Kendalle Burlin O'Connell, Esq.’s Post

Employers face challenges when it comes to understanding drug price markups due to various factors: - **Complexity and Opacity:** The involvement of multiple players like PBMs, insurers, and drug manufacturers makes it hard for employers to grasp where markups occur and how they impact costs. - **PBM Contracts:** Employers relying on PBMs for managing prescription benefits may not always benefit from negotiated prices and rebates due to potential savings retention by PBMs. - **Focus on Overall Benefits Costs:** Employers prioritize managing overall health benefit costs, which include medical services, hospital stays, and other expenses, over solely focusing on drug price markups. - **Lack of Transparency:** The absence of transparency in drug pricing and PBM practices can obscure true markup extents, leaving employers unaware of actual drug costs. - **Regulatory and Market Pressures:** Employers might find it challenging to challenge or alter the current system due to regulatory constraints and market influences. Understanding these dynamics is crucial for employers navigating the complexities of drug pricing and benefits management. #Employers #DrugPricing #HealthcareCosts #Transparency #ManagementChallenges

CVS Skewered: This Is What Effective Cross-Examination Looks Like Rep. Jake Auchincloss is like a dog with a bone on #drugaffordability issues. He’s been highly effective in showing the #patient harm created by #PBMs and #plans through their abusive and unlawful use of #accumulators and #maximizers (which, BTW, I’m sad to say was NOT a topic included in the House Oversight Committee’s PBM report—that was my biggest disappointment about the report—such an obvious miss). At this #OversightCommittee hearing, Rep. Auchinclous ups his already impressive game by using some original research to slice, dice, mangle, and then stomp on the CVS Health witness. He effectively builds his cross around awful examples of hideous drug mark-ups by CVS that sure sound like “spread pricing”—the deceptive practice of charging a plan (and its #costsharing patients) much more than what the #pharmacy #reimbursement actually was. According to the Representative, CVS #Caremark's “own data” shows the following “percent mark-ups”, as compared to #NADAC, from an #employer in Massachusetts: #Multiplesclerosis Rx – 38,352% #Leukemia Rx – 13,591% #Prostate #cancer Rx – 6,375% #Chronickidneydisease #Rx – 5,037% #HIV Rx – 4,124% #Heartfailure Rx – 161% It’s a withering use of cross examination techniques to gain control over a witness and use the witness to tell the examiner’s story. Classic technique, very ably executed. The #CVS witness implicitly demurs on whether these ridiculous mark-ups are “spread pricing”, rather weakly suggesting that the mark-ups were the “client” sponsor’s decision, because it choose not to use CVS pricing. That would be a great follow-up written request, Representative. I bet those mark-ups can’t be explained away as a #sponsor or #employer decision. Well done, sir! #lifesciences #managedcare #pharmaceuticals All Copays Count Coalition

Key takeaways for #healthplans and #plansponsors and #patients from yesterday's House Committee meeting with Jake Auchincloss: For insurers and #brokers: 1. Specialty generics constitute an extremely small percentage of claims (<1%), but can have huge margins for pharmacies. Plans and patients are subsidizing these egregious margins for PBMs and PBM-owned pharmacies. 2. A proposal to an insurer may create a facade that shows "savings" on paper by adopting an exclusive dispensing agreement with the PBM-owned pharmacy, but results in billions in excess margin. Assessing overall contract value should include an independent benchmark like #nadac. 3. Don't overlook the indirect impact to your members through your plan design. If you concede and accept higher rates for specialty reimbursement, does your formulary also have higher copays or coinsurance for those medications? If so, the negotiating concession has impact on your members. Consideration of member cost should be made downstream of negotiating PBM network concessions. For patients: If you are taking a "specialty" medication, it is likely your #insurance will require it to be dispensed by a "specialty" pharmacy. This is because of contracts with their PBM. Few people realize there's often nothing "special" about the medication beyond the contract agreement to shift the prescription to the partnered pharmacy. ASK if the specialty medication is generic. If it is, you are likely paying more through your insurance than what your #local #independent or #retail pharmacy would charge without insurance. Go to your local pharmacy and ask for cash price or check pricemymeds.com Bonus: Most "specialty" drugs not only require you to go to a specific pharmacy, but will then also require a prior authorization, further delaying your care. Requesting the generic at your local pharmacy and paying cash will not only make it potentially cheaper but also allow you to bypass the prior authorization. Wouldn't it be nice if a solution existed that could optimize the lowest price and automate it? #getgreenback #pricemymeds

A crisis of trust and transparency exists with the biggest PBMs. If you are under 65 and have health insurance through your employer, you are likely paying for it. These big PBMs are playing a high-stakes game of hide and seek. With healthcare inflation at +5.2%yoy their antics compound it for self-funded organizations. Our organization TrueScripts was founded more than a decade ago to give self-funded plan sponsors an alternative to these abusive practices cloaked in ambiguity by the big six. +90% prefer to stick with the status quo and suffer their abuses at the expense of your budgets. Tired of handing down higher premiums and out-of-pocket expenses for your members each year? Their is a simple way HR leaders and executives can stop the big six profiteering without waiting on help from legislators to force the leopards to change their spots. Consider talking to your broker consultant about working with a partner who is conflict-free and contractually obligated to put your organization’s interest first to maximize plan savings for you and your members with trust and transparency—TrueScripts. Our mission is to be the best, not the biggest, at maximizing your savings with trust and transparency. Can your PBM say that?

Congressman thank you for bringing light to the big 3 PBM Mafia. There are 3 questions I would love to hear you ask. 1) Mr. Joyner what is your annual salary? 2) Why on average does your PBM reimburse independent pharmacies less than the cost of the medication forcing many local independent pharmacies in small towns to close across America leaving those in the most need with no access to a pharmacy and pharmacist? 3) Why does an elderly person have a $400/month copay for a life saving medication like Eliquis when your company reports billion dollar profits to Wall Street and while also paying the CEO upwards of $30 million dollars a year?

As we all know, there's much news about PBMs and the transparency and accountability required to represent employers and employee populations nationwide. Take five and listen to what is shared here: https://lnkd.in/g3fG7yb5

Addressing drug markups is crucial for ensuring equitable access to healthcare and improving public health outcomes because it makes essential medications more affordable and accessible, reduces financial strain on vulnerable populations, minimizes health disparities, and promotes better adherence to treatment plans. This leads to improved health outcomes and a more equitable healthcare system. #DrugPricing #HealthcareAccess #HealthEquity #HealthJustice

Great post below talking about National Cancer Prevention Month, the cancer epidemic, drug shortages, diminished access, and the threat that all this gets much worse under the IRA. The only part missing in this discussion of an unfolding train wreck is the lack of access to co-payment support. I feel like a voice crying out in the desert here. As of just a few days ago, 82% of cancer co-payment assistance funds were closed or otherwise restricted—8 in 10 cancer related funds are unavailable to newly diagnosed patients struggling to afford their therapy. #patientaccess #copays #medicare #aks #oig #patientassistance #healthcarecompliance ##hhs #ussenate #ushouse #patientsfirst #nationalcancerpreventionmonth

February is National Cancer Prevention Month. If it seems that more and more American families are being touched by cancer, it’s because they are. The number of cancer cases among young people is skyrocketing across the U.S., with more than 85,000 American adolescents and young adults diagnosed with cancer each year. One 2022 study went as far as calling it an “early-onset cancer epidemic.” Even more concerning, these patients can’t get the treatments they need because of a shortage of chemotherapy drugs, and they may have the Inflation Reduction Act (IRA) partly to blame. In 20+ years in federal policy, I can say this is the worst policy-led innovation environment I've ever seen. In general, this environment contributes to all kinds of bad outcomes, including drug shortages. What is truly needed is a comprehensive federal policy approach across programs that incentivizes the lowest price to generate stable, consistent, and high-quality manufacturing. Children battling #cancer, forced to spend their childhoods in hospitals undergoing painful surgeries and treatments instead of playing with their friends and families, often do not have a year, let alone a decade, to wait for these drug shortages to end. Read my post at CAHC. #CancerPreventionMonth #CancerPrevention #AwarenessToAction #Cancer #Healthcare #Health #HealthPolicy #Innovation #DrugPricing #cancerresearch #Congress #healthcarecosts #InflationReductionAct 

More and more children are being diagnosed with cancer. This National Cancer Prevention Month, as we discuss ways to improve diagnoses and treatments, it is essential to acknowledge that there is a shortage of drugs because of the Inflation Reduction Act. Learn more: https://lnkd.in/ecanuw5Q #CancerPreventionMonth #CancerPrevention #AwarenessToAction #Cancer #Healthcare #Health #HealthPolicy #Innovation #DrugPricing #cancerresearch #Congress #healthcarecosts #InflationReductionAct