The “Dark Side” of Health Care and other bad behavior

Coupons, oh all those coupons. (09/02/2015)

Sometimes when you’re in the Dr.s office you might be given a coupon that can be applied against your charge from the pharmacy.  When we can use them we certainly do, however most of the coupons can’t be used for many patients, due to the restrictions in fine print on the coupon.  Most notable are exclusions for Medicare, Medicaid and many others.  Another problem with these coupons is like samples they generally are for expensive name brand medication.

Look what happened to K-Mart when they didn’t follow these rules.

Kmart pays $1.4 million to settle U.S. charges over Medicare inducements
Reuters (09/01/15)

Kmart has paid $1.4 million to settle U.S. allegations that it violated the federal False Claims Act by inducing Medicare beneficiaries to fill prescriptions at its pharmacies. The U.S. Department of Justice says the accord resolves allegations that Kmart let beneficiaries use drug manufacturers’ coupons to reduce or eliminate prescription copayments. The Department of Justice says this caused people to seek out brand-name drugs rather than cheaper generics, boosting the government’s costs. The government says Kmart’s improper activity lasted from June 2011 to June 2014, and violated a federal prohibition against offering benefits to Medicare beneficiaries to influence their decisions about which pharmacies to use.

Doing the right thing (Aug 28, 2015)

Washington has the same law, so ok mail-order, Wal-Mart, Rite-Aid, K-Mart, Costco, Walgreens, and on and on, let’s start doing not only what is required by law, but is just sound medically.

The Big get Bigger and Smaller all at the same time

Each year the number of Medicare Part D (Drug) plans seems to get smaller and smaller.  What is happening now is that the BIG insurance carriers, i.e. and other health entities have been eating one another in a feeding frenzy of buying out your competition.  It is surprising that the Federal Trade Commission(FTC) is letting this go on, but that is a topic for another post.  

So in 2008 when Part D first started there were 1,875 Part D plans, well this year there are ONLY 1,001 plans that will be offered in 2016.  So as the consolidation continues you find less choices, less coverage and higher costs to you the patient.

CVS Controlling Cholesterol-lowering Drugs

CVS, the No 2 manager of drug benefit plans for U.S. employers and insurers, will wait until a second new cholesterol-lowering drug is approved by regulators before negotiating for price discounts or adding either of new drugs to its list of covered medications. The FDA has approved Praluent, which works by blocking a protein called PCSK9 that helps “bad” LDL cholesterol stay in the bloodstream. An FDA decision on a second PCSK9 inhibitor, Repatha, is expected later this month.


CVS Health Paying Government $450,000 to Settle Dispute

CVS Health has agreed to pay $450,000 to the federal government to settle allegations that some of its retail pharmacies in Rhode Island filled forged and invalid CDS prescriptions. The agreement is the culmination of a two-year investigation by the U.S. Attorney’s office and the DEA Office of Diversion Control into several of the Woonsocket, Rhode Island-based CVS’s retail pharmacy locations.

PBMs Wield “Potent Weapon” Controlling Drugs

Geoffrey Porges, a Sanford C. Bernstein analyst, calls the coverage exclusions a “potent weapon” for PBMs and estimates the number of drugs excluded by at least one of the two major PBMs will rise to 165 in 2016 from 130 this year. Express Scripts CMO stated, “We’re often able to extract over-sized discounts from the pharma manufacturers” by holding out the option of coverage exclusion. Historically, PBMs wouldn’t typically exclude drugs from coverage but would try to direct patients to cheaper options by requiring them to pay more out-of-pocket for less favored drugs. However, CVS began excluding drugs from its preferred list in 2012, and Express Scripts later followed suit.


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