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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…
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…
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…
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…
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…
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…
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…
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,…
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.…
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…
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…
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…
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…
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…
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…
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…
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…
News Brief | November 7, 2022 | CMS makes big changes to Medicare ACOs
Practice Transformation Americans give health care cost and equity low scores A plurality of Americans gives the U.S. health care system overall a poor or failing grade, and most rank affordability and equity the same way, according to the West Health-Gallup 2022 Healthcare in America Report. Care quality scored somewhat better. In all, 21% of U.S. adults grade the health care system with an "A" or a "B," 34% with a "C," and 44% with a "D" or an "F." Grades…
News Brief | November 1, 2022 | Bodenheimer: Fund primary care, add nurses and pharmacists to the team
Practice Transformation Ads: direct consumer to prescriber It’s not only patients and providers who benefit from online prescribing; so do a growing number of drug companies. They connect people scrolling their sites with a virtual prescriber. This “powerful mashup” of telehealth and DTC advertising worries policy experts, who fear that gaps in regulatory oversight leave patients vulnerable, STAT reports. It blurs the boundaries between manufacturer and prescriber,” says Nathan Cortez, a health law expert at Southern Methodist University. That makes it difficult…
News Brief | October 24, 2022 | Providers still leaving the profession, report finds
Practice Transformation AMA to take on senior polypharmacy Following up on recommendations from the AMA Senior Physicians Section, AMA delegates recently adopted “Reducing Polypharmacy as a Significant Contributor to Senior Morbidity.” It directs the AMA to work with appropriate stakeholders such as pharmacists, EHR vendors, PhRMA and AARP to, among other things, encourage physicians and their teams to initiate discussions with patients on improving their medical care through the use of only the minimal number of medications needed to optimize their…
