Sarah Cullen Wheeler, MBA

It strikes me as very important that the court did not rule on geographic restrictions for #340B covered entities. Contract Pharmacy geographic restrictions will: 1. Reduce access for patients 2. Restrict innovation related to patient engagement and access, 3. Likely increase costs to patients, and 4. Create a non-competitive business environment that will likely result in higher dispensing fees. There is no evidence that “remote” pharmacies harm program integrity. More detail on follow on posts on each of these points. Health Resources and Services Administration (HRSAgov), HHS Centers for Medicare & Medicaid Services National Association of Community Health Centers (NACHC) PhRMA #340B #CoveredEntities Advocates for Community Health

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If I asked you to choose between Trader Joe's or Target, which would you choose? It's a silly question, really. Because both offer unique benefits. As major GPOs shift in the market, exclusive agreements are becoming common. But are they truly driving value for health systems and patients? Exclusive GPO contracts limit choice. It's like forcing someone to choose between Trader Joe’s and Target. At Advantus Health Partners, we offer diverse vendor partnerships and PPI contracts, enhancing both economic benefits and patient care. By rethinking exclusivity, we prioritize patients and empower health systems with choice. Ready to supplement your supply chain with value-added partnerships? Contact Advantus today to learn more about our non-exclusive contracts. https://lnkd.in/deiYRgfE #SupplyChainStrategy #GPOExclusivity

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GLP-1 Agonists for Weight Loss: Questions about semaglutide (Wegovy) and tirzepatide (Zepbound) persist. Is it okay to switch to a different GLP-1 agonist? In some cases. Semaglutide or tirzepatide seem to be the most effective meds for managing overweight or obesity. Read our article in Pharmacist's Letter to learn more.

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The Hidden Middlemen Driving Up Healthcare Costs: A Closer Look at Pharmacy Benefit Managers (PBMs) - Part 2 Recent Federal Trade Commission (FTC) action has shed light on a critical issue in healthcare: the complex and often opaque world of PBMs. These intermediaries are dramatically impacting drug pricing and accessibility in ways most people don't realize. How do PBMs make money? Their revenue streams are both creative and controversial: • Spread Pricing: Charging health plans more than they pay pharmacies, pocketing the difference • Manufacturer Rebates: Negotiating "kickbacks" that often incentivize higher-priced drugs • Pharmacy Fees: Collecting network participation and retroactive fees • Vertical Integration: Owning pharmacies to capture additional dispensing profits To put this into perspective, Optum Rx (owned by UnitedHealth Group) generated $116.09 billion of revenue in 2023 - 16.4% more than the previous year. The FTC's recent lawsuit against the big 3 PBMs (Express Scripts, Caremark, and OptumRx) reveals shocking practices. They've been accused of creating a system that artificially inflates drug prices, particularly for critical medications like insulin. For instance, Eli Lilly's Humalog insulin price skyrocketed from $21 in 1999 to $274 in 2017. The human cost is real: patients are forced to ration life-saving medications due to these pricing mechanisms. Legislative efforts like the Pharmacy Benefit Manager Transparency Act are now pushing to prohibit these deceptive practices and protect consumers. This isn't just a corporate issue - it's about healthcare accessibility and affordability for millions of Americans.

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Reason #9 any proposed #340B legislation should not include geographic restrictions = #specialtypharmacy Specialty Pharmacy geographic restrictions will hinder access for patients reduce the ability to generate margin as a 340B Covered Entity by essentially blocking community health centers from the predominant distribution method of specialty drugs. The Specialty Pharmacy Market is dominated by 6 national providers. 75% of all specialty medications are dispensed by pharmacies that patients are often incentivized or required to use because of their benefit design. These specialty pharmacies are also most likely to have access to drugs not available to all pharmacies and have built infrastructure that provides enhanced care for patients suffering from complicated disease states. Restricting the ability of #FQHCS to contract with the specialty pharmacies that are most likely to provide service to patients will undermine community health centers’ ability to ensure their patients have the medications they need and will unnecessarily reduce their ability to support their mission. Health Resources and Services Administration (HRSAgov), HHS Centers for Medicare & Medicaid Services National Association of Community Health Centers (NACHC) PhRMA #340B #CoveredEntities Advocates for Community Health

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💡New #Avalere Study 💡Do #340B contract pharmacies serve patients in rural areas? Do 340B hospitals contract with chain or independent pharmacies? Our team crosswalked a couple of data sets to get some snapshots of trends in contract pharmacy use in 340B to inform the ongoing debate in Congress. Reach out to learn how we can help you with policy design and analytics. #drugpricing #drugs #lifesciences https://lnkd.in/evXZRZ2N

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In #NEMT, transportation vendors are often blamed for discharge bottlenecks due to their performance. While on-time performance is a critical factor, it's not the only one. For example, giving ample notice to EMS vendors vs just ordering a BLS for "right now" is essential. Unless there is a truck in the parking lot, it's impossible for the crew to be there right away. Health systems who understand this, optimize internal workflows, and collaborate with EMS vendors to collect data on what is reasonable for the market are the ones who will see real results in transportation program improvement. #rideeconomics #healthcareinnovation

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Transparency is key, especially in healthcare. Did you know that most PBMs do not disclose to employers either the price that they pay to retail pharmacies or drug acquisition costs for their mail operations? This lack of clarity can make it incredibly difficult for large employers to understand and control their pharmacy benefit costs. This can impact your organization with unclear pricing structures and hidden fees, limited negotiation power for favorable terms, and employees may experience frustration and dissatisfaction when faced with unexpected or excessive prescription costs. What steps can your organization take to address this issue? Do you feel confident your PBM has done all it can for your employees? #pharmacybenefits #healthcarecosts #transparency #humanresources

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As a 3rd post behind the Cigna and CVS/Aetna posts about rates going up due to 'assumed' or 'possible' increases in medical/pharmacy prices next year, here is a similar article from the Stop Loss side of the house. Some highlights - "The average rate increases for coverage renewing in January 2025 will be twice as big as the average rate increases for January 2024 renewals were, Don Templin, Voya's chief financial officer, said during a conference call with securities analysts." - "Although premiums at the stop-loss business exceeded benefits payments, and the severity of the claims was comparable to that reported in the past, increased claim frequency was observed across most categories, the company says." Because Sun Life built a return to pre-pandemic utilization rates into its stop-loss prices, its current stop-loss prices are adequate, even though utilization rates are up, Fishbein said. But "no question that pricing is going to harden in the near future." ((Hmmm...all of the reports/analysis I have seen and read this year point to the PRICE/Billed Charges of services and drugs being the issue, and that utilization has not increased) PRICE is the issue. With probably 90% of what these carriers are quoting on are BUCA style PPO plans with traditional PBMs and Carrier ASO models, no wonder they are increasing their prices. You need to attack the cost of Claims. Claims are ~85% of the total cost of a health plan and traditional Spread Pricing PBM models and PPO Network models do nothing to lower the cost of claims. Why? Those models make more money when we all spend more money. There is no incentive to reduce the price. Co-fiduciary models of Direct Contracting, Medical Bill Review/claims Editing, Fair market reimbursement strategies, transparent/passthrough/no spread model PBM, steerage based on price/quality, and independent TPAs can and do attack price which results in flat renewals and when with the right stop loss carrier/MGU, result in lower premiums as well Seems like a winner, don't you think?! 😉 https://lnkd.in/g8SjgssP

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If you build it, will they come? I’ve heard countless organizations - #MA plans, #Medicaid plans, risk-bearing providers, vendors, PBMs, and retail players - say “we need to build the capabilities to XX”. Many are looking to vendors for solutions, but few vendors are ready to invest in new capabilities without contracts.  Anyone else sensing this (problematic) new conundrum? Here’s my quick take and a few ideas to break through this barrier. Many sales meetings are often held with functional departments, and often do not include the #MedicareAdvantage #StarRatings, #RiskAdjustment, #HEDIS, IT or P&L owners. We must collaborate to get those departments’ urgent needs integrated into new vendor purchases in order for new activities to meet new and emerging needs, remembering that: 🌟 Vendors are vital to your success.  🌟 Vendors operate in a more volatile environment than plans. 🌟 Vendors have smaller budgets than plans. 🌟 Vendors need signed contracts to make significant investments.   🌟 Vague RFPs waste vendors’ time and resources. Collaboration creates win-win contracts which expand capabilities of both parties. I encourage plans to: ✅ Ask vendors about their roadmap; including timing and certainty of planned enhancements. ✅ Include the #Stars, Risk Adjustment and #PartD teams in new vendor discussions. ✅ Consider adding a vendor's roadmap capabilities to contracts. ✅ Co-create with trustworthy vendors. I encourage vendors to: ✔ Ask about the customer’s unmet needs. ✔ Offer to co-create solutions to new and emerging needs with willing customers. ✔ Offer to accelerate roadmap capabilities with willing customers.   ✔ Articulate the things you would be willing to do if a customer would be willing to contract for it. This is a #MarketMakingMoment as #CMS has thrown down the gauntlet with #NewNeedsOfStars and #NewNeedsOfMA. This is a stellar time for vendors to review current and planned capabilities with a broader lens on new and emerging MA, #Compliance, Stars, #ECDS, #Interoperability, #HealthEquity, Medicaid & #SNP Aligment, and Risk Adjustment needs. If you need help, reach out to us.  #WhatGotYouHereWontGetYouThere  ⭐ ⭐ ⭐ ⭐ ⭐

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New 2024-2025 #PBM Report identifies and profiles nearly 70 PBMs - market leaders, mid-market, non-traditional http://bit.ly/4dbITVU #pharmacybenefit #transparency #pharmacy #drugpricing #CVS #OptumRx #ExpressScripts #report

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"At DisclosedRx, we understand that managing pharmacy benefits isn't just about numbers and contracts – it's about people." This isn't just a tagline, it's the core of our philosophy at DisclosedRx. In an industry often focused on metrics and bottom lines, we never lose sight of the human element. Our approach means: - Personalized care for each member - Decisions driven by health outcomes, not just cost - A focus on building trust and relationships - Commitment to improving overall well-being We believe that by putting people first, we can deliver better results for everyone – members, clients, and healthcare providers alike. How could this people-centric approach transform your organization's pharmacy benefits? Let's start a conversation about prioritizing the human side of PBM services. #PeopleCentricPBM #HealthcareWithHeart #DisclosedRx

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The ability to be compensated for work carried out in the healthcare space has become increasingly difficult and complicated. It is imperative that our industry remains current on trends, changes, and projected challenges, to ensure our readiness in combatting them. The ambulance industry of today is far different from when our organization first opened in 2010, and we have continuously evolved to meet these challenges head-on. This will remain a big talking point for years to come, and/or until significant changes are made to the benefit of providers. In healthcare, you expend a great deal of capital to provide a service, and in return, you "hope" for reimbursement. Try doing that at a local restaurant - order and eat your food, and tell the staff you MIGHT come back with payment in 90-120 days. Let's see if you make it out of there without cleaning some dishes on your way...

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3 of the biggest problems in healthcare benefits right... 1. Managing high-cost claimants 2. Managing cost of specialty drugs 3. Enhancing benefits without tanking quality Find out how to directly solve 1 & 2 -> https://lnkd.in/grFn778m #HR #EmployeeBenefits #Health #COE #Surgery #Spend #SelfFunded #SelfInsured

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🔍 Key Insights from EDPMA’s No Surprises Act (NSA) Implementation Survey 🔍 EDPMA's recent survey reveals critical issues since the NSA took effect in 2022. Highlights include: 📉 Reimbursement Drop: Out-of-network (OON) physician reimbursement fell by 39% in 2023 compared to 2022, impacting cash flow and emergency care quality. ⚖️ IDR Process Delays: Only 7.6% of disputes are resolved, averaging 211 days. Providers prevail in 73% of disputes, yet health plans often fail to pay promptly. 🔄 Contract Instability: Many physicians report terminated or reduced contracts, driven by health plans leveraging the QPA to force rate cuts. 🚫 Compliance Issues: 82% of OON claims lacked proper QPA calculation, and 56% missed inflation adjustments, leading to underpayments. 🚨 Action Needed: Enforcement of NSA regulations is crucial to ensure fair compensation and maintain high-quality emergency care access. Read more on our findings and implications for the future of emergency medicine. #EmergencyMedicine #NoSurprisesAct #Healthcare #EDPMA

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The Federal Trade Commission is taking a closer look at pharmacy benefit managers (PBMs) and their role in driving up prescription drug costs, as detailed in a recent MedCity News article. The investigation highlights concerns about how #PBM practices may contribute to higher prices, delay, deny, or increase the cost of necessary medications. For independent #communityoncology practices and dispensing pharmacies, this scrutiny is crucial. PBM practices not only inflate costs but also create barriers to timely treatment, which can severely impact patient outcomes. Patients with #cancer are particularly vulnerable to PBM abuses, facing delays or denials in their medication. Greater oversight and reform of PBM practices are essential to ensure that savings are passed on to patients rather than benefiting multibillion dollar for-profit middlemen. Learn more: https://lnkd.in/egxwcXbQ

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I hole heartedly agree Benjamin Schwartz, MD, MBA. Anywhere else in an economic system, innovators who can deliver a better product at lower costs are almost always rewarded with greater market share, and frequently set the direction for the future of a product or industry. Not so in healthcare. I think that Terry Adirim, MD, MPH, MBA (below) hit the nail on the head when she references for-profit health insurers in the mix. Although policies have been enacted with the idea of providing better healthcare at lower costs, they have always given the job of administering those policies to a middleman (insurance companies) whose motives are at odds with the objective they claim to be administering. Profit! Innovation is not in the best interest of the payer. They profit through the inefficiency of the system. Until this lack of alignment between quality patient care at low costs and for-profit health care plans is addressed, process innovation and improvement will only be able to nibble at the edges.

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