Citizen Cartwright

Tips if you’re paying too much for prescription drugs

You and I have talked before about pharmacy benefit managers, which "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,” according to The New York Times.

 

So the Times investigated these gastric juices and found that "the largest PBMs often act in their own financial interests, at the expense of their clients and patients.”

 

The Times article is too long for me to summarize here; if you’re thwarted by its pay wall, you can find explainers in this item I ran last year. (By the way, the legislation I mentioned then, which would make PBMs more transparent, hasn’t moved forward since then, in case you want to contact your lawmakers.)

 

The Times has published a separate article on tips for consumers:

 

How your PBM affects you

It picks the drugs that will be covered by your insurance and decides how much you'll pay out of pocket for them.

 

The PBM puts together a list of covered drugs called a formulary. It also decides which drugs it'll encourage you to take by making them cheaper for you. It discourages you from taking other medications by making them more expensive or putting up hurdles like requiring you to try other drugs first. Your insurer or employer signs off on the recommendations of the PBM.

 

Finding out which PBM you have

Most Americans have one of the big three PBMs: CVS Caremark, Express Scripts or Optum Rx. Even if you have a smaller PBM like Prime Therapeutics, you may be affected by the business practices of the three giants; many smaller PBMs delegate some of their dealings with drug companies and pharmacies to their bigger competitors.

While you typically can choose your health plan during your employer’s open enrollment period every year, your PBM is picked for you.

You usually get an ID card in the mail that shows which PBM you have, though you may need to ask your employer’s human resources department.

If you’re on Medicare, you can choose an insurance plan each year, but the government website that enables you to compare plans doesn’t identify which PBM is attached to which plan. You may be mailed an ID card identifying your PBM, or you can try calling your Medicare plan.

 

Finding out if you’re being overcharged

If your out-of-pocket costs seem high, it could be that your employer or your insurance company is offering stingy benefits.

 

But here are some reasons the PBM’’s business practices are to blame:

 

PBMs sometimes force patients to take a brand-name drug even though there’s a cheaper generic version available. Ask your doctor or pharmacist if there’s a cheaper alternative.

 

If you’re taking a generic, your PBM may be forcing you to pay more than it would cost if you pay for it with your own money — not using insurance — at your local drugstore or an online pharmacy (this is a frequent problem with generics for chronic conditions like cancer and multiple sclerosis).

 

Options for paying out of pocket for your medication include GoodRx, which lists prices at pharmacies near you, or the Mark Cuban Cost Plus Drugs Company, an online pharmacy that sells hundreds of drugs.

 

Getting help

Pharmacists have insight into how PBMs cause patients to pay more. Your pharmacist may suggest that you forgo insurance to get a lower price or point you to a manufacturer’s coupon.

If you have medication sent through the mail from a pharmacy affiliated with your PBM, it still can be worth visiting your local pharmacy to see what options you have.

If you have a big bill for a drug that you can’t afford, you can ask your pharmacy if you can pay over time.

 

Changing PBMs

If you have insurance through your employer, you can’t switch PBMs, but you can try talking to human resources. Complaints from workers about the high costs they’re facing for a certain drug often are the only way the employer finds out that there’s a problem.

If you’re on Medicare and want to switch PBMs, you can choose a new plan for the next year. You’ll need to do some research to make sure you're actually picking a different PBM, since many Medicare plans use the same PBMs.

Because you have so many choices with Medicare plans, the best advice is to focus on what you can find out about a plan’s benefits, the drugs it covers and how much you'll pay for specific medications each month. All that information is on Medicare’s website.

How private equity is harming healthcare

You and I have been talking for a long time about private equity’s impact on healthcare. This seems to me a good summary of the dimension of the issue and the increasing response at the state and federal levels:

 

“Over the past decade, private equity has spent hundreds of billions of dollars acquiring healthcare businesses from emergency care to anesthesiology to nursing homes,” says the first in a series of articles on “concentration” in U.S. healthcare by The Wall Street Journal’s “Heard on the Street” column. "Where private equity has gone, studies show, prices have tended to increase.”

“Nowhere else in the world do so many healthcare dollars encounter so few mechanisms to limit profiteering,” the WSJ says.

 

“The U.S. commercial market relies on negotiations between insurers and medical providers to deliver the best possible quality and price for patients. Increasingly, though, it is becoming less competitive by design,” the WSJ says.

 

“In the U.S., many doctors used to work for physician-owned businesses. These days, about three-quarters work for a hospital or a corporate owner. As for your hospital, a private-equity firm or a larger medical system probably owns it,” the WSJ says.

 

“There are massive incentives to consolidate,” says the WSJ. “At nearly $5 trillion, U.S. healthcare’s gross domestic product would rank it third in the world if it were a country.”

 

Political action is intensifying, says the WSJ:

 

States across the country are enacting laws to curtail private equity healthcare acquisitions, as Congress and regulatory agencies examine the effects of private equity investments. In May, the Justice Department established a task force focused on healthcare monopolies and collusion.

What people on Medicare Advantage need to know

While traditional Medicare rarely requires prior authorization for services, virtually all Medicare Advantage plans invoke it before agreeing to cover certain services — especially ones with high price tags like chemotherapy, hospital stays, nursing home care and home health, says The New York Times.

 

“Most people come across this at some point if they stay in a Medicare Advantage plan,” says Jeannie Fuglesten Biniek, associate director of the program on Medicare policy at KFF.

 

More than half of Medicare beneficiaries now are enrolled in Advantage plans, which are administered by private insurance companies.

 

“The rationale plans use is they want to prevent unnecessary, ill-advised or wasteful care,” says David Lipschutz, associate director of the nonprofit Center for Medicare Advocacy. But, he says, it’s also “a cost-containment measure.” 

 

Insurers can save money by restricting coverage, and they’ve learned that few beneficiaries challenge denials — though they usually win when they do, according to KFF.

 

Some patients don’t know they have the right to appeal, and people already facing health crises may be unable to deal with what can be a complex appeals process, says the Times.

 

Among those calling for change are patients and advocacy groups, the American Medical Association, the American Hospital Association and other professional and trade groups. Congressional representatives in both parties have introduced legislation.

 

Two new rules from the federal Centers for Medicare and Medicaid Services aim to protect consumers and streamline prior authorization.

 

Among other actions, one rule clarifies that Medicare Advantage plans must cover the same “medically necessary care” as traditional Medicare.

 

Starting in 2026, the second rule will speed the process, cutting the time insurers are given to respond to prior authorization requests to seven days from 14 (for “expedited requests,” it’s 72 hours). The rule also will require insurance companies to post prior authorization information — numbers of requests, review times, denials and appeals — on their websites. The following year, plans will be required adopt a new digital system so plans and providers can more efficiently share information about prior authorization review.

 

Will the new rules make a difference? 

Lipschutz says, “It’s clear the intention is there, but the jury’s still out on whether this is working. It comes down to enforcement.”

 

And he points out one lesson from researchers: It pays to appeal.

Good news on maternal survival, U.S. crime, India environment

Among the items in this week’s edition of Fix the News:

 

— The global community has made significant progress in reducing the number of women who lose their lives to pregnancy-related causes, according to Our World in Data, citing World Health Organization statistics. Maternal mortality has dropped by half since 1985.

 

— "Americans tend to believe crime is up, even when official data shows it is down,” says the Pew Research Center. “In 23 of 27 Gallup surveys conducted since 1993, at least 60 percent of U.S. adults have said there is more crime nationally than there was the year before, despite the downward trend in crime rates during most of that period.”

 

Between 1993 and 2022, the U.S. property crime rate dropped 59 percent, burglary dropped 75 percent, larceny/theft dropped 54 percent and motor vehicle theft dropped 53 percent, according to the FBI. U.S. violent and property crime rates each dropped 70 percent between 1993 and 2022, according to Bureau of Justice statistics.

 

— Over the past 15 years, India has made "significant advancements in forest conservation" and ranks third globally in net gain of average annual forest area, The Times of India reports. 

 

The country also has celebrated 50 years of Project Tiger and 30 years of Project Elephant to protect habitats.

Get your health insurance through your employer? Here’s another way private equity may affect you.

One of the items I set aside during my time off was a New York Times investigation saying big health insurers are working with the little-known private-equity-backed firm MultiPlan to drive down payments to medical providers, drive up patients’ bills, and earn billions in fees for itself and the insurers.

 

Here’s how, according to the Times:

 

The most common way Americans get health coverage is through their employer, which pays for workers’ medical care itself and pays an insurance company to administer the plan. Providers in the plan’s network have agreed-on rates, but out-of-network providers often have to negotiate payments.

 

When people see medical providers outside their plans’ networks, UnitedHealthcare, Cigna, Aetna and other insurers often send the bills to MultiPlan to recommend a payment amount. 

 

By using MultiPlan’s low recommendations, insurers say they're saving employers money. But the insurers and MultiPlan also benefit because their fees typically are based on the size of the “savings” or “discount” — the difference between the original bill and the amount actually paid.

 

People have seen their bills increase after their insurers began routing claims to MultiPlan, as providers charge them for the unpaid balance. Some people say they've scaled back or stopped long-term treatment as a result. It can be especially difficult for people who depend on out-of-network specialists, including for mental health or substance abuse treatment.

 

Sometimes insurers and MultiPlan have collected more for processing a claim than the provider received for treating the patient, the Times says.

 

Former MultiPlan employees told the Times they had an incentive to lock in unreasonably low amounts: Their bonuses were tied to the size of the reductions.

 

MultiPlan’s "premier offering" is an algorithm-driven tool called Data iSight, which recommends the lowest payments to doctors — typically resulting in the highest processing fees, says the Times.

In examples of the power of investigative reporting:

— Two days after the Times' April 7 report on its investigation, the American Hospital Association asked the Labor Department to investigate.

— The hospital company Allegiance Health Management sued MultiPlan and seven health insurers on April 22 alleging that MultiPlan conspired with the insurers to underpay providers by tens of billions a year.

— Sen. Amy Klobuchar, D-Minn., chair of the Senate Judiciary Committee’s antitrust subcommittee, has written to the Justice Department’s antitrust division and the Federal Trade Commission urging them to investigate.

 

Two separate articles are part of the Times’ investigation. One is headlined "Insurers reap hidden fees by slashing payments. You may get the bill.” The other is titled “In battle over health care costs, private equity plays both sides.”

Good news on tolerance in Africa, malaria decline in India, deforestation drop in Brazil

Among the many other items in this week’s issue of Fix the News, this roundup on the United States:

 

“Marriage rates are up and divorce rates are down, the percentage of Americans without health insurance has fallen by almost half since 2010, employment for people in their prime working years is at its highest level in more than two decades, manufacturing construction spending has climbed to $225 billion per month, cholesterol levels are gradually improving across the country, and life expectancy has increased for the first time in two years thanks to a levelling off of overdose deaths.”

 

Fix the News also highlights a study in Nature on the media mantra “if it bleeds it leads” — or as I was thinking recently, if it frightens, it heightens (profits) — as media compete for reader attention. Check out the study's findings on the effect of negative words on online news consumption.  

'One of the most unfair aspects of medical insurance'

While patients can change insurance only during end-of-year enrollment periods or when there are “qualifying life events” like a job change, insurers’ contracts with doctors, hospitals and pharmaceutical companies can change at any time.

 

And this is “one of the most unfair aspects of medical insurance,” says Elisabeth Rosenthal, senior contributing editor at KFF Health News and author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back,” in a Washington Post opinion essay.

 

It's “particularly galling for patients because, whether obtaining insurance through an employer or buying it on the marketplace, they generally choose a policy based on whether it covers their desired doctors and hospital or an expensive drug that they need. Turns out that particular coverage could evaporate at any time during the policy term,” Rosenthal says.

 

Consumers are put at risk, according to a report by the Robert Wood Johnson Foundation, “in the escalating warfare over pricing between big, consolidated hospital systems and ever-bigger insurers in a cutthroat market,” Rosenthal says.

 

State and federal regulators have the authority to regulate insurers’ networks and could end the practice, says Allison Hoffman, a University of Pennsylvania law professor. But until now there hasn’t been federal regulation about continuity of coverage, particularly how to define it, she says.

 

Hoffman suspects that the apparent surge in contract disputes between insurers and providers stems from hospital price transparency regulations that took effect in 2021 and have enabled hospitals to compare reimbursement rates with each other.

 

Many insurers say they'll continue paying for a period after a contract ends — often 60 to 90 days — or to complete an “episode of care,” for a pregnancy in particular, says Rosenthal. 

 

“But,” says Rosenthal, "with, say, cancer, would that mean one round of chemotherapy or the full course of treatment, which could last for many years? Is it continuity of coverage if a patient has to change oncologists midstream or if a patient has to leave an effective therapist?”

If you’re one of the millions of Americans with medical debt

The Consumer Financial Protection Bureau wants to help you.

 

In the past two years, the CFPB has penalized medical debt collectors, issued warnings to health care providers and lenders that target patients, and published reports on how the health care system is undermining the financial security of Americans, says KFF Health News.

 

Now the agency, created after the 2008 financial crisis, is developing rules to keep medical debt off consumer credit reports, a change that could make it easier for Americans with medical debt to rent a place to live, buy a car, even get a job. The rules are expected to be unveiled later this year, KFF says. 

 

Last year, the three nationwide credit reporting companies – Equifax, Experian, and TransUnion – started removing all paid medical debts from consumer credit reports and those less than a year old. They've also taken steps to remove from their reports all medical collections under $500. 

 

The CFPB suggests that you check your Equifax, Experian, and TransUnion credit reports to make sure they’re accurate. You can get free online credit reports once a year through AnnualCreditReport.com.

 

The CFPB also has lots of information on its website to help you.

Doctors trying to do the right thing amid states’ abortion bans

Without clarification from legislators and prosecutors on how to handle the real-life nuances that have emerged in hospitals across America, doctors in states that ban abortion tell ProPublica they're unable to provide care to high-risk pregnant patients that meets medical standards.

"Under threat of prison time and professional ruin, they are finding their personal interests pitted against their patients’ and are overriding their expert training for factors that have nothing to do with medicine, like political perceptions and laws they aren’t qualified to interpret,” ProPublica says. "As a result, some patients are forced to endure significant risks or must travel out of state if they want to end a pregnancy. Sometimes, their doctors aren’t even giving them adequate information about the dangers they face.”

 

A New Yorker article focuses on Caitlin Bernard, “one of the last abortion doctors in Indiana,” who provided a legal medication abortion to a ten-year-old who came to her from Ohio.

 

“The most senior complex-abortion doctor in a state that recently outlawed almost all abortions, Bernard has struggled to balance her work — which involves delivering babies, as well as ending pregnancies — with the fraught task of supporting her patients through medical decisions that increasingly require the advice of an attorney,” The New Yorker says.

 

“Mostly, it’s just incredibly sad,” says Bernard. “All of these absolutely brilliant clinicians have just spent their entire lives fighting for one basic human right that is literally the easiest procedure that you’ve ever done in your entire life.”

Private equity’s increasing role in caring for our most vulnerable

We’ve already talked about the role of private equity in assisted living facilities, nursing homes, hospices, hospitals (you may recall the series of articles in 2022 by KHN, since renamed KFF Health News). 

 

Now, each of the top five for-profit child care chains — KinderCare, Learning Care Group, the Goddard School, Primrose Schools and Bright Horizons — is controlled by private-equity funds, and private-equity-backed centers have 10 to 12 percent of the market, says The Atlantic.

 

I recently discovered that private equity also is in psychotherapy.

 

And physical therapy.

 

And the care of children with autism.

 

The Atlantic article reminds us of some of the problems of the private equity business model, according to the book "Plunder: Private Equity's Plan to Pillage America,” by Brendan Ballou, former special counsel for private equity at the Justice Department:

 

— Private equity buys a business with the intention of flipping it for a profit, not long-term sustainability, meaning it's trying to maximize value in the short term and is less likely to invest in staff or facilities. 

 

— It tends to load businesses with debt and a lot of fees. 

 

— Its business structure insulates private equity firms from liability.

 

I’m always grateful when someone who points out a problem also recommends solutions, as Ballou does in his book. I’ve been meaning to summarize them here.