PBM Reform Podcast

Dave Teckman, Executive Chairman at ActiveRADAR joins the PBM Reform Podcast series about the impact of therapeutic interchange technologies on PBM pricing & the powerful data at the pharmacist's fingertips with ActiveRADAR.

Through rigorous clinical evaluation of all drugs in over 112 therapeutic categories, ActiveRADAR first establishes which drugs are clinically equivalent and therefore therapeutic alternatives to one another. This creates our Clinical Catalog of over 26,000+ therapeutically equivalent “perfect pairs”. Then ActiveRADAR determines the economic value using plan specific data to value each drug within its respective therapeutic class and sets pricing and reimbursement accordingly. This type of program has historically been called “reference pricing”, however ActiveRADAR takes it a step further by establishing both THE CLINICAL AND ECONOMIC VALUE OF EACH AND EVERY DRUG IN EACH THERAPEUTIC DRUG CLASS.

About ActiveRadar:

ActiveRADAR, formerly RxTE Health, is a healthcare analytics and patient education company providing unique data-driven, cost-saving customized prescription options. Using proprietary technology, ActiveRADAR identifies the lowest cost prescription options.

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Madelaine A. Feldman, MD, FACR

Dr. Madelaine Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans, LA. She is President of the Coalition of State Rheumatology Organizations, Chair of the Alliance for Safe Biologic Medicines and past member of the American College of Rheumatology insurance subcommittee.

Dr. Feldman is a Clinical Assistant Professor of Medicine at Tulane University School of Medicine, and lectures extensively to patients, physicians, regulators, and legislators both locally and nationally, speaking before the Health subcommittee of Energy and Commerce in 2019.  She has spoken and written on the drug supply channel, particularly the effect that formulary construction and utilization management tools have on pricing and access to drugs (availability & affordability).

Dr. Feldman is honored to be the recipient of the American College of Rheumatology's 2021 Innovation in Clinical Care award. She received the Distinguished Service Award for Tulane Medical School, was named one of the Top Women in New Orleans by City Business in 2017 and is the former radio talk show host of “Driving with Dr. Mattie.”

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Speaking to the Pharmacy Podcast Network, Dr. Marion Mass, a pediatrician, patient advocate and founding member of the Practicing Physicians of America, spoke about the original intent of PBMs, which started in 1968, and what they’ve become today.

“PBMs were created with the vision that they would act like giant drug-buying networks, with their buying power cutting health care costs and consumers realizing the savings in the end. However, through consolidation, three companies now control 90 percent of the market,” she said.

Dr. Mass further explained, “This unhealthy market share has led to an unhealthy control over formularies,” which can cause life-and-death situations for her young patients. “Patients are at risk of death or harm when drugs such as chemotherapies, antibiotics, epinephrine and anesthetics are not available.”

Pharm D Mel Brodsky, executive director of the Philadelphia Association of Retail Druggists and former CEO of the Keystone Purchasing Alliance, explained, “This outsized market share takes advantage of drug manufacturers, pharmacists and, most importantly, patients. The result is a net negative for all parties except for the large PBMs.”

In his estimation, the net result of this imbalance “has led to an erosion of the doctor-patient relationship and a decimation of Main Street pharmacists throughout the nation.”

“With the current system in place, independent pharmacists are being squeezed to the point that many jump when the large groups offer to buy them out. With the depletion of community pharmacists comes the loss of personal touch and a watered-down version of health care to patients,” Brodsky said. 

Both participants agreed that action must be taken on the federal level, citing Pennsylvania Sens. Bob Casey and Pat Toomey’s abilities to rein in the large PBM market imbalance

Our Guests: 

Dr. Marion Mass. Dr. Mass is a pediatrician in the Philadelphia suburbs. She received her medical degree from Duke University School of Medicine and has been in practice for more than 20 years. She is the co-founder of Practicing Physicians of America - and leadership in the Free2Care coalition-a consortium of grassroots physician advocacy groups that believe that the key to good care starts with the relationship between a patient and their doctor. She sits on the editorial board of the Bucks County Courier, Times and is a member of the Bucks County Health Improvement Partnership.

Mr. Mel Brodsky is the Executive Director of the Philadelphia Association of Retail Druggists (PARD), an association of community pharmacies representing 250 independently owned pharmacies in Southeast Pennsylvania. PARD works closely with State Associations like the Pennsylvania Pharmacists Association (PPA). Mr. Brodsky is also CEO of the Keystone Pharmacy Purchasing Alliance, headquartered in Philadelphia with 400 member stores in 5 States. Mel has an amazing understanding of how PBMs impact the effectiveness and growth of vital healthcare service providers like Community Pharmacies.  

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Special interview w/  award-winning ProPublica reporter Marshall Allen, a primer for anyone who wants to fight the predatory health care system--and win.

We welcome back two patriots in PBM Reform on the interview w/ Marshall. 

Monique Whitney - CEO of Pharmacists United for Truth & Transparency and PUTT President and Pharmacy Owner Scott Newman.  

Every year, millions of Americans are overcharged and underserved while the health care industry makes record profits. We know something is wrong, but the layers of bureaucracy designed to discourage complaints make pushing back seem impossible. At least, this is what the health care power players want you to think.

Never Pay the First Bill is the guerilla guide to health care the American people and employers need. Drawing on 15 years of investigating the health care industry, reporter Marshall Allen shows how companies and individuals have managed to force medical providers to play fair, and shows how you can, too. He reveals the industry's pressure points and how companies and individuals have fought overbilling, price gouging, insurance denials, and more to get the care they deserve. Laying out a practical plan for protecting yourself against the system's predatory practices, Allen offers the inspiration you need and tried-and-true strategies such as:

Analyze and contest your medical bills, so you don't pay more than you should

Obtain the billing codes for a procedure in advance

Write in an appropriate treatment clause before signing financial documents

Get your way by suing in small claims court

Few politicians and CEOs have been willing to stand up to the medical industry. It is up to the American people to equip ourselves to fight back for the sake of our families--and everyone else.

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Capital Rx and 3 Axis Advisors Study Finds Potential for Billions in Prescription Drug Savings With Transparent Pricing Practices

Mandatory NADAC responses by pharmacies for 1,600 unique oral solid products could create additional savings of $1.5 billion over 10 years

Comparing generic drug costs with NADAC and Alabama actual acquisition cost, study finds $937 million in potential annual savings across Medicaid

Implementing and improving transparency in pricing practices can restore public trust in U.S. drug pricing system, results suggest

CMS proposes delaying drugmaker rule days after PhRMA suesThe lawsuit also casts blame on health plans and pharmacy benefit managers that allegedly "siphon the benefits" meant for consumers.

Today's guests: 

Antonio Ciaccia

3 Axis Advisors www.3axisadvisors.com 

A. J. Loiacono

CEO at Capital Rx

https://www.healthcarefinancenews.com/news/cms-proposes-delaying-drugmaker-rule-days-after-phrma-sues

This episode is sponsored by the Ultiguard Safe Pack. UltiGuard Safe Pack is the only pen needle product that comes with an all-in-one sharps container. Learn more about why UltiGuard Safe Pack is the best choice for your patients and your pharmacy., 

Learn more about the UltiGuard Safe Pack: 

https://www.ulticare.com/ultiguard-safe-pack/podcast

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LIPA v ESI: Fight for the Right to Be Paid 

What happens when a state implements provider fee statutes that are officially approved by CMS but one of the big 3 PBMs still claims exemption?

Join guest host Monique Whitney with special guests Randal Johnson, JR Whaley, and MJ Terrebonne as they discuss Louisiana's legal battle with ESI over 10 cents per claim, and the ramifications this could have on state Medicaid programs nationwide.

Host: 

Monique Whitney, Executive Director, Pharmacists United for Truth & Transparency 

Guests:  

Randal Johnson, CEO, Louisiana Independent Pharmacies Association 

JR Whaley, Legal Counsel, Louisiana Independent Pharmacies Association 

MJ Terrebonne, Health Policy Expert & retired Director of Pharmacy, Louisiana Medicaid

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Tennessee Gov. Bill Lee signed HB 786, a comprehensive PBM reform bill that strengthens existing fair pharmacy audit laws, limits PBM adjudication fees, and prohibits a PBM from reimbursing a pharmacy less than it reimburses a PBM-affiliated pharmacy.May 30, 2019

Tennessee SB650

Present law defines "pharmacy benefits manager" (PBM) to mean a person, business, or other entity and any wholly or partially owned subsidiary of the entity, that administers the medication and/or device portion of pharmacy benefits coverage provided by a health insurance plan, subject to certain exceptions.

Present law provides detailed requirements for the conduct of an audit of records of a pharmacist or pharmacy by a health insurance plan, a PBM, the state or its political subdivisions, or any other entity representing the same. One such audit requirement is that a clerical or recordkeeping error regarding a required document or record may not, in and of itself, constitute fraud; however, the claims may be subject to recoupment. This bill instead provides that a clerical or recordkeeping error identified during an audit is not prima facie evidence of fraud or intentional misrepresentation and must not be the basis of a recoupment unless the error results in an actual overpayment to the pharmacy or the wrong medication being dispensed to the patient. As under present law, a clerical error will not be subject to criminal penalties without proof of intent to commit fraud. 

Shane Reeves is an American businessman, pharmacist and politician who is the State Senator for the 14th District of Tennessee, which is composed of Bedford County, Moore County, Lincoln County, Marshall County, and part of Rutherford County. As a seventh-generation Tennessean, Senator Shane Reeves has spent his life raising a family and opening businesses in middle Tennessee. He understands the importance of family, character, and conservative values to the people in this community.

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What's the expected outcomes of a transparent PBM? How does a fiduciary driven pharmacy benefit management company compare to the 3 largest PBMs in the country processing more than 76% of all the prescriptions per year in the United States. 

The PBM market is dominated by three major players, who together handled about 76 percent of all prescription claims in 2018, according to Drug Channels Institute.  

A breakdown of PBM market share, by total equivalent prescription claims managed in 2018:  

Caremark (CVS Health) / Aetna: 30 percent

Express Scripts: 23 percent  

OptumRx (UnitedHealth): 23 percent  

Humana Pharmacy Solutions: 7 percent  

MedImpact Healthcare Systems: 6 percent  

Prime Therapeutics: 6 percent  

All other PBMs + cash pay: 4 percent 

TrueScriptsmission is to build lasting relationships. They provide prescription benefit management expertise at a personal and customized level to ensure optimum value at the lowest possible cost. The TrueScripts team of nurses, pharmacists, legal experts, data scientists, and care specialists work together as one to bring prescription benefit expertise and a level of service that far exceeds that of any industry standard. 

Today's guest is Nathan Gabhart RPh Founder & CEO of TrueScripts. 

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We talk with Community Pharmacy owner Dr. Steve Moore, PharmD about the Implications of the Rutledge versus PCMA Supreme Court decision on Independent Pharmacy. 

About Condo Pharmacy: 

Condo Pharmacy is an independently owned and operated pharmacy dedicated to meeting the unique healthcare needs of each individual patient. In addition to providing both traditional and specialty pharmacy services, Condo Pharmacy is proud to be a part of the CPESN USA network of pharmacies and offer enhanced pharmacy services and care management protocols.

Special guest: Steve Moore, PharmD

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Georgia House of Representatives Earl L. “Buddy” Carter joins CEO of RxSafe Bill Holmes to summarize the The Supreme Court of The United States (SCOTUS) has rescheduled the Rutledge v. The Pharmaceutical Care Management Association (PCMA) hearing for October 6, 2020.1 The initial April hearing date had been postponed due to the coronavirus disease 2019 pandemic (COVID-19)

Rutledge v. PCMA revolves around whether states have the right to regulate pharmacy benefit managers (PBMS). Arkansas Attorney General Leslie Rutledge has petitioned the court to overturn the US Court of Appeals for the Eight District’s earlier decision to maintain Arkansas’ statute regulating PBMs’ drug reimbursement rates. In a legal brief filed in February 2020, however, Rutledge argues the statute is preempted by the Employee Retirement Income Security Act of 1974.3

At least 4 pharmacy groups, The American Pharmacists Association, The Arkansas Pharmacist Association, The National Alliance of State Pharmacy Associations, and the National Community Pharmacists Association have publicly expressed their support for states’ rights to regulate PBMs.3 According to an earlier report, these 4 groups have jointly argued that unregulated PBM business practices limits access to pharmacists care and prevents the optimal use of medications.3

In April 2020, the Academy of Managed Care Pharmacy (AMCP) filed an amicus brief in support of the Eighth District’s decision.4 The brief argues that ruling in favor of Rutledge will drive up health care costs, and also will have a big effect on patients too by limiting their ability to access affordable medications, hindering health outcomes.4

The AMCP brief also argues that ruling in favor of Rutledge can lead to issues at the administrative level, and can lead to varying and possibly contradictory state laws as well.4

Supreme Court to hear Rutledge v. PCMA Oct. 6

The US Supreme Court has released its October 2020 oral argument calendar, with Rutledge v. PCMA now scheduled to be heard on Tuesday, Oct. 6. The case was originally scheduled to be argued in April but was postponed due to the coronavirus pandemic. Rutledge v. PCMA is a landmark case on whether states can adopt meaningful regulations on pharmacy benefit managers.

If you would like to contribute to the NCPA Legislative/Legal Defense Fund, your support would be much appreciated.

Resources

Brief of Arkansas Pharmacists Association, National Community Pharmacists Association, American Pharmacists Association, National Alliance Of State Pharmacy Associations, and Fifty-One Other Pharmacist Associations As Amici Curiae Supporting Petitioner

Latest Information on Rutledge v. PCMA

NCPA Analysis of Rutledge v. PCMA

Rutledge v. PCMA: 15 Years in the Making

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