PBM Reform Podcast

Pennsylvanians Suffer while Pharmacy Middlemen Profit | PBM Reform Podcast Series

Pennsylvanians suffer while pharmacy middlemen profit
By Suzanna Masartis
Pennsylvanians are getting crushed by the costs they face at their neighborhood pharmacy counter. The situation has grown so bad that a shocking one in five Keystone State residents report they are unable to take their medications as prescribed due to the cost burden.[1]
As a lawmaker and an advocate who speaks to patients in Pennsylvania every day with liver disease, diabetes and other chronic conditions, I am convinced more strongly than ever that we need to reform the prescription drug supply chain.
To understand how we got here we need to understand what’s driving increasing costs. A new report found that, in 2020, manufacturers of brand-name and generic medications received only 37 cents of each dollar of the more than $680 billion spent on medications. If you look exclusively at manufacturers of brand-name medications, the drug makers are taking in just under 50 cents on the dollar. So where is the money going? Turns out that it’s little-known middlemen corporations, Pharmacy Benefit Managers (PBMs), that are taking a bigger and bigger share of the pie.[2]
PBMs were created to negotiate with insurers and drug manufacturers and establish which prescription drugs are covered by a health plan. In reality, they demand steep discounts from drug makers off of the original list price as a condition to include those drugs on the approved list of medications – and then keep the savings for themselves. But here's the real rip-off: Patients at the pharmacy counter still face co-insurance charges based on the list price -- not the discounted price insurers actually pay. In other words, PBMs are enriching themselves while hiking prices for the rest of us. {3}
Worse still, PBMs manipulate their powerful market position to reduce the availability of prescription medications by excluding them from formularies. PBMs make their money when they demand exorbitant rebates from drugmakers and charge patients full cost, meaning they prefer to include drugs with higher list prices on their formulary over an equally effective drug with a lower list price. As a result, a number of drugs are excluded from formularies because PBMs can’t make as much money from them. In 2020, the three largest PBMs excluded 846 FDA-approved drugs, denying patients access to more medications than ever before.
This market manipulation has disastrous results for patients. A study published last year found that these practices, called “drug utilization management,” can lead patients to abandon their prescribed medications and delay treatment. Approximately 20% of prescriptions in the U.S. are never filled, according to the study.[4] This outcome is simply unacceptable, and our leaders need to take action.
Congress needs to ensure that any attempt to rein in out-of-pocket prescription drug costs includes taking a close and hard look at PBMs. Doing so would go a long way toward ensuring every patient and healthcare consumer in our state can access and afford to take their medications as prescribed by their doctor.
Suzanna Masartis of Pittsburgh is the CEO of the Community Liver Alliance.
[1]https://www.healthcarevaluehub.org/advocate-resources/publications/pennsylvania-residents-worried-about-high-drug-costs-support-range-government-solutions
[2]https://ecommunications.thinkbrg.com/44/2328/uploads/brg-pharmaceutical-supply-chain-2022.pdf?intIaContactId=24HydQaSTYqd85tTztTDcQ%3d%3d&intExternalSystemId=1
[3] https://www.fiercehealthcare.com/payer/study-drug-utilization-costs-health-industry-93b-a-year-patients-bearing-most-cost
[4] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2021.00036
Learn more about your ad choices. Visit megaphone.fm/adchoices

Therapeutic Alternatives, Reimbursements, and the Economic Impact of ActiveRADAR | PBM Reform Podcast Series

Dave Teckman, Executive Chairman at ActiveRADAR joins the PBM Reform Podcast series about the impact of therapeutic interchange technologies on PBM pricing & the powerful data at the pharmacist's fingertips with ActiveRADAR.
Through rigorous clinical evaluation of all drugs in over 112 therapeutic categories, ActiveRADAR first establishes which drugs are clinically equivalent and therefore therapeutic alternatives to one another. This creates our Clinical Catalog of over 26,000+ therapeutically equivalent “perfect pairs”. Then ActiveRADAR determines the economic value using plan specific data to value each drug within its respective therapeutic class and sets pricing and reimbursement accordingly. This type of program has historically been called “reference pricing”, however ActiveRADAR takes it a step further by establishing both THE CLINICAL AND ECONOMIC VALUE OF EACH AND EVERY DRUG IN EACH THERAPEUTIC DRUG CLASS.
About ActiveRadar:
ActiveRADAR, formerly RxTE Health, is a healthcare analytics and patient education company providing unique data-driven, cost-saving customized prescription options. Using proprietary technology, ActiveRADAR identifies the lowest cost prescription options.
Learn more about your ad choices. Visit megaphone.fm/adchoices

The Public Deserves the Truth about Pharmacy Benefit Managers with Madelaine A. Feldman, MD, FACR

Madelaine A. Feldman, MD, FACR
Dr. Madelaine Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans, LA. She is President of the Coalition of State Rheumatology Organizations, Chair of the Alliance for Safe Biologic Medicines and past member of the American College of Rheumatology insurance subcommittee.
Dr. Feldman is a Clinical Assistant Professor of Medicine at Tulane University School of Medicine, and lectures extensively to patients, physicians, regulators, and legislators both locally and nationally, speaking before the Health subcommittee of Energy and Commerce in 2019.  She has spoken and written on the drug supply channel, particularly the effect that formulary construction and utilization management tools have on pricing and access to drugs (availability & affordability).
Dr. Feldman is honored to be the recipient of the American College of Rheumatology's 2021 Innovation in Clinical Care award. She received the Distinguished Service Award for Tulane Medical School, was named one of the Top Women in New Orleans by City Business in 2017 and is the former radio talk show host of “Driving with Dr. Mattie.”
Learn more about your ad choices. Visit megaphone.fm/adchoices

Leaders in Pharmacy & Medical Communities Speak Out Against Damaging PBM Practices | PBM Reform

Speaking to the Pharmacy Podcast Network, Dr. Marion Mass, a pediatrician, patient advocate and founding member of the Practicing Physicians of America, spoke about the original intent of PBMs, which started in 1968, and what they’ve become today.
“PBMs were created with the vision that they would act like giant drug-buying networks, with their buying power cutting health care costs and consumers realizing the savings in the end. However, through consolidation, three companies now control 90 percent of the market,” she said.
Dr. Mass further explained, “This unhealthy market share has led to an unhealthy control over formularies,” which can cause life-and-death situations for her young patients. “Patients are at risk of death or harm when drugs such as chemotherapies, antibiotics, epinephrine and anesthetics are not available.”
Pharm D Mel Brodsky, executive director of the Philadelphia Association of Retail Druggists and former CEO of the Keystone Purchasing Alliance, explained, “This outsized market share takes advantage of drug manufacturers, pharmacists and, most importantly, patients. The result is a net negative for all parties except for the large PBMs.”
In his estimation, the net result of this imbalance “has led to an erosion of the doctor-patient relationship and a decimation of Main Street pharmacists throughout the nation.”
“With the current system in place, independent pharmacists are being squeezed to the point that many jump when the large groups offer to buy them out. With the depletion of community pharmacists comes the loss of personal touch and a watered-down version of health care to patients,” Brodsky said. 
Both participants agreed that action must be taken on the federal level, citing Pennsylvania Sens. Bob Casey and Pat Toomey’s abilities to rein in the large PBM market imbalance
Our Guests: 
Dr. Marion Mass. Dr. Mass is a pediatrician in the Philadelphia suburbs. She received her medical degree from Duke University School of Medicine and has been in practice for more than 20 years. She is the co-founder of Practicing Physicians of America - and leadership in the Free2Care coalition-a consortium of grassroots physician advocacy groups that believe that the key to good care starts with the relationship between a patient and their doctor. She sits on the editorial board of the Bucks County Courier, Times and is a member of the Bucks County Health Improvement Partnership.
Mr. Mel Brodsky is the Executive Director of the Philadelphia Association of Retail Druggists (PARD), an association of community pharmacies representing 250 independently owned pharmacies in Southeast Pennsylvania. PARD works closely with State Associations like the Pennsylvania Pharmacists Association (PPA). Mr. Brodsky is also CEO of the Keystone Pharmacy Purchasing Alliance, headquartered in Philadelphia with 400 member stores in 5 States. Mel has an amazing understanding of how PBMs impact the effectiveness and growth of vital healthcare service providers like Community Pharmacies.  
Learn more about your ad choices. Visit megaphone.fm/adchoices

Never Pay the First Bill | PBM Reform Podcast Series

Special interview w/  award-winning ProPublica reporter Marshall Allen, a primer for anyone who wants to fight the predatory health care system--and win.
We welcome back two patriots in PBM Reform on the interview w/ Marshall. 
Monique Whitney - CEO of Pharmacists United for Truth & Transparency and PUTT President and Pharmacy Owner Scott Newman.  
Every year, millions of Americans are overcharged and underserved while the health care industry makes record profits. We know something is wrong, but the layers of bureaucracy designed to discourage complaints make pushing back seem impossible. At least, this is what the health care power players want you to think.
Never Pay the First Bill is the guerilla guide to health care the American people and employers need. Drawing on 15 years of investigating the health care industry, reporter Marshall Allen shows how companies and individuals have managed to force medical providers to play fair, and shows how you can, too. He reveals the industry's pressure points and how companies and individuals have fought overbilling, price gouging, insurance denials, and more to get the care they deserve. Laying out a practical plan for protecting yourself against the system's predatory practices, Allen offers the inspiration you need and tried-and-true strategies such as:
Analyze and contest your medical bills, so you don't pay more than you should
Obtain the billing codes for a procedure in advance
Write in an appropriate treatment clause before signing financial documents
Get your way by suing in small claims court
Few politicians and CEOs have been willing to stand up to the medical industry. It is up to the American people to equip ourselves to fight back for the sake of our families--and everyone else.
See omnystudio.com/listener for privacy information.
Learn more about your ad choices. Visit megaphone.fm/adchoices

Study Finds Potential for Billions in Prescription Drug Savings with Transparent Pricing Practices | PBM Reform Podcast

Capital Rx and 3 Axis Advisors Study Finds Potential for Billions in Prescription Drug Savings With Transparent Pricing Practices
Mandatory NADAC responses by pharmacies for 1,600 unique oral solid products could create additional savings of $1.5 billion over 10 years
Comparing generic drug costs with NADAC and Alabama actual acquisition cost, study finds $937 million in potential annual savings across Medicaid
Implementing and improving transparency in pricing practices can restore public trust in U.S. drug pricing system, results suggest
CMS proposes delaying drugmaker rule days after PhRMA suesThe lawsuit also casts blame on health plans and pharmacy benefit managers that allegedly "siphon the benefits" meant for consumers.
Today's guests: 
Antonio Ciaccia
3 Axis Advisors www.3axisadvisors.com 
A. J. Loiacono
CEO at Capital Rx
https://www.healthcarefinancenews.com/news/cms-proposes-delaying-drugmaker-rule-days-after-phrma-sues
This episode is sponsored by the Ultiguard Safe Pack. UltiGuard Safe Pack is the only pen needle product that comes with an all-in-one sharps container. Learn more about why UltiGuard Safe Pack is the best choice for your patients and your pharmacy., 
Learn more about the UltiGuard Safe Pack: 
https://www.ulticare.com/ultiguard-safe-pack/podcast
See omnystudio.com/listener for privacy information.
Learn more about your ad choices. Visit megaphone.fm/adchoices

Express Scripts Fails to Defeat Louisiana Prescription Fee Suit | PBM Reform Podcast Series

LIPA v ESI: Fight for the Right to Be Paid 
What happens when a state implements provider fee statutes that are officially approved by CMS but one of the big 3 PBMs still claims exemption?
Join guest host Monique Whitney with special guests Randal Johnson, JR Whaley, and MJ Terrebonne as they discuss Louisiana's legal battle with ESI over 10 cents per claim, and the ramifications this could have on state Medicaid programs nationwide.
Host: 
Monique Whitney, Executive Director, Pharmacists United for Truth & Transparency 
Guests:  
Randal Johnson, CEO, Louisiana Independent Pharmacies Association 
JR Whaley, Legal Counsel, Louisiana Independent Pharmacies Association 
MJ Terrebonne, Health Policy Expert & retired Director of Pharmacy, Louisiana Medicaid
See omnystudio.com/listener for privacy information.
Learn more about your ad choices. Visit megaphone.fm/adchoices

Tennessee Senator Shane Reeves | PBM Reform Podcast Series

Tennessee Gov. Bill Lee signed HB 786, a comprehensive PBM reform bill that strengthens existing fair pharmacy audit laws, limits PBM adjudication fees, and prohibits a PBM from reimbursing a pharmacy less than it reimburses a PBM-affiliated pharmacy.May 30, 2019
Tennessee SB650
Present law defines "pharmacy benefits manager" (PBM) to mean a person, business, or other entity and any wholly or partially owned subsidiary of the entity, that administers the medication and/or device portion of pharmacy benefits coverage provided by a health insurance plan, subject to certain exceptions.
Present law provides detailed requirements for the conduct of an audit of records of a pharmacist or pharmacy by a health insurance plan, a PBM, the state or its political subdivisions, or any other entity representing the same. One such audit requirement is that a clerical or recordkeeping error regarding a required document or record may not, in and of itself, constitute fraud; however, the claims may be subject to recoupment. This bill instead provides that a clerical or recordkeeping error identified during an audit is not prima facie evidence of fraud or intentional misrepresentation and must not be the basis of a recoupment unless the error results in an actual overpayment to the pharmacy or the wrong medication being dispensed to the patient. As under present law, a clerical error will not be subject to criminal penalties without proof of intent to commit fraud. 
Shane Reeves is an American businessman, pharmacist and politician who is the State Senator for the 14th District of Tennessee, which is composed of Bedford County, Moore County, Lincoln County, Marshall County, and part of Rutherford County. As a seventh-generation Tennessean, Senator Shane Reeves has spent his life raising a family and opening businesses in middle Tennessee. He understands the importance of family, character, and conservative values to the people in this community.
See omnystudio.com/listener for privacy information.
Learn more about your ad choices. Visit megaphone.fm/adchoices

Outcomes of Transparent PBMs V.S. the Status Quo | PBM Reform Podcast Series

What's the expected outcomes of a transparent PBM? How does a fiduciary driven pharmacy benefit management company compare to the 3 largest PBMs in the country processing more than 76% of all the prescriptions per year in the United States. 
The PBM market is dominated by three major players, who together handled about 76 percent of all prescription claims in 2018, according to Drug Channels Institute.  
A breakdown of PBM market share, by total equivalent prescription claims managed in 2018:  
Caremark (CVS Health) / Aetna: 30 percent
Express Scripts: 23 percent  
OptumRx (UnitedHealth): 23 percent  
Humana Pharmacy Solutions: 7 percent  
MedImpact Healthcare Systems: 6 percent  
Prime Therapeutics: 6 percent  
All other PBMs + cash pay: 4 percent 
TrueScriptsmission is to build lasting relationships. They provide prescription benefit management expertise at a personal and customized level to ensure optimum value at the lowest possible cost. The TrueScripts team of nurses, pharmacists, legal experts, data scientists, and care specialists work together as one to bring prescription benefit expertise and a level of service that far exceeds that of any industry standard. 
Today's guest is Nathan Gabhart RPh Founder & CEO of TrueScripts. 
See omnystudio.com/listener for privacy information.
Learn more about your ad choices. Visit megaphone.fm/adchoices

The Implications of Rutledge v. PCMA | PBM Reform Podcast Series

We talk with Community Pharmacy owner Dr. Steve Moore, PharmD about the Implications of the Rutledge versus PCMA Supreme Court decision on Independent Pharmacy. 
About Condo Pharmacy: 
Condo Pharmacy is an independently owned and operated pharmacy dedicated to meeting the unique healthcare needs of each individual patient. In addition to providing both traditional and specialty pharmacy services, Condo Pharmacy is proud to be a part of the CPESN USA network of pharmacies and offer enhanced pharmacy services and care management protocols.
Special guest: Steve Moore, PharmD
See omnystudio.com/listener for privacy information.
Learn more about your ad choices. Visit megaphone.fm/adchoices