#medicaredisadvantage

[aunti-christ-ine]

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A post shared by Ady Barkan (@adybarkan)

Change IS possible.

Thank you, @SenJeffMerkley, for sharing your thoughts about why all elected leaders should take a hard look at Medicare “Advantage” (aka "Part C").

SEE ALSO AT-- https://twitter.com/AdyBarkan/status/1712483274613018858

Merkley had until recently been supportive of private Advantage plans, but changed his mind following investigative reports on rampant billing fraud and widespread delays and denials of care. Watch the full interview with @AdyBarkan to hear about his evolution on the issue.

#MedicareAdvantage #MedicareDisAdvantage

[arthritiscenterstl]

Profits Over Patient Care

The Affordable Care Act was curated to improve access to health insurance, and it did. It reduced the number of Americans who were uninsured through the Medicaid expansion and the creation of the health insurance marketplaces. Unfortunately, what it did not do was protect people from rising out-of-pocket expenses in the form of deductibles, copays and coinsurance. PBMs (Pharmacy Benefit Managers) are putting their profits before your medications and health. " Insurers and their PBMs decide what medicines are covered, what medicines aren’t and what you pay for them. Regardless of what your doctors prescribed. Which leaves you fighting them for your medicines, instead of fighting your illness." states PHRMA For services like hospital stays and doctor visits, health plans routinely share the negotiated prices they receive with patients. When it comes to life saving medicines, that is not the case. Health insurers and pharmacy benefit managers have shifted more health care costs to patients through higher deductibles and coinsurance. Commercially insured patients with a deductible have seen their out-of-pocket costs for brand medicines increase 50% since 2014. Most drug companies offer patient assistance programs to help patients that are insured afford out of pocket costs associated with their insurance coverage for their medications or treatments. Unfortunately, health insurers and pbm's are using malicious tactics to deny patients the benefit of this assistance at the pharmacy. Out-of-pocket costs occur only if a person uses their insurance to obtain health care, we also consider the deductible when determining whether someone is underinsured. The deductible is an indicator of the financial protection that a health plan offers as well as the risk of incurring costs before a person gets health care. The average insurance deductible for employer health plans with single coverage is more than $1,000 ($1,434 for all covered workers in 2021), and it’s more than $2,000 ($2,825) for HealthCare.gov marketplace plans. Out-of-pocket maximums average $4,272 for single coverage in employer plans and range up to $8,700 in marketplace plans.

Commonwealth orchestrated a survey last year, between March and July where they interviewed 8,022 adults between ages 18-65. They considered a person underinsured if they experienced one of three circumstances:

Excluding health insurance premiums, an individual during the previous 12 months faced out-of-pocket health expenses amounting to at least 10% of the household’s income.

Out-of-pocket costs apart from premiums over the previous year were at least 5% of a household’s income for an individual whose income was under 200% of the federal poverty line (in 2022, that is $27,180 for an individual or $55,500 for a family of four).

The health plan’s deductible requirement constituted 5% or more of the household income.

The survey demonstrated that more than 40% of people who obtained individual plans for 2022, including those purchasing plans on the Affordable Care Act marketplaces, were underinsured as well as almost 30% of those whose healthcare is through their employer. To anyone that does not physically work in a medical field, insurance is pretty black and white. Unfortunately, that is not the case when it comes to insurance policies, there's a lot more gray that many people overlook. I was someone who did not understand the backside of insurance and would make the assumption that if my bill were too high, that doctor was charging too much.I didn't realize that the insurance companies had preferred medications, co insurance, and could enforce a medication be used for your treatment instead of the prescription your doctor suggested would work best for your treatment.

Originally intended to process claims on behalf of clients, PBMs profit at every stage of the supply chain from drug maker to patient. They are often called the “invisible middleman” because they are hidden between the patient’s insurance company, who the PBM works for, and the pharmacy, who the PBM reimburses for dispensing the prescription. Currently the three largest PBMs are Fortune 500 companies and control nearly 80% of the prescription benefits market in the United States. PBMs take the decision making out of the hands of doctors and their patients.

Barriers: Even if a doctor prescribes a medication, patients face barriers when trying to access that medication. That’s because a PBM may have a financial incentive to steer patients to other medications that are more profitable for the PBM but not in the best interest of the patient.

No Choice: PBMs pick medications that are allowed to be included on the list of prescription drugs covered by a prescription drug plan. This limits patients’ choice and incentivizes PBMs to place profits above patients.

PBM-Owned Pharmacies: PBMs require or financially steer patients to use the large pharmacies they own or have affiliations with rather than allowing patients to use their local pharmacy of choice.

Rebates: PBMs refuse to share rebates and discounts from pharmaceutical companies directly with patients at the pharmacy counter. Instead, they keep the savings for themselves. I would much rather my physician who is informed on my clinical background make the medical decisions, not some pharmacy benefit manager that hasn't spoken to me a day in my life. The fact that they have the ability to deny patients their prescribed medication due to formulary restrictions (that insurer doesn't have a contract with the drug manufacturer so they do not make as much money back.)

Prescription list prices are generally far above a pharmacy’s actual net acquisition cost. That’s because a pharmacy benefit manager (PBM) will not reimburse a pharmacy above the pharmacy's U&C list price. PBMs no longer simply negotiate drug prices on behalf of their clients, but rather fully administer the drug benefit creating formularies, making coverage decisions, and determining medical necessity with utilization management tools. "The PBM market is highly concentrated: three PBMs – Express Scripts, CVS Caremark and OptumRx – control more than 70 percent of the market.These three PBMs, by representing somany covered lives, have substantial bargaining power in their negotiations with drug manufacturers. Complicating the market concentration is the trend toward PBMs merging with health insurers, and how that could impact pharmacy networks available to patients. CVS-Aetna announced their proposed merger in December of 2017. The US Department of Justice (DOJ) has approved the CVS-Aetna merger, contingent on a federal court approving a settlement in which Aetna has agreed to divest its Medicare Part D prescription drug plan business. At the time this report was written, a federal court is reviewing that settlement. Cigna-Express Scripts announced their intention to combine in March of 2018. The Cigna-Express Scripts merger has been approved and is being consummated. Pertaining to PBM operations, the health insurers in these instances are trying to merge with the entity that is providing them with PBM and pharmacy services. Concerns have been raised by the AMA and others that the CVS-Aetna merger could substantially lessen competition in PBM services, health insurance, retail pharmacy, Medicare Part D, and specialty pharmacy." (CMS Rep. 5-A-19 -- page 2 of 10) “I don’t know why the hell they even exist,” said Sen. Jon Tester, D-Montana. “There is no transparency in PBMs. When you combine that with non-compete tactics, this is a recipe where the only people who win in healthcare costs are PBMs.” PBMs are the single biggest influence on the surging price of prescriptions.

Patients shouldn’t be denied access to life-saving medicines by PBMs or insurance companies – especially those medications prescribed by their doctor. PBM-negotiated savings should go to patients at the pharmacy counter to begin reducing out-of-pocket costs for the millions of Americans who need medication and face financial challenges. Business decisions shouldn’t come at the expense of our health. These patient principles establish a simple, straightforward way to emphasize transparency and build upon the clinician-patient relationship to achieve real savings.

There’s only one option: Let doctors and patients decide.