy and substitute bureaucratic oversight for individualized medical decision-making.
Responding to criticism from scientists, physicians and patients, the CDC made minimal and meaningless changes to the guidelines in 2022.
Health practitioners who deviate from these restrictions do so at great risk − facing liability, regulatory scrutiny and even law enforcement action. Police department drug task forces may unfairly label doctors as “high prescribers” for treating patients requiring higher doses, leading to high-profile raids on their clinics.
Desperate, abandoned patients sometimes turn to street drugs, which adds to the toll of fentanyl overdoses.
Prescription painkillers aren’t the cause of opioid epidemic
The public, with help from the news media, still believes the myth that prescription painkillers are responsible for the overdose crisis. This is demonstrably false.
Prescribing peaked in 2012 and is now at 1993 levels – a reduction of about 50%.
Despite this, overdose deaths soared from approximately 40,000 in 2012 to 97,000 in 2024. Illicit fentanyl, often mixed with cocaine or methamphetamine, is almost always the culprit, not prescription pain pills.
The impact on the sick and powerless is staggering. One pain refugee cut off from medicine asked one of us if we knew how to test her street-bought pill − she took a small dose and vomited for 24 hours. A terminal cancer patient entered hospice, where doctors denied her oxycodone, causing pain and withdrawal. A mountain-climbing athlete was disabled by a serious accident and, now with brain cancer, sought advice on suicide due to unbearable nerve pain.
These are a few examples of the cruelty caused by the CDC’s misguided medical interference − an agony beyond most people’s comprehension. Even this tiny sample reveals the unimaginable torment caused by the CDC’s flawed foray into medicine.
Founded in 1946 as the Communicable Disease Center, the CDC’s mission was to stop the spread of communicable and infectious diseases. After helping eradicate malaria, which was endemic in the southern states, the CDC then tackled scourges like tuberculosis and smallpox.
Over the years, the agency has undergone mission creep, offering advice on many private health and lifestyle choices. An agency that takes on too many responsibilities can end up doing none of them well.
Fortunately, Secretary Kennedy can address this issue. In the spirit of compassion, we urge him to reform the CDC, restoring trust by ending its interference with patient-physician autonomy and refocusing on protecting lives from communicable diseases and public health threats.
Unwanted involvement from an agency that was never qualified to engage in personal medicine has caused unspeakable harm. Any one of us is one accident or illness away from facing the same fate − suffering that we wouldn’t allow for our pets.
There’s a growing problem for older Americans: doctors who specialize in geriatric care are dwindling.
More than 80 million Americans are expected to be older than 65 by 2050, according to the US Census Bureau.
However, geriatricians are in short supply, which could complicate access to care.
Jerry Gurwitz, a 68-year-old geriatrician based in Massachusetts, is at a tricky point in his career.
He’s spent decades taking care of older Americans, but now, as Gurwitz approaches the age of some of his own patients, he sees a brewing problem with his profession: there aren’t many people willing to take his job, and he has serious doubts over whether there will be enough doctors to properly take care of people as they get older, he told Business Insider.
Gurwitz, who graduated medical school in 1983, said he saw this problem brewing decades ago as he was completing his medical education. Part of the reason he chose to specialize in geriatric medicine was because practically comparatively few people were interested in the field, he said, a trend that hasn’t improved more than forty years later.
“These people are going to be retiring. There’s not substantial interest on the part of trainees to go into the field,” he said of the supply of geriatricians today. “I can’t see how the healthcare system isn’t going to be overwhelmed over the next decade. It’ll be too much, and too many people to take care of.”
Medical professionals say the problem has been in the making for years, with the supply of doctors trained specifically to treat older adults nowhere near keeping pace with a quickly aging US population.
There’s no clear path to addressing the shortage, Gurwitz said. He and other medical professionals told BI the influx of older patients could lead to a quality-of-care crisis.
The problem is visible in the numbers.
According to an estimate from the American Geriatrics Society, the US will need some 30,000 geriatricians by the end of the decade. Yet, the total number of board-certified geriatricians declined to around 7,400 in 2022, according to the American Board of Medical Specialities, down from around 10,000 at the start of the century —and the US population is quickly getting older.
According to the latest projections, the number of Americans aged 65 and older is expected to soar to 82 million by 2050, up 47% from 2022 levels.
Timothy Farrell, a geriatrician and a professor of medicine at the University of Utah, says the signs of strain on the profession have been increasing for years, but have become more severe recently.
Across the board, wait times have gotten longer, with the average wait for a physician appointment rising to 26 days, according to one 2022 survey, up 8% in five years.
“We could probably double our space, and we would very quickly fill,” Farrell said, adding that he believed stress in the geriatric unit could be higher than in other areas of the hospital.
R. Sean Morrison, a geriatrician at Mount Sinai, says he knows others in the industry who say they have waiting lists that stretch for six months.
The strain of caring for older adults is particularly evident in nursing homes. A survey of over 400 nursing homes conducted by the American Health Care Association found that 72% had fewer employees in 2024 than they did prior to the pandemic.
The survey also showed that 57% of nursing homes said they had a waiting list, 46% said they began to limit their intake of residents, and 7% said they were turning away patients on a daily basis.
“We don’t have right now, nor will we unfortunately ever have enough people who are trained,” Morrison said. “That’s evidenced by the amount of time it takes for an appointment within our geriatric practices. It’s evidenced by the number of older adults that need to be taken into the hospital that the inpatient services don’t have the capacity to see. And it’s just the tip of the iceberg.”
A dwindling medical profession
Gurwitz says he had always wanted to be a geriatrician, but the sentiment is rare among medical professionals. Data from the National Resident Matching Program showed that only 174 out of 419 available positions in geriatric specialty programs were filled in 2023, making it one of the most unfilled programs the organization tracks.
Convincing people to specialize in the field isn’t easy.
For one, the profession doesn’t pay as much as some specializations. According to data from Salary.com, the median salary for a geriatric physician in New York hovered around $264,163. That’s less than half the median salary of a cardiologist in New York, which stood at $573,498 a year as of March 1.
There is also a perception that geriatrics medicine is a less distinguishing field than other areas, Gurwitz said.
“I think there are certain fields of medicine that are more prestigious in which they are more respected than others. Geriatrics, for one reason or another, is not among those,” he added.
Farrell said he thinks that the complexity of treating older patients could be another factor turning professionals away from the trade. Geriatricians treat older adults who typically have overlapping health conditions, with some patients taking as many as 20 medications, he said.
“How do you prevent falls? How do you manage multiple chronic conditions for the same person?” he said. “I think there’s people in primary care who have more or less comfort with the complexity taking care of complicated, older adults, and that’s what geriatrician is trained to do.”
Hopelessness. Fear. Isolation. These are the feelings reflected in the stories we heard from people living with low back pain (LBP) who participated in two focus groups held by the Duke Clinical Research Institute These patients, members of our 300-person “Spine Squad,” volunteered to share their lived experiences with us.
Threading through the conversation was frustration with their doctors. These patients are not alone in their pain, and their experiences with physicians are not outliers.
LBP is the leading cause of years lived with disability worldwide and one of the most expensive conditions to treat. It is one of the top reasons why patients seek healthcare from both primary care physicians (PCPs), physiatrists, and spine surgeons. Most PCPs have little in their toolboxto directly address the needs of patients with LBP, but specialty care is also not the answer for many patients. Evidence supports the use of nonpharmacological (non-drug) care, including spinal manipulation, acupuncture, and exercise as first-line care. However, these treatments do not fall under the purview of PCPs or specialists, resulting in a significant disconnect between clinical practice guidelines and real-world patient care.
Neither providers nor patients are satisfied with the status quo. Doctors are frustrated because they have limited time to spend with patients, LBP is difficult to definitively diagnose, and effective medical treatments are elusive. Patients are frustrated because the treatments they try often do not work well and they feel unheard or misunderstood by the medical community.
Value-based care models emphasizing patient-centered approaches offer hope for change. In the meantime, we can improve how we approach LBP care now by focusing on these five things patients told us they need from their doctors.
To Feel Heard
“He acted like the pain was all in my head” and “All she wanted to talk about was my diabetes.”
Patients with low back pain want their concerns taken seriously, to feel that you, their provider, are listening, and that you respect their lived experience. They often feel ignored or dismissed by healthcare professionals. It is important to figure out what matters mostto the patient. Listen to their concerns and acknowledge their experiences and frustrations before talking about their other health issues, even if this means making another appointment. An empathetic, patient-centered approach will build trust.
To Understand the Cause of Their Pain
“They told me, ‘It’s just chronic pain.’ That isn’t a diagnosis. Something’s causing it, and I want to know what it is.”
Patients are searching for answers. Inherent in the biomedical model is the expectation of a diagnosis and a cure. This is one reason why PCPs order imaging — patients want proof that their pain is real and hope imaging will lead to a solution. Unfortunately, early MRIs and x-rays are rarely helpful. Ancillary findings or common conditions of aging can exacerbate fear-avoidance behavior. They can also increase the likelihood of unnecessary procedures and the transition from acute to chronic LBP. An alternative to consider is recommending several weeks of guideline-concordant non-drug care first.
Reassurance and Support
“The uncertainty of living with pain forever is worse than the pain itself.”
Chronic LBP often leads to social isolation, exacerbating other mental and emotional challenges. Patients crave reassurance that they’re not dealing with a life-threatening disease, that their pain won’t be permanent, and that they can maintain a fulfilling life despite their chronic pain. It is important to remember not only the actual words said, but also how they are said. Patients want clear information delivered in plain language with an empathetic tone. There is a difference between reassurance and casual dismissal of their lived experiences.
Access to Effective Treatment Options
“I just don’t know what to do next.”
The frustration patients feel with a casual dismissal is compounded by the often unclear treatment options presented. They want to know what treatments are most likely to help and how to access them. Good sources of information include the Lancet series on LBP and the American College of Physicians LBP guideline Providing education on first-line, non-drug treatments, along with appropriate referrals, can empower patients to take an active role in their health. This may lead to more positive outcomes as patients feel more involved in their healing process.
Care Coordination
“Doctors don’t talk to each other, so I have to piece together my own treatment plan.”
Patients can find themselves caught in a loop between their PCP and specialists. It is well known that lack of coordination in healthcare delivery can create confusion and delay effective treatment. It can also increase patient burden when patients are forced to develop their own treatment plans, navigating multiple prescriptions and sometimes conflicting physician advice without a clear sense of how everything fits together. This situation is particularly challenging for individuals with multiple chronic conditions. One solution is the use of multidisciplinary integrated pain management teams. Such teams are becoming more common and offer models for improving patient outcomes and fostering a more patient-centered approach.
We have much to gain by listening to the needs expressed by LBP patients. They remind us to pay greater attention to the power of the spoken word, offer reassurance whenever appropriate, and provide guidance on effective treatment options. We can also learn from new models of care, including multidisciplinary approaches and value-based options. While considerable work lies before us to optimize management and treatment for LBP, these initial steps can help transform the experience of those living with LBP, offering them relief from their physical symptoms and the respect they deserve.
When the CDC in 2016 created their version of opioid dosing guidelines, no one with any authority or visibility stood up and stated that the CDC did not have any statutory authority to create those guidelines and they had no statutory authority to cause any prescriber to follow those guidelines. Because they were JUST GUIDELINES, and the FDA has the statutory authority to create dosing guidelines FOR ALL Rx MEDICATIONS. Then 30 odd states’ legislatures decided to codify the CDC guidelines, which are not based on any clinical studies. Apparently, State medical licensing boards, pharmacy licensing boards, and/or any of the state boards that license various mid-level medical professionals pushed back.
It would seem that people who are attorneys seem like they operate under the saying, “no one is above the law… except those who are in charge of enforcing our laws”
Maybe someone needs to call this issue to the attention of Trump, Kennedy, and Musk. Maybe they need to look at defunding the DEA?
White House Press Secretary Karoline Leavitt strongly criticized recent rulings by federal judges ordering the reinstatement of thousands of probationary federal employees fired by the Trump administration. In a statement, she accused a “single judge” of attempting to “unconstitutionally seize the power of hiring and firing from the Executive Branch,” asserting that such authority belongs exclusively to the president. Leavitt emphasized that “singular district court judges cannot abuse the power of the judiciary to thwart the president’s agenda” and suggested that if judges wish to exercise executive powers, they should run for president themselves. She declared that the administration would “immediately fight back against this absurd and unconstitutional order”137.
The rulings, issued by judges in California and Maryland, challenge the administration’s mass firings of probationary employees across multiple federal agencies as part of its efforts to reduce government size. The judges argued that these terminations violated federal laws governing workforce reductions and were improperly directed by the Office of Personnel Management, which lacks statutory authority to fire employees in other agencies3910.
This video is from 1996, from an action taken by a Humana medical reviewer in 1987. Back then, many healthcare companies would call themselves Managed Care companies. Some out in the community often referred to these entities as “Mangled Care”. This video seems to explain why many within healthcare referred to some of these healthcare providers were referred to as mangled care.
Over 90% of independent pharmacy owners worry the program would severely hurt their finances, one survey reported.
Independent pharmacies are sounding the alarm on Medicare Part D’s drug price negotiation program.
The program, created under the 2022 Inflation Reduction Act (IRA), lets the Centers for Medicare and Medicaid Services (CMS) work with drugmakers to set lower costs for select Part D drugs in hopes of lowering healthcare costs for patients.
But up to 93.2% of independent pharmacy owners said they either will no longer carry Part D drugs or are considering not carrying them, as owners anticipate the negotiation program would “cause massive financial losses,” according to a survey of 8,000 pharmacy owners and managers conducted by the the National Community Pharmacists Association (NCPA), a trade group representing the nation’s roughly 19,000 independent pharmacies.
How it works. Under the current payment model, pharmacies pay drug wholesalers for medications, then pharmacy benefit managers (PBMs) reimburse the pharmacies a previously agreed-upon amount for each claim covered by a customer’s health insurance plan. It usually takes about 14 days for PBM reimbursement to reach pharmacies, according to Ronna Hauser, SVP of policy and pharmacy affairs at NCPA.
Under the new model, pharmacies will still pay wholesalers the same price to buy the drugs, but PBMs will reimburse pharmacies based on the updated negotiated prices, Hauser told Healthcare Brew. The negotiated drug prices are anywhere from 38% to 79% lower than the original list prices, according to the White House.
Drugmakers will then make up the difference. For example, if a pharmacy spends $500 to buy a drug, a PBM may pay the pharmacy $200, and then the drugmaker would reimburse the other $300 in the form of a manufacturer refund.
The new rules state drugmakers are required to reimburse pharmacies within 14 days of receiving confirmation that a prescription was dispensed to a Part D beneficiary, according to CMS. But pharmacy owners are concerned it will take longer as the new payment system gets set up, Hauser said.
In effect, pharmacies find themselves having “to float thousands of dollars every month waiting for refunds from the manufacturers,” NCPA CEO B. Douglas Hoey warned in a statement.
“I don’t have the cash flow or the financial stability to be able to ride those expensive drugs for that length of time,” Bill Osborn, president of independent pharmacy Osborn Drugs in Oklahoma, as well as president of the Oklahoma Pharmacists Association, told Healthcare Brew. “My question is, why are they not charging us up front the rebate price? Why are they making us carry it when we are the least financially viable?”
Osborn, who used to serve as NCPA’s president, is among those considering not stocking Part D drugs in his pharmacies, he said, which could lead to some patients in his community being unable to receive their prescriptions.
“It will be a hardship mostly on the patients because if they want to use us…they’ll have to find another place to get that one medicine,” Osborn said. “Hopefully they’ll stay with us, but that’s a risk.”
The financial effects. Part D drugs typically make up a significant portion of business for many independent pharmacies—about 35% on average for NCPA members, Hauser said.
If drugmakers reimbursed pharmacies seven days after the pharmacies receive their PBM reimbursements , pharmacies would have roughly $10,800 less cash on hand per week, according to a February analysis from healthcare consulting firm 3 Axis Advisors, commissioned by the NCPA. Annually, the analysis projected independent pharmacies could lose up to $46,475 in revenue.
Hauser said the NCPA and other pharmacy organizations have brought these concerns to CMS since the price negotiation program was first created in 2022. NCPA has asked CMS to freeze the program until they can find a way to implement it that wouldn’t cause financial hardship on pharmacies. While the agency has acknowledged the issues, it has claimed it doesn’t have the authority to change the IRA’s statutes, according to Hauser.
When asked for comment, CMS directed Healthcare Brew to a statement the agency released in January, saying it was “committed to incorporating lessons learned to date from the program and to considering opportunities to bring greater transparency in the negotiation program.”
Healthcare Brew reached out to several drugmakers with medications on the negotiated prices list that’s going into effect Jan. 1, 2026, but did not receive responses.
A broader implication. Approximately 10% of independent pharmacies in rural areas closed between 2013 and 2022, and Osborn said he’s concerned the new payment system will lead to even more closures.
“Here we are trying to maintain pharmacist access in rural environments, and now we’re going to make it to where it’s going to be even less accessible,” he said. “I worry about these rural locations that we could lose.”
Above is a link to a synopsis of the nearly 600-page agreement between 40+ state AGs and the three major drug wholesalers – who control about 80%-85% of all Rx med distribution to pharmacies. This agreement was not to see the light of day, and it took 1-1.5 yrs for someone to leak it. These 3 wholesalers agreed to restrict the number of controlled meds sold to pharmacies. There is no concern about the pts that have a valid medical necessity for some of these meds. Up front, these wholesalers don’t have a legal right to know what meds they sell to pharmacies and what patients are dispensed to. The questions that I have are this, 100 dose limit, a policy of the pharmacy, or multiple pharmacies have colluded to do this 100 dose limit. Did the 3 drug wholesalers in this agreement collude to impose this limit on all community pharmacies?
My opinion, one of the primary functions of the practice of medicine is the starting, changing, or stopping a pt’s therapy. Given that, any entity that is restricting the availability of any medications to pts, could be guilty of practicing medicine without a license. Could this rationing be a violation of the Interstate Commerce laws?
private pharmacies are being told. They cannot dispense more than 100 opioid pills to each patient. He had to call so many patients even if they are on palliative care this also applied to them.. i’m unclear where to try to address this I have given copies of the recent Illinois bill that was passed regarding opioids to see if someone would sponsor a similar bill, but I’m trying to figure out. Why would the private pharmacies be told they cannot dispense more than 100 opioid pills per month to each patient? this very kind young pharmacist had to call all of his customers and let them know they could no longer get more than 100 pills dispensed. And whoever told him this was how things had to be did not discriminate. It was across-the-board whether you’re on palliative care or not. The medical condition, diagnosis, terminal or not, the reason didn’t matter. 100 pills max.
