Tuesday, July 25, 2023

Drug Channels News Roundup, July 2023: GoodRx + CVS Caremark, Accumulators vs. Patients, Hospitals vs. Taxes, and UnitedHealthcare Prior Auth Humor

Let’s cut through the steamy summer haze with Drug Channels’ refreshing breeze of questions for you to ponder while on your favorite pink beach:
  • Why does the biggest PBM need a discount card partner?
  • How do copay accumulators affect prescription adherence?
  • Do nonprofit hospitals deserve their tax exemption?
Plus, Dr. Glaucomflecken asks: What would happen if UnitedHealthcare hired physicians who practiced evidence-based medicine?

P.S. Join my more than 43,000 LinkedIn followers for daily links to neat stuff. You can also find my daily posts at @DrugChannels on Twitter, where I have more than 16,600 followers. (I recommend that you follow me on LinkedIn, because the quality of comments and engagement is much higher than they are on Twitter. I’m not posting to Threads yet.)

CVS Caremark and GoodRx to launch Caremark® Cost Saver™ to help lower out-of-pocket drug costs for CVS Caremark clients' members , PR Newswire

Hmm. CVS Health’s Caremark pharmacy benefit manager (PBM) will now incorporate the GoodRx discount card into its pharmacy benefits offering.

Presumably, some beneficiaries’ out-of-pocket costs will be lower with a discount card than under their PBM-managed benefit plan. That’s because GoodRx will allow patients to access the network rates of another PBM—or possibly even the rates of another network from CVS Caremark. I wonder how many people have been overpaying uncer a Caremark plans? (The figure was 1 in 10 for OptumRx.)

In Behind the GoodRx-Express Scripts Partnership: How PBMs Profit from Discount Cards in Pharmacy Benefits, I explained how placing discount cards within the pharmacy benefit enables a PBM to monetize a new fee stream from the card vendor. The complex and opaque financial flows between and among PBMs and discount card vendors continue to flummox me—and should concern pharmacies and plan sponsors.

For more on these developments, watch a replay of Discount Cards, Cost-Plus Pharmacies, and PBMs: Trends, Controversies, and Outlook or read Sections 4.3. and 12.4.3. of The 2023 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

Patient Liability and Treatment Adherence/Persistence Associated with State Bans on Copay Accumulator Programs, Sheinson, D., et al

This research study leverages variance in state bans on copay accumulator adjustment programs (CAAPs) to show how accumulators reduce patients’ adherence to specialty therapies. Out-of-pocket costs declined (see the article) and adherence rose (see below) following an accumulator ban.

[Click to Enlarge]

The results are unsurprising. That's because an accumulator allows the plan to collect the value of two deductibles: one paid by the manufacturer, followed by a deductible paid by the patient. Many patients face an out-of-pocket deductible “surprise” when a copay assistance program’s benefits are exhausted. The patient then has an unexpectedly large coinsurance or deductible payment in the middle of the year.

Despite the logic behind these findings, my LinkedIn post about this study generated a heated debate about accumulators and benefit design. The post also received nearly 500 reactions and more than 50,000 views.

P.S. The study was presented at a recent AcademyHealth meeting and funded by Genentech. That doesn’t mean the results are not accurate.

Do Nonprofit Hospitals Deserve Their Tax Exemption?, New England Journal of Medicine

Check out this must-read New England Journal of Medicine article. (If you don’t subscribe, you can access the article for free with registration.)

Ge Bai, a professor at Johns Hopkins, has emerged as the leading academic critic of hospitals’ nonprofit status. In this article, Dr. Bai and her co-authors systematically debunk the false narrative behind charity care and Medicaid shortfall arguments. They also take aim at the 340B Drug Pricing Program, which “has evolved into a ‘buy low, sell high’ program that enables eligible hospitals to generate profits by providing these drugs to well-insured patients.”

ICYMI, the American Hospital Association (AHA) issued an evidence-free, ad hominem attack on Dr. Bai and her research. AHA also attacked the “Shadowy Arnold Ventures.”

Health Insurance Physicians, Dr. Glaucomflecken

Dr. Glaucomflecken, the funniest physician on the internet, parodies prior authorization at UnitedHealthcare. Not for the squeamish!

In the video, a (fake) UnitedHealthcare executive says: “If we hired physicians who actually practiced evidence-based medicine, do you have any idea how many claims we’d have to pay?” Ouch.

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