The US healthcare system is plagued by corruption, and Pharmacy Benefit Managers (PBMs) are taking advantage of it. Express Scripts, the largest PBM, is sending out letters to dozens of clinicians and provider practices warning them of fraud, waste, and abuse for off-label prescribing of FDA-approved drugs. PBMs are making more money than the insurers that own them, and they engage in spread pricing and clawbacks. To become a good consumer of healthcare, David Contorno and Emma Fox suggest price shopping pharmacies, exploring manufacturer assistance programs, using coupons, and international sourcing. Consumers should also be their own advocates and ask their doctor what other options are available.
Episode Outline:
(00:00:00) Express Scripts Fraud
(00:18:21) Prescription Drug Costs
(00:04:45) PBM Profits
(00:13:56) Pharmaceutical Pricing
(00:09:29) Negotiating Drug Prices
Quotes:
(00:07:57) It's a long game, right? It's expensive right now. I get that. But if we're able to cure obesity along with who knows how many other comorbidities, what does that look like ten years from now, right?
(00:21:31) Be your own advocate, because at the end of the day, you're the only one who pays clinically and financially for not being an advocate for yourself.
(00:03:17) But I wish we could find something where literally they were defrauding people. I think that's ultimately what they're doing.
(00:13:17) Every single other country negotiates drug pricing. They say you cannot bring that drug into this country unless you agree to this price. And not only does the US. Not do that, but there's a federal law that says we can't do that.
(00:15:59) The hard part is not having coverage for it, because if you have coverage, but a deductible you can't afford, you don't qualify for this program.
Social Post:
Are you tired of the healthcare system's corruption? Tune in to the Healthcare Hangover podcast with David Contorno and Emma Fox to learn about the shady practices of PBMs (Pharmacy Benefit Managers). Did you know that PBMs are making more money than the insurers that own them? Or that Express Scripts alone manages the pharmacy benefits for nearly a third of the US population? Don't miss this eye-opening episode and learn how to fight back against the healthcare system's corruption. #HealthcareHangover #PBMs #HealthcareSystem
Are you tired of the healthcare system telling you what you can and can't do? Then you need to listen to the latest episode of The Healthcare Hangover podcast! In this episode, David Contorno and Emma Fox discuss the frustrations of dealing with insurance companies and how to get around them. Did you know that you can get the same medication for up to 70% less by importing it from a different country? Tune in to find out more about how to get the most out of your healthcare experience! #TheHealthcareHangover #HealthcareSystem #InsuranceCompanies
Are you struggling to afford your medications? Did you know that there are ways to get name brand drugs for free or at a discounted rate? On the latest episode of The Healthcare Hangover, David Contorno and Emma Fox discuss how the Part D law and Prescription Assistance Programs can help you get the medications you need at a price you can afford. Tune in to learn more about how to get the best deal on your medications! #TheHealthcareHangover #PrescriptionAssistancePrograms #AffordableMedications
Blog Post:
The US healthcare system is in a state of disarray. Pharmacy Benefit Managers (PBMs) are taking advantage of this by sending out letters to dozens of clinicians and provider practices warning them of fraud, waste, and abuse for off-label prescribing of FDA-approved drugs. Express Scripts, the largest PBM, alone manages the pharmacy benefits for roughly 100 million people. It's no surprise that PBMs are making more money than the insurers that own them. They get an admin fee every time a transaction is processed, mark up the drugs, and do clawbacks. Optum, which is owned by UnitedHealthcare, accounts for the majority of their profit.
Doctors are outraged that a PBM would have any right to tell them how to make clinical decisions for their patients. Alex Lickerman supports GLP-1 for weight loss, and it is effective. However, GLP-1 is a lifelong medication, and there are some concerns about it, such as muscle mass loss. Education is missing from these medications. Express Scripts is accusing some providers of falsifying diagnosis of type two diabetes in order to get through the prior authorization process.
It's up to us to become good consumers of healthcare. David Contorno and Emma Fox suggest price shopping pharmacies, exploring manufacturer assistance programs, using coupons, and international sourcing. Consumers should also be their own advocates and ask their doctor what other options are available.
Membership with a PBM such as Drexi can be a great way to save money. Drexi does not do spread pricing or clawbacks, but requires a small monthly fee. When using the Drexi card, the system looks like the consumer has insurance, but the insurance is not paying for anything. Manufacturer assistance programs and coupons are also a great way to save money. It's important to price out pharmacies as prices can vary widely. Employers are making choices for their health plans that can affect the cost of prescription drugs.
The US healthcare system makes money when people are sick, unlike other countries. This is why the pharma industry charges high prices for drugs because they can and still make a profit. However, there are Prescription Assistance Programs (PAP) for name brand drugs for those who don't have coverage. Income limits for PAP vary by drug and number of people in the household. Good RX and Script Co offer discounts on drugs even if you have insurance.
Express Scripts is threatening doctors for trying to get cheaper drugs for patients. Pharmacists have had their clinical roles stripped away due to PBMs deciding what is covered and what is not. Pharmacists can help those without insurance get name brand drugs for free or at a discounted rate. Doctor tweeted a pediatric oncologist in Texas saying he was "sick and tired of these insurance companies telling me what I can prescribe and what I can't prescribe." Insurance companies don't tell doctors what they can and can't prescribe, they just tell them what they're willing to pay for.
Pre-certification and prior authorization are two processes that doctors and patients have to go through. Doctors are burned out because they're "sick and tired of insurance companies telling me what I can do and what I can't do." People can import medications from other countries, such as Canada, UK, New Zealand, or Australia, which are 40-70% less expensive than in the US.
At the end of the day, it's important to be an informed consumer. Ask your doctor what other options are available, look into manufacturer assistance programs and coupons, price out pharmacies, and explore international sourcing. It's also important to be your own advocate and fight against the corruption in the US healthcare system.
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