Category: Pharmacy, PBMs, and Pharma costs

Jun
28

Good news Friday – Opioid settlement rejected, lower drug costs, and a solid economy

Posted by Joe Paduda on Friday, June 28th, 2024 | Comments

A beautiful Friday morning here in New York’s Finger Lakes…here’s the good news from this week.

First, the Supreme Court rejected the Purdue Pharma opioid settlement agreement – thereby allowing victims to pursue legal action against the Sackler family. As one who’s been deeply involved in the opioid disaster for a decade and half, I have somewhat mixed feelings about this – but have to support the Court’s decision.

The settlement would have shielded the Sackler family – many of whom were top execs and owners of Purdue – from personal liability.

It’s not hyperbole to say the Sacklers were directly responsible for the deaths of tens of thousands of daughters, sons, moms and dads, husbands and wives, friends and neighbors.  The settlement would have allowed these killers to keep some of their billions while avoiding any potential criminal or civil liability.

The downside is the settlement would have provided hundreds of millions of dollars for treatment and recovery services for addicts…losing those dollars is a tragedy.

That said, its very likely the Sacklers and Purdue will still have to provide funds to victims…and some of the Sacklers will now face civil – and potentially criminal – prosecution.

Lower drug costs

From CNBC:

  • The Biden administration  will impose inflation penalties on 64 prescription drugs, lowering costs for certain older Americans enrolled in Medicare.
  • A provision of Biden’s Inflation Reduction Act requires drugmakers to pay rebates to Medicare if they hike the price of a medication faster than the rate of inflation.

Lastly…

The economy grew by 3.1% YoY last year…a really solid result!

What does this mean for you?

Sacklers don’t avoid prosecution and liability, drug costs will drop, and the economy is pretty darn solid. 

Reminder – switching to Substack shortly – this may look differently in your email!

Jun
27

Opioid reduction in work comp and the impact on patients and prescribers

Posted by Joe Paduda on Thursday, June 27th, 2024 | Comments

A just-published research study examined the impact of reductions in opioids on workers’ comp patients and prescribers in Ohio and Washington.

(our research which includes payers’ opioid spend is here)

Key takeaways:

  • Providers reported more limited and cautious prescribing than in the past
  • Both patients and providers reported collaborative pain-management relationships and satisfactory pain control for patients.
  • Despite the fears articulated by pharmaceutical companies and patient advocates, opioid review programs have not generally resulted in:
    • unmanaged pain or reduced function in patients,
    • anger or resistance from patients or providers, or
    • damage to patient–provider relationships or clinical autonomy.
  • Other insurance providers with broad physician networks may want to consider similar quality-improvement efforts to support safe opioid prescribing.

From Milbank Quarterly:

The data analyzed in this study were a subset of data collected within a larger parent project—a comparative effectiveness study of the WC agency ORPs [opioid reduction programs] implemented in WA and OH.

I’d note that some Ohio patients and providers surveyed had real and significant challenges with access to care, approvals and care management. The report noted:

The fact that some of the problems described above seem to be particularly acute in OH could be a result of the fact that most WC claims in OH are handled by MCOs, whereas in WA, claims are processed directly by the L&I. The uniquely negative experiences of patients and providers navigating injuries and pain management in OH could be because of MCO dynamics, such as staffing challenges, management issues, or other operational problems. In addition, some MCOs are for-profit companies, which may render them more likely to deny expensive medications, procedures, or consultations.

Note – I was a member of the Advisory Committee for this research project; it was funded by the Patient-Centered Outcomes Research Institute.

What does this mean for you?

Overall, efforts to reduce inappropriate opioid use have been:

  • effective,
  • helpful in getting patients and providers to collaborate, and
  • have not resulted in unmanaged pain. 
Jun
25

Solving pain – opioids, NSAIDs, and better options

Posted by Joe Paduda on Tuesday, June 25th, 2024 | Comments

WCRI’s latest report on drugs in workers’ comp has some excellent news...opioid usage dropped 29% from Q1 2021 to Q1 2023.

WCRI’s data is from 28 study states representing the vast majority of workers’ comp drug spend.

It may well be that NSAIDs are replacing opioids, a welcome event but not without potential downsides, namely side effects of some NSAIDs and far too much physician dispensing of these (mostly) very cheap drugs.

Fortunately other promising therapies – with very low risk – are also now available.

The FDA has authorized AppliedVR’s RelieVRx for treatment of chronic low back pain. RelieVRx’s authorization came after extensive research and massive clinical trials; the latest included over 1,000 participants.

The study was a large randomized controlled trial (RCT), evaluating virtual reality (VR) therapy for treating chronic low back pain (CLBP) at home.  Published in Mayo Clinic Proceedings: Digital Health, the study found AppliedVR’s RelieVRx program produced clinically meaningful improvements in clinically severe and diverse adults with CLBP.

What does this mean for you?

Much safer and quite effective treatment for chronic low back pain = lower risk and excellent outcomes.

AppliedVR is an HSA consulting client. And I’m damn proud to work with them.

Jun
24

State moves that will affect workers’ comp

Posted by Joe Paduda on Monday, June 24th, 2024 | Comments

The state legislation that will MOST affect workers’ comp is often not ABOUT workers’ comp – rather it deals with other parts of the healthcare ecosystem.

For example:

Regulating Pharmacy Benefit Managers

FromWaPo:

At least 41 state legislatures introduced bills targeting pharmacy benefit managers (PBMs), which are third parties that help manage prescription drug benefits on behalf of both public and commercial insurers. That includes California, New Hampshire and Rhode Island, where bills have passed at least one legislative chamber and lawmakers are still in session.

Notably, governors in 13 states signed PBM reforms into law this year. For instance, Washington and Oregon banned spread pricing, in which prescription drug middlemen charge health plans more than they pay pharmacies and keep the difference. Idaho, meanwhile, implemented legislation requiring PBMs to transfer 100 percent of manufacturer rebates on to insurers.

Gotta say some of these are short-sighted and based on faulty understanding of the roe and actual practices of PBMs. That’s not to say PBMs are faultless…my firm has audited a number of work comp payers’ pharmacy programs…and suffice it to say there’s a lot of gaming out there.

By far the worst was the Federal program…

What this means – legislation may well lead to changes in WC PBM contracts and pricing.

Expanding Medicaid:

  • stabilizes hospital financials a lot,
  • helps ensure rural and inner-city facilities keep their ERs open,
  • improves the health of lower-income folks and workers, and
  • likely reduces hospitals’ and health systems’ shifting costs to workers’ comp payers.

One of the last holdouts is Mississippi, the poorest state with the worst health outcomes, highest infant mortality rate, and shortest life expectancy. Pushed by a broad coalition of business, not-for-profits, and consumer groups, at long last the state’s legislature is attempting to expand Medicaid, although it’s doubtful the bill will pass and be signed into law.

Nonetheless, one has to celebrate small victories, and the fact that the legislature is even considering expansion is good news. 

Frankly, detractors’ arguments against expansion are tissue-thin, not fact-based, and when questioned, beyond superficial.

What this means – Medicaid expansion -> healthier workers, more access to care and lower healthcare  costs. 

Hospital and provider consolidation

WaPo – A recent study found that hundreds of hospital mergers have escaped federal antitrust scrutiny in the past two decades because the Federal Trade Commission lacks the funding and staffing to crack down on all anticompetitive deals.

And, states are increasingly concerned about private equity investors’ impact on  healthcare access and cost. 16 state legislatures – both blue and red – have introduced bills dealing with this issue this year.

What this means – a possible slowdown of provider consolidation. 

ALSO – MCM will be changing from WordPress and MailChimp to Substack next week – if you don’t get a blog post notification by July 5 check your spam/junk/trash folder. 

Jun
20

Workers’ comp pharmacy – the latest

Posted by Joe Paduda on Thursday, June 20th, 2024 | Comments

We are finishing up our Annual Survey of Pharmacy Benefit Management in Workers’ Comp…here’s three findings from the 15+ we’ve done so far.

1) 60% of respondents are reporting an increase in overall drug spend – with reasons varying from more claims to an uptick in catastrophic cases to jurisdictional impacts.

While we’re a long way from done and more respondent data is coming in, if the trend continues this would be the second year of “non-decrease” in spend, signaling that the years-long drop in spend has stopped – and may have reversed.

This from last year’s Survey…this year’s will include 2022 and 2023 data.

2) Conversely, 80% of respondents are reporting lower opioid spend year over year. If other respondents’ data is consistent, this marks the seventh consecutive year of a decrease – wonderful news indeed as patients and providers choose safer – and often more effective – solutions to pain.
This from last year’s survey

3) Most respondents see a future for AI in the PBM world… but the emphasis is definitely on the future. There seems to be significant hesitation around implementing AI-based tools at this point. Ultimately, respondents see a range of “futures” – ranging from 100% automation of the entire process driven by AI to those who see AI focusing largely on early trend identification and clinical management improvements.

If you woulds like to participate, leave your info in the comment box below.

Public versions of our Annual Survey report are available for download here at no cost and no registration – note respondents get a much more detailed version of the report. 

Thanks to HSA’s Jay Stith and Helen Knight of CompPharma for their work on this year’s Survey.

May
10

Good News Friday…Strong economy, lower drug costs, more jobs in Wisconsin, and no more noncompetes

Posted by Joe Paduda on Friday, May 10th, 2024 | Comments

Lots of really good stuff to end your week…

the Economy…

remains quite good with 175,000 new jobs last month. This was not as many in previous months…

BUT it looks increasingly like (From NYT) “the exuberance of the last two years might be settling into a more sustainable rhythm”.

Stock markets jumped (the Dow is up 723 (!!!) points this week), interest rates declined modestly,

Seniors’ lower drug costs…

Insulin prices are capped at $35 per month, a major reduction from an average of $300…even better, next year President Biden’s Inflation Reduction Act will limit seniors’ out-of-pocket costs for all prescription medications $2,000 per year.

There’s activity in Congress and by the Biden Administration that would limit everyone’s cost – young, old, and in-between – for insulin to no more than $35 a month…here’s hoping the pols get this done.

This means...With diabetes affecting more Americans, improving access to insulin means healthier families and employees, which leads to lower healthcare costs.

More good news…the Medicare Hospital Trust Fund’s financial solvency was extended to 2036, a five year extension. Not to worry, there’s no doubt this will be extended again.

This means…better finances for hospitals and seniors.

Lots more jobs in Wisconsin and…No more noncompetes!

In the “government CAN actually make life better” category,  we have…lots of great jobs coming to Wisconsin…AND a ban on non-competes.

Microsoft is building a giant AI Center near Racine, Wisconsin. The city was hit hard by the collapse of the Foxconn deal which promised gazillions of dollars and jobs…but never happened. Supported by the Investing in America project, this brings new investment why private companies in Wisconsin to $5 billion – and counting.

The Federal Trade Commission effectively banned non-competes...thereby freeing you up to…actually control where you want to work.

Non-competes are contractual controls that effectively prohibit employees from working at specific jobs, customers, or companies for a defined period in exchange for a/some defined “benefit(s).”

This is a MAJOR bonus for anyone working today as it allows you – not some corporate entity – to control your life. And, the rule is quite broad, clearly empowering workers.

This from Harvard Business Review…

“Worker” is defined not just as an employee but also includes independent contractors, externs, interns, volunteers, apprentices, or a sole proprietor who provides a service. The rule also broadly defines noncompete clauses not only as terms or conditions of employment that explicitly prohibit a worker from competing with a former employer, but also to mean any other clauses that “penalize a worker for” or “function to prevent a worker from” competing. With this definition, the FTC also prohibits clauses that operate as de facto noncompetes, including overly broad NDAs, nonsolicitation clauses, and TRAPs — training repayment agreement provisions. [Emphasis added]

Have a most excellent weekend!

Mar
15

Good news Friday – fixing past mistakes, more progress on Medicaid, and lower drug prices

Posted by Joe Paduda on Friday, March 15th, 2024 | Comments

Medicaid

Checking in on Medicaid…41 states have expanded Medicaid, and by dribs and drabs some of the holdouts are moving to do the same.

Georgia may well be the next state to follow suit; a court recently ruled in favor of the Peach State’s approach.

Medicaid is one of those rare programs that delivers way more than it costs – economic impact is strongly positive, beneficiaries are much more likely to be healthy enough to work, clinical outcomes improve…

Oh, and uncompensated care costs drop – a LOT…so health systems and hospitals have less incentive to hoover dollars out of employers’ pockets.

Infrastructure investment – Billions of dollars will be invested to  improve infrastructure in places that need it most. From WaPo:

Earlier this week the White House unveiled $3.3 billion in federal grants to remove or retrofit highways that separate minority neighborhoods in many cities from jobs, entertainment centers, hospitals and other services.

In one of my adopted hometowns – Syracuse – the process is well underway. This rights a wrong done decades ago when politicians steamrolled poor folks in poor neighborhoods to build highways to suburbs.

Employment and long-term care

Yes, healthcare worker staffing is a big issue...the good news is much of the potential shortfall can be addressed by immigrants. 

Longterm care is particularly affected…three out of ten workers in long term care are adult immigrants.

What does this mean for you?

More opportunities, improved health, and more healthcare workers = a better place to live and work and raise a family.

Feb
27

Opioids in workers comp – spend is down a billion dollars.

Posted by Joe Paduda on Tuesday, February 27th, 2024 | Comments

More than 20 years ago I posted this:

Oxycontin in WC

Where are we today?

After a horrific spike in opioid prescribing for workers’ comp, the industry has done a remarkable job reducing unnecessary and inappropriate opioid usage.

Well, except for the Federal Office of Workers’ Compensation Programs, which was way too late to take action.

Leaving OWCP aside (if only we could), here’s a few statistics:

Our annual Survey of Prescription Drug Management has tracked opioid prescriptions for more than a decade.

  • The 2021 Survey showed a 12.5% drop in opioid spend over the previous year.
  • Opioids represented 13.4% of all respondents’ pharmacy spend, the lowest figure in the history of this survey.
  • A decade ago, opioids accounted for 29.4% of drug spend.
  • And, a decade ago drug spend was MUCH higher than it is today.

Net – workers’ comp has reduced opioid spend by roughly a billion dollars over the last decade.

What does this mean for you?

Thousands of lives saved, families preserved, moms and dads alive, kids not orphaned, addictions avoided.

Thanks to all who have done this – you are treasured.

Feb
8

Drug prices and the power of consensus.

Posted by Joe Paduda on Thursday, February 8th, 2024 | Comments

We Americans pay much more for drugs than anyone else.

Those very high prices are a major contributor to increasing health insurance premiums and Federal and state budgets.

Across the political spectrum, Americans support more government regulation of drug pricing.

Good news is Medicare is now actively negotiating drug prices with manufacturers. That will save patients and taxpayers billions of dollars.

What does this mean for you?

When we agree on what is the right thing to do we get things done.

And will save families and taxpayers lots of money.

Nov
3

Good news Friday…paid sick leave. more $ for home care workers, bye yellow pill bottles, and a NEW THING!

Posted by Joe Paduda on Friday, November 3rd, 2023 | Comments

Here’s some of the good stuff happening these days…

The number of workers with paid sick leave has jumped…lowest-wage workers’ access to paid sick leave has nearly doubled from 20% to 39% since 2010 – driven by more states enacting paid sick leave laws, according to a new Economic Policy Institute report. Overall, almost 4 out of 5 U.S. private-sector workers have paid sick leave, up from 3 of 5 in 2010.

Home care workers’ pay is going up...almost every state has bumped up wages for home care workers, a long-needed change that might help ease the hone care staffing crisis.

Know those yellow pill bottles that have been around forever…and will be around almost forever? Almost 200 billion are added to landfills and trash every year… CabinetHealth is pioneering recyclable – and refillable – glass pill containers…a way better way to get your meds.

Ok, leaving aside the obvious positivity – this is definitely facepalm worthy…there’s this NEW THING among Gen Z’ers...a “silent walk”…aka going for a walk without your phone!!

Who woulda thunk it? Just…walking? And yes, a TikTok’er discovered this revolutionary new idea, and it is…trending!!!

Next up…Silent Walking athleisure wear, shoes, hats, and rain gear, maybe logo that says “don’t disturb – Silent walking”.