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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 the series. PMS are supposed to reduce cost. Instead, they …steer patients toward pricier drugs, charge steep markups on what would otherwise be inexpensive medicines and extract billions of dollars in hidden fees,” according to the investigation. (New York Times)

So, just what is a PBM?

Pharmacy benefit managers, or PBMs, are driving up drug costs for patients, employers and the government, according to The New York Times report mentioned above. But how? And just what is a PBM? NYT pharmaceutical reporter Rebecca Robbins explains in this short video.(New York Times)

Practice Transformation

SCOTUS nixes Purdue bankruptcy; OptumRx PBM settles opioid case

The US Supreme Court ruled that the Sacklers cannot be shielded from future claims through Purdue’s bankruptcy. Some victims and recovery advocates wanted the bankruptcy deal to go through so the settlement could start funding addiction services. Others said it would be unacceptable for the Sacklers to evade responsibility. In other opioid news, UnitedHealth Group’s OptumRx PBM unit has agreed to pay $20 million to settle claims by U.S. authorities that it improperly filled certain opioid prescriptions. This appears to be the first federal settlement with a PBM over allegedly illicit opioid prescriptions. (KFF Health News)

Rosenthal: Pain scales don’t help alleviate patient pain

Pain can’t be measured on a zero to 10 scale, Elisabeth Rosenthal, senior contributing editor at KFF Health News and a former physician, writes in The Atlantic. The AMA and the AAFP, among others, have rejected the notion that patients can meaningfully self-report pain numerically. But prescribers have no good alternatives. “The 2021 Nobel Prize in Physiology or Medicine went to scientists who discovered the mechanisms that allow us to feel the most basic sensations: cold and hot. In comparison, pain is a hydra. A simple number might feel definitive. But it’s not helping anyone make the pain go away.” (The Atlantic)

Evidence & Innovation

Data-blocking rule draws starkly different responses

When HHS issued its final rule codifying the financial disincentives to be levied against provider organizations for data blocking, provider industry groups were largely unhappy. For example, the American Hospital Association said it is “highly concerned that the disincentive structure retained in the final rule is excessive, confusing and imbalanced.” However, EHR, analytics, clinical automation and managed services firms see the final rule as long overdue. “The stringent penalties it now imposes serve as a strong impetus for compliance,” said Medicomp’s Dr. Jay Anders. (Healthcare IT News)

Policy Solutions

SCOTUS gives courts, not agency experts, final say on regs

The US Supreme Court overturned a 40-year-old precedent (the “Chevron doctrine”) that gave federal agencies, rather than judges, the power to interpret ambiguous laws passed by Congress. The ruling means courts can no longer defer to agency (e.g. CMS, FDA and HHS) interpretations of ambiguous statutes. These agencies will likely face increased legal challenges. Medicare and Medicaid may be disrupted, given the need for regular revisions. Bipartisan efforts to set limits on AI in healthcare, expand telehealth and curb PBMs will need to be revisited. (STAT News; Modern Healthcare; Healthcare Dive)

ACA prevention mandate stays in place—for now

The Fifth Circuit Court of Appeals upheld the ACA’s preventive services mandate. Insurers must continue to provide coverage of certain preventive services at no cost to the patient. However, the court ruled that the plaintiffs, a group of Christian companies, did not have to comply. This decision leaves the door open for future challenges that could potentially undermine the mandate nationwide. It asked a lower court to review the legality of other no-cost preventive services—vaccines and contraceptives. The court also ruled that the United States Preventive Services Task Force, which issues preventive-care recommendations that insurers must cover, didn’t have constitutional authority to issue recommendations. (Healthcare Dive; Axios)

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