#Express Scripts

[mostlysignssomeportents]

What the fuck is a PBM?

TOMORROW (Sept 24), I'll be speaking IN PERSON at the BOSTON PUBLIC LIBRARY!

Terminal-stage capitalism owes its long senescence to its many defensive mechanisms, and it's only by defeating these that we can put it out of its misery. "The Shield of Boringness" is one of the necrocapitalist's most effective defenses, so it behooves us to attack it head-on.

The Shield of Boringness is Dana Claire's extremely useful term for anything so dull that you simply can't hold any conception of it in your mind for any length of time. In the finance sector, they call this "MEGO," which stands for "My Eyes Glaze Over," a term of art for financial arrangements made so performatively complex that only the most exquisitely melted brain-geniuses can hope to unravel their spaghetti logic. The rest of us are meant to simply heft those thick, dense prospectuses in two hands, shrug, and assume, "a pile of shit this big must have a pony under it."

MEGO and its Shield of Boringness are key to all of terminal-stage capitalism's stupidest scams. Cloaking obvious swindles in a lot of complex language and Byzantine payment schemes can make them seem respectable just long enough for the scammers to relieve you of all your inconvenient cash and assets, though, eventually, you're bound to notice that something is missing.

If you spent the years leading up to the Great Financial Crisis baffled by "CDOs," "synthetic CDOs," "ARMs" and other swindler nonsense, you experienced the Shield of Boringness. If you bet your house and/or your retirement savings on these things, you experienced MEGO. If, after the bubble popped, you finally came to understand that these "exotic financial instruments" were just scams, you experienced Stein's Law ("anything that can't go forever eventually stops"). If today you no longer remember what a CDO is, you are once again experiencing the Shield of Boringness.

As bad as 2008 was, it wasn't even close to the end of terminal stage capitalism. The market has soldiered on, with complex swindles like carbon offset trading, metaverse, cryptocurrency, financialized solar installation, and (of course) AI. In addition to these new swindles, we're still playing the hits, finding new ways to make the worst scams of the 2000s even worse.

That brings me to the American health industry, and the absurdly complex, ridiculously corrupt Pharmacy Benefit Managers (PBMs), a pathology that has only metastasized since 2008.

On at least 20 separate occasions, I have taken it upon myself to figure out how the PBM swindle works, and nevertheless, every time they come up, I have to go back and figure it out again, because PBMs have the most powerful Shield of Boringness out of the whole Monster Manual of terminal-stage capitalism's trash mobs.

PBMs are back in the news because the FTC is now suing the largest of these for their role in ripping off diabetics with sky-high insulin prices. This has kicked off a fresh round of "what the fuck is a PBM, anyway?" explainers of extremely variable quality. Unsurprisingly, the best of these comes from Matt Stoller:

https://www.thebignewsletter.com/p/monopoly-round-up-lina-khan-pharma

Stoller starts by pointing out that Americans have a proud tradition of getting phucked by pharma companies. As far back as the 1950s, Tennessee Senator Estes Kefauver was holding hearings on the scams that pharma companies were using to ensure that Americans paid more for their pills than virtually anyone else in the world.

But since the 2010s, Americans have found themselves paying eye-popping, sky-high, ridiculous drug prices. Eli Lilly's Humolog insulin sold for $21 in 1999; by 2017, the price was $274 – a 1,200% increase! This isn't your grampa's price gouging!

Where do these absurd prices come from? The story starts in the 2000s, when the GW Bush administration encouraged health insurers to create "high deductible" plans, where patients were expected to pay out of pocket for receiving care, until they hit a multi-thousand-dollar threshold, and then their insurance would kick in. Along with "co-pays" and other junk fees, these deductibles were called "cost sharing," and they were sold as a way to prevent the "abuse" of the health care system.

The economists who crafted terminal-stage capitalism's intellectual rationalizations claimed the reason Americans paid so much more for health care than their socialized-medicine using cousins in the rest of the world had nothing to do with the fact that America treats health as a source of profits, while the rest of the world treats health as a human right.

No, the actual root of America's health industry's problems was the moral defects of Americans. Because insured Americans could just go see the doctor whenever they felt like it, they had no incentive to minimize their use of the system. Any time one of these unhinged hypochondriacs got a little sniffle, they could treat themselves to a doctor's visit, enjoying those waiting-room magazines and the pleasure of arranging a sick day with HR, without bearing any of the true costs:

https://pluralistic.net/2021/06/27/the-doctrine-of-moral-hazard/

"Cost sharing" was supposed to create "skin in the game" for every insured American, creating a little pain-point that stung you every time you thought about treating yourself to a luxurious doctor's visit. Now, these payments bit hardest on the poorest workers, because if you're making minimum wage, at $10 co-pay hurts a lot more than it does if you're making six figures. What's more, VPs and the C-suite were offered "gold-plated" plans with low/no deductibles or co-pays, because executives understand the value of a dollar in the way that mere working slobs can't ever hope to comprehend. They can be trusted to only use the doctor when it's truly warranted.

So now you have these high-deductible plans creeping into every workplace. Then along comes Obama and the Affordable Care Act, a compromise that maintains health care as a for-profit enterprise (still not a human right!) but seeks to create universal coverage by requiring every American to buy a plan, requiring insurers to offer plans to every American, and uses public money to subsidize the for-profit health industry to glue it together.

Predictably, the cheapest insurance offered on the Obamacare exchanges – and ultimately, by employers – had sky-high deductibles and co-pays. That way, insurers could pocket a fat public subsidy, offer an "insurance" plan that was cheap enough for even the most marginally employed people to afford, but still offer no coverage until their customers had spent thousands of dollars out-of-pocket in a given year.

That's the background: GWB created high-deductible plans, Obama supercharged them. Keep that in your mind as we go through the MEGO procedures of the PBM sector.

Your insurer has a list of drugs they'll cover, called the "formulary." The formulary also specifies how much the insurance company is willing to pay your pharmacist for these drugs. Creating the formulary and paying pharmacies for dispensing drugs is a lot of tedious work, and insurance outsources this to third parties, called – wait for it – Pharmacy Benefits Managers.

The prices in the formulary the PBM prepares for your insurance company are called the "list prices." These are meant to represent the "sticker price" of the drug, what a pharmacist would charge you if you wandered in off the street with no insurance, but somehow in possession of a valid prescription.

But, as Stoller writes, these "list prices" aren't actually ever charged to anyone. The list price is like the "full price" on the pricetags at a discount furniture place where everything is always "on sale" at 50% off – and whose semi-disposable sofas and balsa-wood dining room chairs are never actually sold at full price.

One theoretical advantage of a PBM is that it can get lower prices because it bargains for all the people in a given insurer's plan. If you're the pharma giant Sanofi and you want your Lantus insulin to be available to any of the people who must use OptumRX's formulary, you have to convince OptumRX to include you in that formulary.

OptumRX – like all PBMs – demands "rebates" from pharma companies if they want to be included in the formulary. On its face, this is similar to the practices of, say, NICE – the UK agency that bargains for medicine on behalf of the NHS, which also bargains with pharma companies for access to everyone in the UK and gets very good deals as a result.

But OptumRX doesn't bargain for a lower list price. They bargain for a bigger rebate. That means that the "price" is still very high, but OptumRX ends up paying a tiny fraction of it, thanks to that rebate. In the OptumRX formulary, Lantus insulin lists for $403. But Sanofi, who make Lantus, rebate $339 of that to OptumRX, leaving just $64 for Lantus.

Here's where the scam hits. Your insurer charges you a deductible based on the list price – $404 – not on the $64 that OptumRX actually pays for your insulin. If you're in a high-deductible plan and you haven't met your cap yet, you're going to pay $404 for your insulin, even though the actual price for it is $64.

Now, you'd think that your insurer would put a stop to this. They chose the PBM, the PBM is ripping off their customers, so it's their job to smack the PBM around and make it cut this shit out. So why would the insurers tolerate this nonsense?

Here's why: the PBMs are divisions of the big health insurance companies. Unitedhealth owns OptumRx; Aetna owns Caremark, and Cigna owns Expressscripts. So it's not the PBM that's ripping you off, it's your own insurance company. They're not just making you pay for drugs that you're supposedly covered for – they're pocketing the deductible you pay for those drugs.

Now, there's one more entity with power over the PBM that you'd hope would step in on your behalf: your boss. After all, your employer is the entity that actually chooses the insurer and negotiates with them on your behalf. Your boss is in the driver's seat; you're just along for the ride.

It would be pretty funny if the answer to this was that the health insurance company bought your employer, too, and so your boss, the PBM and the insurer were all the same guy, busily swapping hats, paying for a call center full of tormented drones who each have three phones on their desks: one labeled "insurer"; the second, "PBM" and the final one "HR."

But no, the insurers haven't bought out the company you work for (yet). Rather, they've bought off your boss – they're sharing kickbacks with your employer for all the deductibles and co-pays you're being suckered into paying. There's so much money (your money) sloshing around in the PBM scamoverse that anytime someone might get in the way of you being ripped off, they just get cut in for a share of the loot.

That is how the PBM scam works: they're fronts for health insurers who exploit the existence of high-deductible plans in order to get huge kickbacks from pharma makers, and massive fees from you. They split the loot with your boss, whose payout goes up when you get screwed harder.

But wait, there's more! After all, Big Pharma isn't some kind of easily pushed-around weakling. They're big. Why don't they push back against these massive rebates? Because they can afford to pay bribes and smaller companies making cheaper drugs can't. Whether it's a little biotech upstart with a cheaper molecule, or a generics maker who's producing drugs at a fraction of the list price, they just don't have the giant cash reserves it takes to buy their way into the PBMs' formularies. Doubtless, the Big Pharma companies would prefer to pay smaller kickbacks, but from Big Pharma's perspective, the optimum amount of bribes extracted by a PBM isn't zero – far from it. For Big Pharma, the optimal number is one cent higher than "the maximum amount of bribes that a smaller company can afford."

The purpose of a system is what it does. The PBM system makes sure that Americans only have access to the most expensive drugs, and that they pay the highest possible prices for them, and this enriches both insurance companies and employers, while protecting the Big Pharma cartel from upstarts.

Which is why the FTC is suing the PBMs for price-fixing. As Stoller points out, they're using their powers under Section 5 of the FTC Act here, which allows them to shut down "unfair methods of competition":

https://pluralistic.net/2023/01/10/the-courage-to-govern/#whos-in-charge

The case will be adjudicated by an administrative law judge, in a process that's much faster than a federal court case. Once the FTC proves that the PBM scam is illegal when applied to insulin, they'll have a much easier time attacking the scam when it comes to every other drug (the insulin scam has just about run its course, with federally mandated $35 insulin coming online, just as a generation of post-insulin diabetes treatments hit the market).

Obviously the PBMs aren't taking this lying down. Cigna/Expressscripts has actually sued the FTC for libel over the market study it conducted, in which the agency described in pitiless, factual detail how Cigna was ripping us all off. The case is being fought by a low-level Reagan-era monster named Rick Rule, whom Stoller characterizes as a guy who "hangs around in bars and picks up lonely multi-national corporations" (!!).

The libel claim is a nonstarter, but it's still wild. It's like one of those movies where they want to show you how bad the cockroaches are, so there's a bit where the exterminator shows up and the roaches form a chorus line and do a kind of Busby Berkeley number:

https://www.46brooklyn.com/news/2024-09-20-the-carlton-report

So here we are: the FTC has set out to euthanize some rentiers, ridding the world of a layer of useless economic middlemen whose sole reason for existing is to make pharmaceuticals as expensive as possible, by colluding with the pharma cartel, the insurance cartel and your boss. This conspiracy exists in plain sight, hidden by the Shield of Boringness. If I've done my job, you now understand how this MEGO scam works – and if you forget all that ten minutes later (as is likely, given the nature of MEGO), that's OK: just remember that this thing is a giant fucking scam, and if you ever need to refresh yourself on the details, you can always re-read this post.

The paperback edition of The Lost Cause, my nationally bestselling, hopeful solarpunk novel is out this month!

If you'd like an essay-formatted version of this post to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:

https://pluralistic.net/2024/09/23/shield-of-boringness/#some-men-rob-you-with-a-fountain-pen

Image: Flying Logos (modified) https://commons.wikimedia.org/wiki/File:Over_$1,000,000_dollars_in_USD_$100_bill_stacks.png

CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0/deed.en

[rogue-ai-cat]

"It is important to note that CVS got big through a series of acquisitions and not due to its quality of service."

It is also important to note that CVS owns Aetna health insurance AND it owns Caremark (a Prescription Benefits Manager, which determines which drugs will be accessible to customers and where) AND it owns multiple chains of doctors offices. TALK ABOUT CONFLICTS OF INTEREST. CVS is being investigated by the DOJ for violating antitrust law and suspected Medicare overcharging.

And CVS/Aetna isn't the only megaprovider threatening the safety of its patients. UnitedHealth Group owns United Healthcare, OptumRx (PBM), Optum Health (doctors offices), and has a deal with Walgreens through their Medicare Advantage plan. UHG is also being investigated by the DOJ for violating antitrust regulations and Medicare billing practices on suspicion of doctors mischaracterizing patients illnesses to increase payments from the government.

And Cigna owns PBM and prescription mailing service Express Scripts. They do not own any doctors offices or brick and mortar pharmacies. Cigna is not being investigated by the DOJ at the moment, but they are trying to buy Humana (a Medicare advantage provider), which shows their vested interest in becoming like the other two megaproviders.

All 3 companies' respective Prescription Benefits Managers are suing the FTC for trying to stop them from overcharging for insulin.

[vaguely-concerned]

lucanis is a 'I could sit in our quiet kitchen on a grey tuesday afternoon drinking coffee and talking with you about nothing much in particular forever and be the happiest man who ever lived' romantic, not a 'classic tropes and grand gestures' romantic. this is a distinction and conceptual gap I personally feel is crucial to understanding what's going on with him when romanced. for all his almost painful sincerity and clear depth of feeling he's not a very effusive guy by nature, but in the history of time no one has ever, with their whole soul, chest and being, been so genuinely and openly happy to just do laundry and taxes with you.

[pesky--dust]

Tbh, for a very long time I thought that the ending of Su-zakana was not addressed in any way later.

But some time ago I realized how dumb I am. Of course it is addressed, and it is addressed at the very beginning of the next episode:

WILL'S FUCKIN' DREAM. THIS IS A CONSEQUENCE OF THE EVENTS FROM THE END OF SU-ZAKANA.

[tharatorns]

In my view, the fabric that represents Kueakiat's feeling for Lady Pin is like a fine and elegant silk with expensive value. Then, are you able to see the fabric which represents my feeling for Lady Pin?

Becky Armstrong as PRINCESS ANIN THE LOYAL PIN | EP. 12

[cirnogaming]

artemis is one of the best characters ever created i think. she likes to feel like a cobb salad when shes having sex. she serves cunt at all hours of the day. shes bisexual. shes jewish. she's always serving a look. she is constantly on psychedelic drugs. she fucks nasty in the dumpster behind wendy's. shes perfect

[themojaveexpress]

God, just thinking about Kellogg pointing a firearm at an unarmed, disoriented parent while some fucking weak ass dipshit nerd pathetically tries to wrestle a baby out of their frozen arms.

First of all, WHY is the institute person SO weak?? They should not be playing tug-of-war at all, just fucking take the goddamn baby. Sure, they're no mercenary, but they also haven't been frozen for 200 years - when the player gets out they collapse to the floor immediately! Just watching them yank and pull at Shaun is hilarious, they treat him like a football. That scene needs Benny Hill music playing over it.

The more likely outcome of that whole shitshow is Kellogg accidentally blows the baby's brains out, OR the baby gets dropped - because the parent and the scientist are fucking jostling around like a couple of siblings fighting over who gets to play with the new toy.

Also why is Kellogg even there if his only course of action for an uncooperative parent was shooting them. They may as well have sent literally any goon with the scientist if that was an acceptable result.

[waxxxwork]

if I think too much about the transition in the script between “the most anger he’s ever expressed to his father” and Kendall immediately playfully hitting Roman like “something from childhood” I will just vaporize from grief

[saryuuchan]

THEY FREAKING KISSED ALREADY???

[cluster-b-culture-is]

aspd culture is reading neurotypical people’s sympathy messages online and seeing that they’re just full of buzzwords and sound super robotic

“Crossing our fingers🥺 such a tough situation. My heart goes out to…” etc

.

[mus1ca1]

(human au)

i may be deeply uncomfortable with how they've written this character but man is she pretty

[amokslime]

Hey! It's me! I'm beyond excited to finally be able to show you my cover art for the @kamehamehamlet script.

Thank you so much, Daniel, for commissioning me to draw two of my favorite characters of all time, during my favorite arc of the series. And a massive thank you to whichever tumblr user/s reached out to ask him about it. Now I'll get to experience a play I never thought I'd get to see again. Seeing it all those years ago really did pull me out of the most difficult art slump of my life. Seeing the actors have so much fun, while being so emotionally sensitive, made me remember why I fell in love with making art in the first place. So I'm really looking forward to reading the script and seeing the staged reading! I hope we can all enjoy it together.

Here's the latest informational post about the script. Please take a look, and please reblog to make everybody look at my drawings of vegeta to make sure all the folks who are lamenting that they missed it get their chance.

[akkivee]

KUUKOU DOES THE HAYAMA SPIN 😭😭😭😭😭😭😭😭😭😭😭😭😭😭

[clumsypuppy]

i love reading what ppl have to say abt my work and then going back and trying to find what they saw too <3

[transpat]

realizing that the lilac betting convo was them having three different conversations at once.

yoon jiwon who's been unsettled the whole week bc of seok jiwon's reappearance was now just totally and utterly humiliated bc seok jiwon witnessed her rejection and breakdown (actually going to talk about that in a separate post). if it isn't entirely obv btw the reason she was crying is actually seok jiwon.

(her whole line is 'i'm crying because these days...')

and then,

'To laugh at me?' obv seok jiwon hasn't even thought of that and probably can't add 2 and 2 together. but to yoon jiwon who was an over achiever in high school, always better than seok jiwon the only person she cared about being better than, and is then dumped wordlessly and cruelly by him, her current living situation compared to his are. embarrassing. she normally doesn't care being not that well off financially but again, this is seok jiwon. everything matters when it comes to him.

anyway, her saying 'he's ruining everything her grandfather worked for' is the only valid excuse she has to shit on this man now. there's so many things she wants to complain about, to scream at him about, but he just abandoned her, left without a word, never picked up a single one of her hundred calls and admitting she's anxious bc he came back would only further add to her humiliation.

insisting the lilacs won't bloom again is like saying, 'anything u touch will be doomed'.

seok jiwon on the other hand, is talking about their romance.

unlike yoon jiwon who's had zero contact w this guy for years and thus believes it'd be both mortifying and insane to still harbor feelings for the dude, hence her vehement denial in the consecutive eps, seok jiwon's seen her at her most miserable and vulnerable. it's why he's never been able to move on no matter how painful this is for him, why he's never been able to love any one else even thou yoon jiwon no longer wants him. in fact, him refusing to come back was precisely bc he knew his presence would only upset her, esp involved in a project that is already destroying her grandfather.

it's only when he's told she possibly forgot about him, that he abandons all reason and runs back. and to his relief—initially—she has not forgotten about him at all. no, rather he's come back to hear her say all of this instead.

(he never said he hated her.)

the lilac is barren, the lilac hasn't bloomed in years, the lilac is probably dead—there are no feelings between us, it's been way too many years, after everything that happened there's no way we'd ever fall in love again. that's what he's hearing.

this is also the girl who dumped him over a tiny little fight and refused to ever see him again no matter how many times he tried to reach out to her. this is also the girl he's still in love w. and he just heard her admit to liking someone else and then spit at the idea of them being together.

his words: 'it's not withered or dead', he still has feelings for her and since she feels so strongly about him, he's dying to know if there truly isn't any love in her opinion; 'this is the 5th year not the 40th', even if it's been almost two decades, it wasn't enough for him to forget about her, after what she did to him, was it that easy for her to move on or did she ever think about him, did she ever regret.

insisting the lilacs will bloom, is him trying to convince himself she still loves or still can love him.

and so the bet conditions:

she wants him gone from her life so she can stop feeling so pathetic and embarrassed about herself and her situation and her somehow persisting feelings for him. she loved him for so, so many years, that even if she's in denial now and thinks she isn't in love with him, seok jiwon's long become a part of her self. and she's convinced the only way she can evict him from her heart, is to evict him from her town first.

he wants to know, once and for all, if yoon jiwon truly truly hates him and will never hold an ounce of emotion towards him again. he needs to see for himself if yoon jiwon doesn't regret their breakup at all, if she's never thought of him in all those 18 years, if she really doesn't love him for all. it's the only way he'll be able to move on.

tldr; the lilacs convo was yoon jiwon's metaphoric way of saying seok jiwon ruins everything (she talks about her grandfather but means her heart) and seok jiwon's way of saying a love as deep as there's was can't die no matter how many years have passed and will bloom again, and the rest of the room only now realizing how fucking insane these both are.

p.s. maeng sua spends a lot of time joking about how jiwon must be confusing her feelings of affection for him as hatred and how hate and love are two sides of the same coin and blah blah blah, but it's only now that she realizes her jokes were on point and she looks scandalized.

she's seen yoon jiwon screaming and kicking at the man but this is what made her jaw drop.

and this is where she realizes that yoon jiwon becoming animated and childish and talkative and lively over the past week was bc she'd finally met someone who matched her freak.

she's the only one excited about the bet lol. funnily, she also stops joking about seok jiwon being her type after this and once she snuffs out gong minsu's feelings for yoon jiwon, she turns her flirty jokes on him instead.

[towersofviolet]

i think sam's intro/outro speeches could cure me of any ailment