Saturday, November 16, 2019

Recent News about Bundle Payments, Opioids, and Pharmacy Costs

Balance Billing

Balance billing, the amount patients are charged after their insurance pays, is creating severe financial burdens for consumers facing these unexpected costs, which are often substantial. The practice occurs when providers are out-of-network. Even when a patient does due diligence and seeks care from an in-network facility and physician, a member of the treatment team may not be in-network, resulting in excessive charges.

  • 1 in 10 insured adults aged 18-64 received a balance bill in the past year (Kaiser Health Tracking Poll).
number of insured adults aged 18-64
Figure 1

Balance billing has angered consumers, leading many states to enact legislation to curb the practice. But advocates say that national legislation is needed, and the movement is gathering steam. Consumers, employers, and insurers are uniting to protect patients from surprise bills, recently putting forth guiding principles (AHIP). You can join in to help enact legislation to keep medical costs affordable for your employees, your business, and your bottom-line.


Efforts are underway to fight the opioid epidemic, but we still have a long way to go. Help is on the way thanks to former NY City Mayor Michael Bloomberg’s charity, which is donating $50 million to 10 states (Washington Post). The first state to receive funding is Pennsylvania, which will receive at least $10 million. In 2017:

  • The Keystone state led the nation in death by drug overdose.
  • Nearly 5,400 residents died of drug overdoses, more than double the national average.

Opioid Fraud

According to the Drug Enforcement Administration, heroin, fentanyl, and other opioids remain the highest drug threats to our nation. Unscrupulous providers continue fueling the fire. In Michigan, 6 doctors from Pain Center USA were indicted for alleged insurance fraud and unnecessarily prescribing opioids to Medicare, Medicaid, and Blue Cross Blue Shield patients (NY Times), raking in more than $464 million.

According to the indictment:

  • The doctors prescribed 13.2 million doses of OxyContin, Percocet, Vicodin, and Dilaudid since 2013.
  • They ordered and performed unnecessary services like non-clinicalMRIs, improper prescribing, etc.

figure of alleged insure fraud by Michigan's Pain Center
Figure 2

Rx Formulary Changes Coming in 2019

Prescription drugs continue to be a major cost driver for employers. One way to control costs is to limit the medications covered by your health plan through pharmacy benefit carve-outs. You’re getting help from pharmacy benefit managers (PBMs), who administer Rx benefits for more than 200 million Americans. According to Good Rx, two PBMs, Express Scripts and Caremark, are removing 90+ medications from their 2019 formularies.

Blog posts May 14 and 21, 2018

Using Data Analytics to Manage Your Rx Costs

Drugs Companies Allegedly Colluded to Raise Generic Drug Prices

Generic prescriptions have long been heralded as low-cost alternatives to expensive brand name drugs. But generic drug prices have experienced dramatic increases over the past few years. And that has caught the eye of investigators.

What started as an anti-trust lawsuit has morphed into a class-action suit, with 47 states as plaintiffs (Washington Post). The suit alleges that at least 16 drug companies fixed pricing on 300 generic drugs.

  • Mylan and Sun, both generic manufacturers of albuterol, an asthma drug on the market for decades, are named in a Kroger grocery store lawsuit:
  • The price jumped from 13 cents a tablet to $4.70, a 3,400% increase.

Happy Holidays!

I want to thank all of you for following my blog. My next post will be January 9, 2019. Happy holidays and best wishes for a prosperous new year!

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