PODCAST: Pharma Rebates to PBMs

Pharma ‘Rebate’ Payments to PBMs No Longer Protected by Federal ‘Safe Harbor’

BY DR. ERIC BRICKER MD

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YOUR COMMENTS ARE APPRECIATED.

HEALTH ECONOMICS CITE: https://www.r2library.com/Resource/Title/0826102549

Thank You

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PODCAST: Prescription Patient Assistance Programs

BY ERIC BRICKER MD

With 43 Million Americans Having Lost Their Job at Some Point During the Pandemic and About 1/2 Those Jobs Providing Health Insurance… the 1st Group–People Who Do Not Have Health Insurance–Needs to Be Aware of How These Programs Work.

In this Video You Will Learn the Patient Assistance Program Process for:

1) 2 of the Most Common Types of Insulin

2) The Highest-Revenue Medication in America: Humira

**Note: At the Time of the Video’s Recording, the Unemployment Rate in the US was 15%. As of November 2021, the Unemployment Rate is 4.2%.

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COMMENTS APPRECIATED

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CITE: https://www.r2library.com/Resource/Title/082610254

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PODCASTS: How Prescription [Rx] Coverage Works

Formulary Tiers, PBM, Rebates, Spread-Pricing Explained

By Dr. Eric Bricker MD

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CITE: https://www.r2library.com/Resource/Title/082610254

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YOUR COMMENTS ARE APPRECIATED.

Thank You

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PODCAST: Health Insurance Carrier STOCK EARNINGS CALLS

BY ERIC BRICKER MD

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YOUR COMMENTS ARE APPRECIATED.

CITE: https://www.r2library.com/Resource/Title/0826102549

Thank You

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PODCAST: PBM Formulary Waste Exposed in Commonwealth Fund Study

15 Self-Funded Employers Analyzed Their Pharmacy Claims Data in Conjunction with the Commonwealth Fund and Discovered the Following Regarding their PBM FormularIES

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YOUR THOUGHTS ARE APPRECIATED

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PODCAST: Employee Health Plan MISALIGNMENT with Fee-for-Service Medicine

Current Partners Not Aligned With PLAN Goals

Dr. Boram (Kim) Park, MD - Dallas, TX | Internal Medicine

BY DR. ERIC BRICKER MD

Employee Health Plans Have Have a MISALIGNMENT Problem with the Current Fee-for-Service Healthcare System…i.e. Their Current Partners Are Not Aligned With Their Goals

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Health Insurance Carriers Are Misaligned by Owning PBMs That Make More Money in Rebate Kick-Backs When the Employee Health Plan Spends More Money on Expensive Prescription Drugs.

Doctors Are Misaligned When They *Are Employed by Hospitals That Tie Test and Procedure Ordering Volume to Doctor Compensation.

Hospitals are Misaligned When They Buy Physician Practices and Raise the Prices for In-Office Testing and Procedures by 300%… Even Though NOTHING Has Changed Other Than the Sign on the Door.

Accordingly, True Employee Health Plan Innovation is ALIGNMENT Innovation That Provides Care Outside the of the Status Quo Fee-for-Service System.

Onsite Clinics, Near Site Clinics, Direct Primary Care and Capitated Virtual Care All Provide Real Alignment Innovation for Employee Health Plans.

ASSESSMENT: Your comments are appreciated.

CITE: https://www.r2library.com/Resource/Title/0826102549

THANK YOU

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Insurers, PBMs and Specialty Pharmacies Today

CIRCA: 2019 Vertical Business Relationships

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Conclusion: Your thoughts are appreciated.

Product DetailsProduct DetailsProduct Details

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Here’s Why Drug-Distribution and Pharmacy Stocks are Bargains Now

On Drug-Distribution and Pharmacy Stocks

Vitaliy Katsenelson, CFA
  Student of Life

These pharnacy stocks are good businesses. In general they have solid balance sheets, above-average returns on capital, and they generate a lot of cash, which is used to pay dividends and buy back stock.

But, these defensive features have not mattered much lately, as we are entering the 10th year of uninterrupted economic expansion.

Accordingly, these companies are significantly undervalued. How under valued? Let’s answer that question by examining two stocks in our portfolio in closer detail.

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Prescription Pill Bottles

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Here’s Why Drug-Distribution and Pharmacy Stocks are Bargains Now

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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On PBM Business Practices

Unfair -OR- Not?

[By staff reporters]

PBMs, like Prime Theraputics, Optum, CVS/Caremark, Walgreens/prime Mail and Express Scripts, Bring no value but huge expense to pharmaceutical medication prices.

The Trump administration and Congress must repeal the GPO and PBM safe harbor that allows them to extort pharmaceutical manufacturers to the tune of $200 billion a year.

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Assessment:

Your thoughts are appreciated.

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On PBMs [Pharmacy Benefits Management]

Pharmacy Benefits Management [PBM]

[By staff reporters]

DEFINITION:

In the United States, a pharmacy benefit manager (PBM) is a third-party administrator (TPA) of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program (FEHBP), and state government employee plans. As of 2018 they have become industrial behemoths in the US health sector.

According to the American Pharmacists Association, “PBMs are primarily responsible for developing and maintaining the formulary, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims.

For the most part, they work with self-insured companies and government programs striving to maintain or reduce the pharmacy expenditures of the plan while concurrently trying to improve health care outcomes”.

DICTIONARY

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Now, read this: https://lnkd.in/eV2q2nB

Assessment

Your thoughts are appreciated.

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meds

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HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

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Who Pays for your Medication?

Understanding the Supply-Chain Management [SCM]

By Business Inside

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Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Contact: MarcinkoAdvisors@msn.com

https://www.amazon.com/Financial-Management-Strategies-Healthcare-Organizations/dp/1466558733/ref=sr_1_3?ie=UTF8&qid=1380743521&sr=8-3&keywords=david+marcinko

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With Obama Election Win “Mr. Market” Weighs in on the ACA Equity Winners and Losers

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The Wisdom of Crowds

By David K. Luke MIM, Certified Medical Planner™

Website: www.networthadvice.com

The first trading session following the election on Wednesday, November 7, 2012 gave us some clues on how different sectors of the health care market may be affected by the ACA, as Obama’s win confirms that health reform marches forward. “Mr. Market” has spoken.

“Mr. Market”

For those that may be unaware, “Mr. Market” was Benjamin Graham’s term for the stock market in explaining fluctuations. Graham is the father of value investing and Warren Buffet’s most influential mentor. According to Graham, Mr. Market is emotionally unstable but doesn’t mind being slighted. If Mr. Market’s quotes are ignored, he will be back again tomorrow with a new quote.

So, the point is that successful investors do not place themselves in emotional whirlwinds often created by the market. This first post-election trading session was such a whirlwind. Large groups of people (such as those that voted with their pocketbook in this telling stock market session) are smarter than an elite few, or so goes the premise of James Surowiecki’s Wisdom of the Crowds.

Now; what did we learn from the combined investing public wisdom about the future of healthcare companies profitability with ACA?

Keep in mind the overall market was down 2.4% on the day as measured by both the Dow Jones Industrial Average and the Standard & Poor 500. The biggest concern of the day was investor worry about the so called “fiscal cliff” and the debate over billions in spending and tax increases. Considering the total market on November 7th, health care stocks performed as a group better than the averages, but Mr. Market definitely parsed health care stocks by sector from “great” to “dreadful” based on the implications of impending health care reform:

Great:

Hospital Stocks

  • Health Management Associates (HMA) +7.3%
  • HCA Holdings Inc. (HCA) +9.4%
  • Community Health Systems Inc. (CYH) +6.0%
  • Tenet Healthcare Corp. (THC) +9.6%

Yes, there were stocks that went up stridently on the big down day. Not surprisingly, hospital stocks are expected to benefit from the estimated 30 million Americans who will line up for insurance coverage beginning in 2014, increasing profits and decreasing bad debts.

Medicaid HMOs

  • Molina Healthcare Inc. (MOH) +4.6%
  • Centene Corp. (CNC) +10.1%
  • WellCare Health Plans Inc. (WCG) +4.4%

Health insurers that typically focus heavily on Medicaid are up in line with ACA provisions to expand care for the poor. Mr. Market tips his hat to Centene Corporation, which has been successful in procuring multi-line coverage contracts with States including long-term care, vision, dental, behavioral health, CHIP and disability.

Good:

Drug Wholesalers

  • McKesson (MCK) +1.3%
  • Cardinal Health (CAH) +.5%
  • AmerisourceBergen (ABC) +1.0%

Growth in prescription drug spending means increased revenues for the drug wholesalers, so ACA should be a positive for this group. But because a majority of wholesaler profits come from generic drugs, and because wholesalers are indirectly affected by changes in pharmacies, pricing pressures will keep the wholesalers in check.

Fair:

Pharmacy Benefit Mangers

  • Express Scripts (ESRX) -0.4%
  • CVS Caremark Corp (CVS) -0.4%

As an intermediary between the payor and everyone else in the health-care system, PBMs process prescriptions for groups such as insurance companies and corporations and use their large size to drive down prices. These companies are incentivized to cut costs and have been thought to benefit greatly from ACA, and will expand prescription drug insurance plans sold through health insurance exchanges starting in 2014.

Generic Pharmaceuticals

  • Teva Pharmaceutical Industries Ltd ADR (TEVA) -0.7%
  • Mylan Inc (MYL) -0.8%
  • Dr. Reddy’s Labs (RDY) -0.6%

Health care reform is good for generic drugs with anticipated increased dispensing of drugs in general.  With more funds spent on Medicaid, the ACA will certainly be generic oriented and should fare better than the name-brand drugs. Pricing pressures are expected over the longer term however.

Testing Laboratories

  • Quest Diagnostics (DGX) -1.5%
  • Laboratory Corp of America (LH) -1.9%

More patients you would think would mean more medical tests. In a recent Gallup survey, physicians attributed 34 percent of overall healthcare costs to defensive medicine (think diagnostic blood tests/invasive biopsies, etc). ACA may curb this expensive part of medicine and appears to have very negative implications going forward as Labs will have intense pressure to reduce rates. However, these larger labs held up better than the market averages suggesting that lab work isn’t going away with ACA.

Big Pharmaceutical Companies

  • Pfizer Inc.  (PFE) -2.2%
  • GlaxoSmithKline PLC (GSK) -0.8%
  • Eli Lily & Co. (LLY) -1.2%

The name-brand large Pharmaceutical companies have agreed to rebate Uncle Sam on Medicaid purchases and must give the elderly discounts. But there will be a lot more of us taking drugs too.

I’ve ranked these 4 health care sectors “fair” considering that broader stock market averages were down 2.4% for the day and Mr. Market was kinder to this group with only a slight negative. Likewise, it appears that he is anointing this group as a benefactor of upcoming reforms.

Not Good:

Medical Device Companies

  • Medtronic Inc. (MDT) -3.0%
  • Stryker Corporation (SYK) -1.6%
  • Boston Scientific Corp. (BSX) -3.6%
  • Zimmer Holdings Inc. (ZMH) -1.8%

The 2.3% excise tax on revenue of medical-device companies is looking more inevitable, in spite of industry lobbying group efforts.

Dreadful:

Medicare Part D Companies

  • Humana Inc. (HUM) -7.9%
  • WellPoint (WLP) -5.5%
  • Cigna Corp. (CI) -0.7%

Even though managed-care companies should gain millions of new customers thanks to the ACA, profit margins are expected to decline significantly.  Mr. Market went easy on Cigna, perhaps because of the company’s focus on self-insured large employers.

Currently

Currently it is unclear how the increased revenue generated from more patients will affect the increased margins to the various sectors of the healthcare market. Also, too much weight should not be placed on this one day action by the market. One thing is clear however, and that is how Mr. Market and the market at large feels at first blush towards the impending implementation of the ACA based on the November 7, 2012 trading of the respective stocks.

Assessment

Remember: Mr. Market is temperamental and can change his mind anytime!

About the Author:

David K. Luke MIM, a Certified Medical Planner™, focuses on helping physicians, medical professionals, and successful retirees with financial planning, investment and risk management. He directs physicians through their complex planning needs, helping them foster a better medical practice and lifestyle. David is a fee-only financial planner.

Disclosure:

Percentage changes in price of stocks represent published change in price from closing price November 6, 2012 to closing price November 7, 2012. Stocks listed here are not considered to be past, present or future recommendations to buy or sell securities and is for educational purposes only. This information should NOT be considered as investment recommendations or advice but rather summary comments and opinions on the health care market by David K. Luke, MIM CMP™, who is entirely responsible for the contents of this article.

Link: www.CertifiedMedicalPlanner.org

Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Prescription Data-Mines and Insurance “Credit-Reports”

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The End to “Rx” Privacy? 

[By Staff Reporters}

Collecting and analyzing [HIPAA protected?] personal health information [PHI] in commercial databases is a fledgling, but exploding industry, despite privacy concerns.

Industry Leaders

For example, Milliman’s IntelliScript provides personal drug profiles to insurers. And, Ingenix’s MedPoint is owned by UnitedHealth, the corporation that owns UnitedHealthCare. UHC is also the nation’s second-largest health insurance company.

Large Data Bases

Both firms created their large profiles by mining rich databases of prescription drug histories [eRXs], kept by pharmacy benefit managers [PBMs], which help insurer’s process drug claims. The data-base then aggregates and ranks the information, based on the drugs and dosages, dates filled and refilled, therapeutic class, and the name and address of prescribing doctor; etc. Higher scores imply higher health insurance premium costs.

Thus, prescription data is used to “rate” or economically judge potential insured patients via these “health credit-reports.”

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matrix pills

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Assessment

And so, while politician’s debate how to regulate electronic medical records [EMRs], and attorneys monitor HIPAA policies, some health insurers have already begun tapping into other information sources such as clinical and pathological laboratories, as well. And, other sources are sure to follow.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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