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GTMRx News Brief

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09Jul 24

News Brief | July 9, 2024 | NYT does deep dive into PBMs. It’s not pretty

NYT does deep dive into PBMs. It’s not pretty The New York Times has set out to explain how PBMs “prioritize their interests, often at the expense of patients, employers and taxpayers.” PBMs largely escape attention “because they operate in the bowels of the health care system and cloak themselves in such opacity and complexity that many people don’t even realize they exist.” But they are driving up drug costs for millions of people, employers and the government, according to…

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11Jun 24

News Brief | June 11, 2024 | CMM primer defines and outlines benefits of CMM

CMM primer defines and outlines benefits of CMM Comprehensive medication management supports population health and value-based care performance, and a recent LinkedIn post from the Population Health Alliance spells it out. CMM can improve quality outcomes and reduce costs among the most complex patients. For example, it can produce an estimated ROI of between 3.5:1 and 12:1 for patients with chronic conditions. The post goes on to define CMM and explain how it’s different from medication therapy management. (Population Health…

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14May 24

News Brief | May 14, 2024 | What’s happening with telehealth?

What’s happening with telehealth? Walmart's decision to shutter its health clinics and virtual care services isn’t just a blow to retail health; it has profound implications for telehealth. And it’s happening at a critical time. Optum is shutting down its virtual care unit. Teladoc CEO Jason Gorevic is out, and the company's stock has fallen by more than 40% this year. Amwell and Doximity are also facing challenges. But telehealth executives and investors tell Modern Healthcare there’s still a tremendous opportunity in…

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12Apr 24

News Brief | April 9, 2024 | Lawsuit: Drugmakers overcharged 340B participants millions

Lawsuit: Drugmakers overcharged 340B participants millions According to a recently unsealed lawsuit from Adventist Health, some of the world’s largest pharmaceutical companies that participate in the 340B drug discount program overcharged the federal government and numerous hospitals by hundreds of millions of dollars. Among those named: AbbVie, AstraZeneca, Novartis and Sanofi. The case highlights issues with the pharmaceutical pricing system, including non-compliance with regulations and the potential exploitation of government payors, as well as concerns about the 340B program's management…

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25Mar 24

News Brief | March 12, 2024 | SOTU address promises cap on OOP drug costs

SOTU address promises cap on OOP drug cost President Joe Biden’s State of the Union Address Thursday included some sweeping proposals, including extending a $2,000 cap on out-of-pocket drug costs to all Americans. Other proposals included expanding the number of drugs that can be negotiated by Medicare, capping the cost of insulin at $35 a month for all patients, and launching a $12 billion women's healthcare initiative. (Modern Healthcare) Practice Transformation “All of Us” releases trove of genetic data The…

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13Feb 24

News Brief | February 13, 2024 | Employee sues J&J over PBM costs

Employee sues J&J over PBM costs A Johnson & Johnson employee is suing the company for allegedly violating ERISA by mismanaging prescription drug benefits. The lawsuit accuses the company of paying inflated costs for generic drugs to its PBM, Cigna’s Express Scripts, resulting in higher costs for employees. One example: a generic MS drug costing over $10,000 for a 90-day prescription through the plan. At retail pharmacies, it’s available for around $40. The J&J suit is just the more recent…

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09Jan 24

News Brief | January 9, 2024 | GTMRx releases latest CMM  evidence document

GTMRx releases latest CMM  evidence document The Get the Medications Right Institute has released its  summary of research on comprehensive medication management (CMM). The December 2023 review, “The Outcomes of Implementing and Integrating Comprehensive Medication Management in Team-Based Care: A Review of the Evidence on Quality, Access and Costs,” highlights the best of the studies demonstrating the value of CMM in achieving all five aspects of the Quintuple Aim. It features 21 studies, three of which are from 2023: a…

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14Dec 23

News Brief | December 12, 2023 | Unions and employers agree on one thing: PBMs

Unions and employers agree on one thing: PBMs Employers and unions are getting fed up with PBMs, arguing that they favor costly over less expensive options, the Wall Street Journal reports. For example, Foot Locker dropped UnitedHealth Group’s OptumRx PBM last year, while a Teamsters fund in Philadelphia recently reupped with its replacement for CVS Health’s Caremark. The employers and unions say they likely get stuck with higher costs because PBMs can pocket some of the bigger rebates negotiated with drugmakers. But…

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14Nov 23

News Brief | November 10, 2023 | GTMRx Institute joins business and health leaders to call for PBM reform

GTMRx Institute joins business and health leaders to call for PBM reform On November 8 the GTMRx Institute joined a coalition of employers, health care providers and patient advocates in urging Congress to support strong PBM reforms this year. In a letter to Senate leadership, the coalition outlines several needed reforms, including commonsense changes to hold PBMs accountable to fair market practices when partnering with employers, the largest customers of PBMs. “PBM transparency alone is NOT enough, but it is…

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10Oct 23

News Brief | October 10, 2023 | Some states establish Rx affordability boards

Some states establish Rx affordability boards At least seven states have set up prescription-drug affordability boards to lower costs for a potentially broader set of prescription medicines, and more states could follow as some officials have expressed interest in establishing similar programs. Some of the boards have much more leeway than Medicare in selecting drugs for cost reviews. In several states, including Colorado and Maryland, the boards have the authority to set upper payment limits for drugs. Yet unlike the…

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12Sep 23

News Brief | September 12, 2023 | AI-based “credit score” for drug use draws criticism

AI based "credit score" for drugs draws criticism  Narx Scores and similar tools help clinicians review controlled substance prescriptions. They influence the prescribing of painkillers much like a credit score influences the terms of a loan. The use of systems to analyze opioid-prescribing data has sparked questions over whether they have undergone enough independent testing. This prescription-drug data has led patients to be dismissed from clinician practices, which could leave patients at risk of being untreated or undertreated for pain,…

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08Aug 23

News Brief | August 08, 2023 | Investigation: PBMs divert patient assistance funds

Investigation: PBMs divert patient assistance funds A local Ohio TV station conducted an in-depth investigation into how PBMs stand between patients and funds from pharmaceutical companies to help pay for medication. They report on how pharmacy benefit managers and their partners have diverted billions in drugmakers’ assistance intended for individual patients. Instead, they use the cash to set up their own health insurance programs for major employers – typically giving themselves a 25% share of the savings, public documents show.…

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11Jul 23

News Brief | July 11, 2023 | Bipartisan efforts seek to rein in PBMs

Bipartisan efforts seek to rein in PBMs  Congress continues to focus on PBMs, crafting several legislative packages that include reforms to make the role of pharmacy benefit managers in drug pricing more transparent and overhaul how PBMs are compensated, and curb potentially anticompetitive behavior. Among the specifics: requiring PBMs to report their negotiations, pricing information, and benefit designs; banning spread pricing (where PBMs reimburse pharmacies less than what they charge payers; Other proposals would ensure PBMs pass on rebates to…

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13Jun 23

News Brief | June 13, 2023 | PBM bill advances

PBM bill advances  Pharmacy benefit managers would be required to report more information on their deals with pharmaceutical companies under legislation unanimously approved by a House committee last month. PBMs would need to create reports for employer clients each year that detail prescription drug spending, acquisition costs, out-of-pocket expenses, formulary placement and rebates. In addition, the Government Accountability Office would produce a report on group health plan pharmacy networks, including those that health insurers own. (Modern Healthcare) SCOTUS revives whistleblower suits  Last…

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09May 23

News Brief | May 9, 2023 | Most payers have outcomes-based contracts with PBM

Most payers have outcomes-based contracts with PBM About 58% of payers had at least one outcomes-based drug contract with a PBM in 2022, according to an Avalere Health survey. Of the payers that had at least one outcomes-based contract, over 35% had more than 10. The top therapeutic areas were cardiology and endocrinology. Most (74%) of plans with at least one outcomes-based contract said that they prefer contracts with both claims-based and clinical outcomes. In fact, 53% said they don’t…

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11Apr 23

News Brief | April 11, 2023 | New drug shortages skyrocketing

New drug shortages skyrocketing Drug shortages are growing dramatically. For example, children's flu medications, common antibiotics, and ADHD treatments are getting harder to buy, according to a report from the Senate Homeland Security and Governmental Affairs. It finds that the number of new drug shortages rose by 30% between 2021 and 2022, an increase that has had "devastating consequences" for patients and doctors. Towards the end of 2022, nearly 300 individual drugs were considered in short supply, affecting treatment for…

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14Mar 23

News Brief | March 14, 2023 | Pharmacists want the option to keep delivering CMM virtually

Practice Transformation Getting the medication information right Do you have the information you need to get the medications right? Pharmaceutical companies’ medical information professionals can be a valuable resource. The non-profit phactMI represents MI professionals across the pharmaceutical industry; it works to make it easier for health care professionals—especially pharmacists--to access unbiased, evidence-based information. To that end, phactMI created the Drug Information Database, a “one stop shop” that enables users to search across manufacturers to access information more quickly and…

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28Feb 23

News Brief | February 28, 2023 | Data privacy: FTC fines GoodRx $1.5M; CMMI responds to Executive Order on Lowering Drug Costs

Practice Transformation February full of deals Last week, UnitedHealth Group closed its $5.4 billion acquisition of the home health and hospice provider LHC Group. LHC will be folded into Optum supporting UnitedHealth’s plan to make Optum the entry point for patients. Modern Healthcare reports. Also last week, Amazon completed its $3.9 billion acquisition of primary care chain One Medical; the deal gives Amazon a network of more than 220 medical offices in 27 markets across the US, according to Healthcare…

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23Jan 23

News Brief | January 23, 2023 | PGx-enriched CMM: Considerations for employers

Practice Transformation Look out, drug chains: Mark Cuban has only just begun Mark Cuban wants to lower drug prices even further and expand his online pharmacy's customer base. These plans could pose a major threat to CVS and Walgreens, TheStreet reports. And he’s in it for the long run. "Our goal isn't to make a lot of money or sell the company," Cuban tells TheStreet. "Our mission is to be the low-cost provider of every medication we are allowed to sell. That's not…

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13Dec 22

News Brief | December 13, 2022 | Proposed rule would reform prior authorization

Practice Transformation MyChart message fees passed on to patient? Cleveland Clinic began billing for certain Epic MyChart messages in November; now, at least seven other health systems have followed suit. But, as Becker’s Hospital Review reports, what remains uncertain is how long Medicare will cover these charges and whether most commercial insurers will pay at all. Ge Bai, PhD, of Johns Hopkins says the price for commercially insured patients likely depends on the health plan. Some patients could pay as much as…

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