Tag: #patientsfirst

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A Bad Prescription for American Patients

Practicing Physicians of America, and the the Free2Care coalition are staunchly against the passage of the highly partisan Inflation Reduction Act (IRA). Like many health care measures before it, there are consequences in the bill that will decrease access and innovation, and increase consolidation and costs for all patients, all while disproportionately harming those with cancer and chronic disease. 

Free2Care experts prescribe four major issues with the bill and legislative priorities that would actually address the issues of affordability and accessibility of health care.

  1. Pharmaceutical middlemen—Pharmacy Benefit Managers aka PBMs—  collect legalized kickbacks and are responsible for 80% of the cost of insulin, get a gift in the Inflation Reduction Act. 

Almost 50% of what is called “deficit reductions” come from repealing the Trump Administration’s ‘rebate’ rule. The rebate rule would have forced PBMs to pass on the ‘rebates’ they collected to seniors at the prescription counter instead of pocketing the rebates themselves.

Rebate is not the appropriate word for the money collected by the PBMs from the drug manufacturers: the PBMs were granted an exemption from the anti-kickback statute in 2003, and thus rebates are actually kickbacks. . Remarkably, the kickback collecting PBMs get to create the formularies—the lists of drugs covered by the insurance companies. A bigger kickback lands a drugmaker on the formulary, so more expensive medications are preferred for the PBMs and the insurers who have now consolidated with the PBM, and in some cases, even the big box pharmacies. The cost of the kickbacks is in the range of $200 Billion per year, all of this is explained elegantly by attorney David Balto.

By denying the “rebate rule” and declaring it to “pay for” new spending, the Inflation Reduction Act is a win for PBMs at the expense of seniors’ savings at the pharmacy counter. Former DNC chair Howard Dean, himself a physician, recognized the gimmick behind using the “rebate” rule as a pay-for.

Furthermore, Pharmacy Benefit Managers have been the driving force behind the cost of many medications necessary to sustain life for patients with chronic diseases or pre-existing conditions. Like Insulin. 

A 2019 bi-partisan report, produced by Senators Wyden and Grassley, found that PBM fees and rebates were responsible for 80% of the cost of the inflated cost of insulin.

2. Chronic disease and cancer patients will lose access, consolidation will increase, and costs will rise down the road.

A new Avalare study has found that part of the Build Back Better Act, now folded into the Inflation Reduction Act, will reduce payments for Medicare providers that furnish Part B drugs (drugs that are given by infusion and therefore delivered in a clinical setting ) by an average of 40%. Drugs for cancer, immunodeficiencies, and rheumatologic diseases such as rheumatoid arthritis fall into this category. 

Remarkably, the payment reduction is substantially higher for physicians in independent practices as opposed to those owned by hospitals. Besides the fundamental unfairness, the increased reduction will lead to the early retirement of independent oncologists and rheumatologists, and the continued consolidation of medical practices into ownership by hospitals. 

Consolidation has been shown to increase costs in a Stanford study. Worse yet, quality of care, and the all-important personal and attentive care required by the vulnerable, especially among the elderly are decreased when independent practices are forced to sell out to hospital systems.

3. Fewer cures and treatments for patients with cancer, chronic and rare diseases. 

The bill before the house imposes a 95% excise tax on innovative drug manufacturers unless they accept a price set by the HHS Secretary.  

This is not negotiation, it is price controls.

A Univ. of Chicago September 2021 study estimates up to a 60 percent decrease in R&D and up to 342 fewer new medication approvals. Loss of life from loss of innovation over the next decade is conservatively estimated as 20 times more than COVID-19 deaths at the time of their study. There is no measure in loss of quality of life as many new meds have immeasurable improvement on quality of life.

Oncology patients will be the hardest hit as half of the medication pipeline is for cancer medications. Innovative research for cancer sufferers will decrease by nearly ten times the amount that the cancer moonshot increased it. 

Small and emerging companies in California alone will have an 88%         reduction in new medications brought to market according to the California Life Sciences Association. This will fundamentally shift the formation of small emerging bio markets across the United States.

4. Higher prices for other medications will lead to higher premiums and overall health care costs.

The Inflation Reduction Act would control the prices of a chosen set of medications. On August 4, the CBO confirmed that price controls will lead to higher prices for new prescription medications. 

In turn, all Americans will pay higher insurance premiums and out-of-pocket costs at their pharmacies. Only the wealthiest Americans will be able to afford many cures. 

PPA and Free2care have been supportive of the Lower Costs, More Cures Act, with bipartisan provisions to lower drug prices while increasing transparency for PBMs and preserving innovation. We are supportive of Senator Wyden’s call to have both CMS and the FTC intervene in the practices of corrupt PBM middlemen.  

We are strongly supportive of Chairman Pallone’s HR-7666, which increases access for mental health and substance use disorder among other measures while reining in PBM.  HR-7666 has the added benefit of having passed the house by more than 400 votes, thus demonstrating the call for the bipartisanship that America craves.

The Inflation Reduction Act will be harmful to the long-term health of Americans, especially those with chronic and pre-existing diseases. We call on all house members to reject this bill and ask the Senate to get back to the drawing board, this time reaching across the aisle.

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PPA is part of Free2Care, a coalition of member organizations dedicated to the doctor-patient relationship and making healthcare affordable, accessible, and of high quality. The 34 member organizations represent over 8 million Americans and include over 70 thousand physicians. 

In the recent request for comment by the Federal Trade Commission, the Free2Care Coalition represented approximately 75% of the 24,100 comments calling for a thorough investigation into the anti-competitive practices and behavior exhibited by pharmacy benefit managers.

 HHS called for comments on the behavior of GPOs and Free2Care submitted comments representing 80% of the 11,930 submitted

For media inquiries contact info@free2care.org

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PBM: Unmask the Villains of Healthcare’s High Costs

Marion Mass, M.D. and Christina Dewey, M.D.

Would you like to lower healthcare costs, restore quality and improve choice? Yes? Then you MUST learn about Pharmacy Benefit Managers (PBMs).

If you look on the Fortune 500 top 12 companies, you will find three companies who own PBM. Dig deeper, and you’ll discover these companies are CVS  health, who owns the PBM CVS Caremark, United Healthcare who owns the PBM Optum Rx, and Cigna, who owns the PBM Express Scripts. These three PBM control 85% of the prescription drug market, and are the biggest revenue generators for their parent companies. 

For example, when the insurance company Cigna, purchased Express Scripts in 2019, their revenues tripled. Take a peek under the hood of CVS Health, and you will discover that CVS’s  PBM CVS Caremark is, to put it frankly, its prize cash cow, its biggest source of revenue.  Moo.  

Until recently, many Americans had no idea what a PBM was, and blamed insurance and pharma and physicians for the high cost of care. The truth is much more complicated, and those making the money don’t want you to pull the mask off the villain of high healthcare costs.  They aim to prevent  the Scooby Doo denouement and keep Americans from discovering the biggest, richest, most devious villains in the healthcare space are the PBM.

Some really important clues to why we should suspect that the PBM are villainous profiteers:

–    The PBM and insurance companies now own one another, and some, like the CVS Health empire, also own pharmacy chains

–    The PBM controls the pharmaceutical companies, by creating the formularies, aka the list of medications that the insurance companies will “cover”. Physicians play no part, nor have any say in  this choice.

–    The PBM can collect legalized kickbacks, called ‘rebates’ from pharmaceutical companies because the PBM were granted an exemption from the anti-kickback statute in 2003 by GW Bush’s HHS secretary. This anti-kickback exemption allows pharmaceutical companies to simply pay for placement on the formulary.  Americans are not necessarily getting the best medication, but the best med a legal bribe can buy.

–    There is no transparency for these kickbacks (aka rebates) but sources have revealed that in 2020, the total amount of kickbacks approached $200 BILLION (yes with a B).

–    PBM like CVS Caremark are now facing charges of preventing elderly Medicare patients, including those with End Stage Kidney Failure from access to affordable life sparing medications.

–    In multiple states, PBM have been found to be helping themselves to Medicaid money… not a small helping, either: In Ohio alone, the PBM subsidiary of Centene as well as CVS and Optum were pocketing $244million per year.

 

–    The big PBM that own pharmacies, like CVS are utilizing shady practices to put trusted Mom and Pop pharmacies out of business.    

 

–    In an NBC News exclusive with Cynthia McFadden, the PBM mail order pharmacies were found to be delivering ineffective medications.  One young pediatric patient with cystic fibrosis was hospitalized after wasting away because of medications delivered by PBM giant Express Scripts, whose agent pooh poohed the concerns of the patient’s mother.

Do you need to hear more? 

Yes, you need to understand who is granting more favors to the behemoth companies responsible for the maleficent behavior noted above.

Let’s look at several recent congressional bills in chronological order of passage. 

The Affordable Insulin Now Act was passed by the House and Lingers in the senate

Although those who support the bill  claim to have lowered the cost of insulin, Lloyd Dogget, a Texas Democrat correctly stated that the bill does not lower the cost of insulin by even a penny.  He’s correct.  It lowers the co-pay, but the uninsured, and those who pay insurance ( whether they be employer or independent purchaser)  will continue to pay the full bloated cost of insulin, 80% of which is flowing to the PBM via kickbacks and fees.  In other words, this bill simply ensures that the taxpayers keep paying the PBM in the form of kickbacks.

Worse yet, the bill grants a delay of the rebate rule for PBM.  The rebate rule was an Executive Order introduced in 2020 and demanded that the kickbacks (aka rebates) would flow to the patient at the point of sale and not the PBM and the insurers.  PBMs are continually telling Americans that they pass on the rebates, yet when the rebate rule was suggested, they have threatened to increase Medicare premiums as soon as the rule is enacted. 

Congress has discovered they can pull the entirely disingenuous accounting sleight of hand of delaying the rebate rule (in other words, allowing the PBM to keep collecting their kickbacks and not forcing them to pass on to patients) and thereby claiming that they are saving money by preventing Medicare premium increases. To put another way, the PBM’s and Insurers are playing Chicken with the rebate rule by threatening Medicare premium increases, and the Congress-people that delay the rebate rule are taking the bait.  I suppose that makes them lower than chickens in the game.  Perhaps they are simply chicken….. oh, never mind. Maybe they simply don’t understand.

The insulin Bill was not the first time Congress  delayed the rebate rule.  Apparently they did it in the infrastructure bill, too.  Howard Dean, a physician and former presidential candidate called them on it in Newsweek, even pointing out that the rebate rule was solid, and potentially the best thing to come from the Trump Presidency. 

Based on the above, we ought to let that insulin bill die and come up with a real way to lower insulin costs.

The recent Gun Bill Passed by the Senate and House and signed into law sneaked in a gift to PBMs.

Why on earth would a bill on guns contain another delay in the rebate rule, yet another gift to the PBM industry?  The same faulty accounting gimmick of using the rebate rule delay as a pay for.  Unbelievable.  Senators Chris Murphy, D-CT and John Cornyn, R-Tx are mum about who put the PBM poison pork into the gun bill.  Interestingly, Murphy’s top donor is the law firm that helps CVS negotiate mergers.  And Cornyn is a top taker from Vizient, a hospital Middleman Group Purchasing Organization.

Good news at last!  PBM reform in the Mental Health Package

Thankfully, some good news exists. .  Some colossally INCREDIBLE news:

HR 7666, the bipartisan mental health bill introduced by Frank Pallone, D-NJ, and Cathy McMorris Rogers –R, Wa passed the house this week with 400 yay votes.

Some of us were really yelling ‘Yay’ when we discovered splendid section 602, quietly added by Rep Michael Burgess (R-Tx), mandating   big time TRANSPARENCY for big PBM/Insurers with shocking penalties of $10K per day for non-compliance.

Requiring  PBM transparency will save $2BILLION/10 years, paying for the bill.  Billion with a ‘B’.  As Mental health and substance abuse medications are largely overpriced due to PBM kickbacks, this provision absolutely belongs in the bill.

Americans will receive  some wonderful services  with this bill for Mental Health and Substance Use Disorders. Full detail can be found in the bill,  but here is a screenshot of some of the high points

WE CANNOT STOP… we must make sure the mental health bill passes in the senate WITH PBM reform Intact. 

Please CALL and EMAIL  both of your US Senators ASAP, (find their numbers and email contact links  here ) and tell them to PASS  the Senate version of HR 7666 with the Burgess amendment to bring PBM transparency and accountability intact.  Ask  your friends to call.  Ask your neighbors to call. Ask everyone in your circle and beyond. Tell YOUR Senators you now know the PBMs are behind the ever increasing healthcare costs and it’s time for Congress  to listen to we the people and not the profiteering villainous Pharmacy Benefit Managers! 

Drs. Mass and Dewey are proud to be pediatricians for over 20 years each and fierce advocates for patients and physicians!

Dr. Mass, graduated from Duke Medical School and trained at Northwestern. She has practiced in the Philadelphia area. She’s a cofounder of Practicing Physicians of America And leadership in Free To Care .

Dr. Dewey attended Loyola University Stritch School of Medicine . She did a year of surgery internship then two years of pediatric surgery research before training in Pediatrics at University of Minnesota. She is founder and CEO of Peds Mama Doc and has published in multiple outlets

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The Kickbacks and the Cost of Insulin

Kudos to board member Marion Mass on her recent letter to the editor of the Wall Street Journal 15 Apr 2022 highlighting the way Pharmacy Benefit Managers contribute to the high cost of insulin (and many other medications) for patients:

“Credit to the editorial board for alluding to the role of PBMs in America’s costly and dysfunctional prescription-drug debacle. The “rebates” collected by the PBMs are more accurately called kickbacks, as the PBMs enjoy an exemption from the antikickback statute.

Given that PBMs create formularies, which are the lists of drugs covered by third-party payers, pharmaceutical companies can pay a kickback to functionally purchase formulary placement, which amounts to market share. This obscene conflict of interest has been plainly stated at congressional hearings. Insulin and every other medication market begs for competition. We won’t have it so long as the market allows drug makers to purchase their market share through legal kickbacks.

The kickbacks account for as much as 80% of the cost of insulin, as highlighted in a 2021 Senate Finance Report. The disingenuously named Affordable Insulin Now Act doesn’t lower the cost of insulin or any other drug, because the bill does nothing to make the PBMs accountable.”

Marion Mass, M.D.

Perkasie, Pa

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Top Ten Reasons to (Still) Be a Physician

With all the negative press, the pay cuts, health care reform, the COVID-19 pandemic, and the consolidation of health systems and corporatization of medicine that diminishes our voice, I am still approached by people who secretly whisper in my ear, “Would you have your child go in to medicine?”

On first blush, I am tempted to answer “No way!” given the administrative hassles, the negative changes in the public’s perception of our profession, the front-load of education and the long hours of clinical training and late nights involved. But those observations, while real, are at best superficial. Drilling down with more careful analysis after a challenging week on call, I find it worthwhile to stop and ask myself what still makes medicine special for those of us crazy enough to subject ourselves to this lifestyle. I decided to put together a list of things that were important to me and would welcome additions to the list from others.

10. Independence – No matter what happens on the larger public policy and procedure scale with guidelines and mandates, when it comes to decisions regarding a patient’s care, it will always be the one-on-one interaction between the patient and the doctor that will ultimately decide the best approach for care for an individual patient.

9. Respect – The title “Doctor of Medicine” still carries weight in our society. With that respect, however, comes significant moral imperatives to maintain that respect.

8. Flexibility – For those not adept at one-to-one interactions with people (hence, the clinical side of medicine), there are a myriad of opportunities opened with the MD or DO degree in public policy, research, the basic sciences, journalism, consulting, business, etc. It is this flexibility of options that are open to doctors that ensures job security.

7. Variety – I have been doing medicine a long time and have yet to see two days’ activities or two patients that are the same. Ever. Bottom line: medicine is never boring.

6. Influence – Physicians matter. People know it. But you’d better be ready to be cornered at cocktail parties.

5. Reward – I cannot not think of anything superior to helping a fellow man or woman at a time when they are most vulnerable or in the greatest need. And while less and less frequent these days, it also occasionally provides an upgrade to business class or a free beverage when you help treat a hyperventilating patient on an airplane.

4. Trust – Like Smith Barney says, you have to “earn it,” but once a patient’s trust and confidence, it’s the tie that binds. By virtue of your title, you are invited into the most secret parts of patients’ lives to share their deepest concerns – a truly remarkable privilege. Corporate meetings never leave me with that feeling, if you get my drift.

3. Humility – Medicine will always keep you humble since there will never be a time when you can know it all or cure it all – ever. It’s both the blessing and the curse of our profession: the learning, both professionally and spiritually, never ends.

2. Fascination – Every day we work with the most amazing technology imaginable. The wonder of it is incredible: ask anyone who’s ever reached in an abdomen to remove ischemic bowel, prescribed an antibiotic to cure a pneumonia, or ablated an tachycardia that affected someone their entire life and rendered it of historic interest only. Even something as simple as cutting the skin with the belly of a 15-blade scalpel while listening to the patient chat idly about their grandkids thanks to remarkable local anesthetics during minor surgery, you are reminded of the amazing wonders of modern medicine every day.

1. Teamwork – Medicine is, by definition, a team sport. No physician can do what we do in isolation. Our “Club Med” has challenging pre-requisites, but once in, it is a vocation where we share collectively in the trials and tribulations of patient care. We win and we lose, together. Whether we are doctors, nurses, technicians, administrators, clerical staff, safety personnel or maintenance workers – each of us are constantly working for a common goal – the health and well-being of our patients – and when it works, nothing, I mean nothing, is as cool as that.

-Wes Fisher, MD
Treasurer and Co-Founder
Practicing Physicians of America

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Champions of Excellent Medical Care

Marion Mass, M.D., Practicing Physicians of America, co-founder

Female mature doctor examining little girl – closeup

Over twenty years ago, I was a fresh new attending, barely out of residency when called to the ER at three am to admit a patient with gastro and dehydration. I found a two -year old little girl, whose family spoke almost no English. She looked uncomfortable, her abdomen was distended, her platelets were slightly low and her potassium was slightly high. Her eyes had no sparkle. On her x ray, she had a paucity of gas in the right lower quadrant. These are all the signs of an intussusception, and needed an emergent enema to try to reduce the telescoping of bowel. The patient had been there for over four hours.

The ER doc, an old seasoned veteran was at the nursing station yukking it up with the nurses. I’m sure he had had a rough night. After I read him the riot act, for not calling sooner, I called the radiologist, who told me he’d handle it at six am when he came in. I politely told him I had no problem calling the hospital CEO and legal right away to let them know of the risk to patient and hospital. He came in immediately. (I offer mercy, as I don’t know what else in their lives these two physicians may have had that distracted them, and God knows, I have had my own mis-steps over 23 years)

All of us should call anyone who stands in the way of excellent patient care: “Disruptor of Patient Care”.

There are a subset of docs that will always speak for the patient, that would put their jobs on the line before they would allow shoddy or inappropriate care. A subset of administrators and government officials call us “disruptive doctors”. Nope. We are Champions of Excellent Medical Care. We are the ones America should trust for the solution.

Some physicians cannot be as vocal as the Champions of Excellent Medical Care. Many have gargantuan loans, many care for their parents, or have a houseful of children. We all must offer mercy to those physicians, who cannot be as vocal. Many of those physicians are spreading the word and supporting the Champions of Excellent Medical Care. The percentage of both of these groups are growing. We are ready to jump the chasm in the chart below.

Some physicians are tired, or scared, or disenchanted. Some are at the end of their career, and don’t want to become “champions” because they will have to call out friends in doing so. Friends that may have become administrators, politicians, industry players.

Some think we must move slowly, take measured steps. True patient champions have been woke for years, or now, newly woke, run to the long-existent code occurring in American medicine. We don’t aspire to place a band aid on a hemorrhage. COVID-19 has opened all of America to knowledge of how bad things have been.

Some physicians have not yet dissected the whole system to see and understand all the players who are the Disruptors of Patient Care. Please do so! Hint: FOLLOW THE MONEY!!! Here are two resources:

1.A primer on corporate care

2.Solutions and rationale for reducing cost and waste that will increase access.            The Free2Care white paper was presented April 2019.  The ideas are supported by the Free2Care Coalition: 8 million American patients and over 70,000 US physicians!  As a coalition of groups, each group does there thing and we come together surrounding ideas.  There is no one group in charge. Go team!

Some physicians know exactly how the system works and sold out, now working as leadership in organizations that take vast monies from the corporates. Some of these organizations have wonderful physicians who are foot soldiers, and are trying to change these organizations from within.  

I’ve had a tiny fear of being fired my entire professional life, for being a Champion of Excellent Medical Care, but deep down, I reasoned that if I put the needs of the patient first, how could I be doing the wrong thing?  Bottom line for all of us who want to be champions: allow us to give our patients, every patient, the best care possible If you choose to disrupt us, we will first ask you nicely to get out of the way, but then will breathe fire at you until you do.

That two-year old little girl… she got her enema, her intussusception was reduced, and the dull eyes I had looked into at three am were lit with a sparkle. I smile still thinking of that sparkle.

Jump the chasm, physicians of America. Sparkle. Do not be some physician: be the physician America’s patients need right now. Be the solution!

Be a stellar doc

Be a Champion of Excellent Medical Care!

With thanks to an old friend and a new physician friend for their inspiration. We all have many muses. I believe they are both champions.