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The OIG introduced several important Work Plan updates in April! Key areas under review include: 📑 Medicaid Updates: Dive deep into the complexities of supplemental payments and their compliance with federal standards. 💊 Pharmacy Oversight: Learn about the upcoming audits on vertically integrated Medicare Part D sponsors and how this could affect drug pricing. 🏥 Vascular Health: Explore the focus on peripheral vascular procedures and the efforts to combat potential fraud and unnecessary surgeries. Don't miss out on the full insights: https://hubs.la/Q02wplMr0 #HealthcareCompliance #OIGUpdates #MedicaidInsights #PharmacyManagement #VascularHealth #MedicalAudits #HealthcareNews

PBM Regulation, Part VIII: PBMs have been in legislative crosshairs for 10 years, driven mainly by pharmacies’ reimbursement complaints. House Behavioral Health and Health Care Chair Rob Nosse plans to convene a large workgroup on the subject, perhaps along the lines of a mid-2010s public Rx cost workgroup. CVS-Caremark CEO David Joyner says in a Fortune op/ed that PBMs try to keep costs down but pricing is the core issue; three innovative drugs in 2023 cost CVS customers more than all generics combined. https://1l.ink/ZHFFLPD

PBM Regulation, Part VIII: PBMs have been in legislative crosshairs for 10 years, driven mainly by pharmacies’ reimbursement complaints. House Behavioral Health and Health Care Chair Rob Nosse plans to convene a large workgroup on the subject, perhaps along the lines of a mid-2010s public Rx cost workgroup. CVS-Caremark CEO David Joyner says in a Fortune op/ed that PBMs try to keep costs down but pricing is the core issue; three innovative drugs in 2023 cost CVS customers more than all generics combined. https://1l.ink/ZHFFLPD

Enlightening #BusinessHike with healthcare industry stalwarts Barry Patel, Pharm.D and Bill Eikost, FHFMA. During our 4-mile journey, we covered a plethora of topics, from single-payer to A.I. to the Magnificent 7 Stocks to Electronic Health Record Integration to GLP-1 Drugs to Full-Body-Scans. Plus, Barry discussed his recent LinkedIn post shedding light on a critical and often overlooked issue within the pharmacy industry, especially concerning the challenges faced by independent pharmacies like Bell's Family Pharmacy in Georgia. The disparity in reimbursement rates from Pharmacy Benefit Managers (PBMs) is stark: for certain prescriptions, independent pharmacies like Bell's receive merely 4 cents for every dollar, in stark contrast to national chains, which are reimbursed the full dollar. See post to learn more: https://lnkd.in/eGjmss7g Not to be left out, Bill referenced his LinkedIn post about the value of identifying patients that qualify for Medicaid, benefiting both the patient and the care delivery organization: https://lnkd.in/etWtuhei On an inspirational note, it was refreshing to get outside with spring on the way, and we were fortunate to have gorgeous weather. Check out our picture!

Dr. Russell J. Ledet, M.D., Ph.D., M.B.A. said it best --> the real work begins after a written prescription. "Writing a prescription is the easy part — but ensuring the patient has access to it? That’s where the real work begins....But there are real barriers standing between patients and their medications: transportation, money, understanding the side effects, and even grasping the disease process itself." ~ Russell J. Ledet, M.D., Ph.D., M.B.A. -------- 💥 This is sadly the reality of healthcare in 2024 💥 In this video, I summarized an experience from this week where: A random 56 yo patient walked into the pharmacy 2 mins before closing with a prescription in hand from the emergency room. We'll call him JV. Rx was for Eliquis, an expensive (>$500) brand-only blood thinner. Indication on the Rx: "Acute DVT of right lower extremity" JV's barriers between him and the Eliquis: - language - no insurance coverage - unfamiliarity with navigating the system; he's never been to the hospital or ER - limited knowledge of the disease process - limited knowledge of prescribing legalities 💥 Barriers are the elephants in the room but they must be addressed 💥 💥 If the system doesn't create room for barriers to be addressed by the prescribers, then patients/caregivers must learn to address them 💥 JV [and other patients/caregivers] should address similar barriers in the little time they have with a clinical staff by asking: 1. Where can I get this medication/device? 2. Would you have an idea of the cost? 3. What other options do I have if I can't get this medication? ❓ What else would you add to my "barrier-busting" questions above for patients/caregivers? Please share! ------- 👋🏾 Hi I'm Ahunna... your favorite pharmacist with a passion for people and problem-solving. My professional superpowers empower patients AND providers in navigating pharmacy/medication-related challenges in outpatient/virtual practices! #PatientCare #TeamBasedCare #Community #Pharmacy #Consultant #PharmD #MD #NP #PA #PatientAdvocacy

On July 17, 2024, Governor Josh Shapiro signed House Bill 1993 into law, marking a significant step in regulating Pharmacy Benefit Managers (PBMs). This new legislation, effective November 14, 2024, introduces critical reforms including: ~Pass-through of Drug Manufacturer Rebates: Ensuring at least 95% of rebates are passed to health plans. ~Provider Freedom of Choice: Allowing individuals to choose their in-network pharmacy without being steered towards PBM-affiliated options. ~Prohibition on Clawbacks: Preventing PBMs from collecting excess cost-sharing amounts. ~Network Adequacy Requirements: Mandating convenient access to a broad network of pharmacies. These changes aim to enhance transparency, fairness, and accessibility in prescription drug coverage for fully insured group health plans in Pennsylvania. #HealthcareReform #PBMRegulation #Pennsylvania #EmployeeBenefits #HealthcareTransparency

We are thrilled to announce the release of our latest article: "Navigating New York State Medical Treatment Guidelines and PARs: 2024." 🔍 What's Inside: - Detailed breakdown of the guidelines - Key changes impacting PARs - Practical advice for seamless implementation - Expert commentary on the implications for healthcare providers Don't miss out on this essential read! Stay informed and stay compliant with us. #Healthcare #MedicalGuidelines #NewYorkState #ViscardiCorp #MedicalTreatment #PARs #HealthcareProfessionals #2024Updates #MTGs

💡 𝗘𝘅𝗰𝗲𝗽𝘁𝗶𝗼𝗻𝗮𝗹 𝗖𝗼𝘀𝘁 𝗖𝗼𝗻𝘁𝗮𝗶𝗻𝗺𝗲𝗻𝘁 𝗖𝗮𝘀𝗲 𝗦𝘁𝘂𝗱𝘆: 𝗢𝘃𝗲𝗿𝗰𝗼𝗺𝗶𝗻𝗴 𝗮 $𝟮𝟮 𝗠𝗶𝗹𝗹𝗶𝗼𝗻 𝗖𝗵𝗮𝗹𝗹𝗲𝗻𝗴𝗲 In a remarkable display of cost containment expertise, Penfield navigated through an intricate $22 million medical claim tied to a newborn's critical cardiac care in California. The journey involved meticulous review and negotiation, ensuring every charge was justified and within the bounds of reasonable coding practices. Amidst this financial odyssey, Penfield identified a significant portion of the bill associated with an experimental drug. Through strategic discussions and steadfast advocacy for fair pricing, Penfield secured a substantial discount, achieving a final settlement at 𝟮𝟬𝟲% of Medicare rates. The outcome? An impressive reduction equivalent to a 𝟲𝟱% 𝗱𝗶𝘀𝗰𝗼𝘂𝗻𝘁, saving $𝟭𝟰,𝟯𝟳𝟯,𝟰𝟴𝟳.𝟯𝟰. This case not only showcases Penfield's dedication to cost efficiency but also sets a precedent for medical cost containment done right. 👉 For an in-depth look at the strategies deployed in this case, stay tuned for upcoming articles. 𝗣𝗲𝗻𝗳𝗶𝗲𝗹𝗱 - the 'Best In Class' organisation and industry experts for medical cost containment/claims negotiations. To discuss your cost containment and medical claims negotiation needs: If your organisation is based outside of the USA, please contact Penfield's Head of International Business, Faz Subhani, at [email protected] or call +44 7719 114999. For US based companies, please contact Penfield's Head of US Business Development, Johnathan Clarke, at [email protected] or call 819-578-5270. #healthinsurance #USAhospital #medicalclaimsnegotiation #reducehealthcosts #medicalassistanceinAmerica #UShospital #medicalcostcontainment #medicine #healthcarecosts

💡 𝗘𝘅𝗰𝗲𝗽𝘁𝗶𝗼𝗻𝗮𝗹 𝗖𝗼𝘀𝘁 𝗖𝗼𝗻𝘁𝗮𝗶𝗻𝗺𝗲𝗻𝘁 𝗖𝗮𝘀𝗲 𝗦𝘁𝘂𝗱𝘆: 𝗢𝘃𝗲𝗿𝗰𝗼𝗺𝗶𝗻𝗴 𝗮 $𝟮𝟮 𝗠𝗶𝗹𝗹𝗶𝗼𝗻 𝗖𝗵𝗮𝗹𝗹𝗲𝗻𝗴𝗲 In a remarkable display of cost containment expertise, Penfield navigated through an intricate $22 million medical claim tied to a newborn's critical cardiac care in California. The journey involved meticulous review and negotiation, ensuring every charge was justified and within the bounds of reasonable coding practices. Amidst this financial odyssey, Penfield identified a significant portion of the bill associated with an experimental drug. Through strategic discussions and steadfast advocacy for fair pricing, Penfield secured a substantial discount, achieving a final settlement at 𝟮𝟬𝟲% of Medicare rates. The outcome? An impressive reduction equivalent to a 𝟲𝟱% 𝗱𝗶𝘀𝗰𝗼𝘂𝗻𝘁, saving $𝟭𝟰,𝟯𝟳𝟯,𝟰𝟴𝟳.𝟯𝟰. This case not only showcases Penfield's dedication to cost efficiency but also sets a precedent for medical cost containment done right. 👉 For an in-depth look at the strategies deployed in this case, stay tuned for upcoming articles. 𝗣𝗲𝗻𝗳𝗶𝗲𝗹𝗱 - the 'Best In Class' organisation and industry experts for medical cost containment/claims negotiations. To discuss your cost containment and medical claims negotiation needs: If your organisation is based outside of the USA, please contact Penfield's Head of International Business, Faz Subhani, at [email protected] or call +44 7719 114999. For US based companies, please contact Penfield's Head of US Business Development, Johnathan Clarke, at [email protected] or call 819-578-5270. #healthinsurance #USAhospital #medicalclaimsnegotiation #reducehealthcosts #medicalassistanceinAmerica #UShospital #medicalcostcontainment #medicine #healthcarecosts

Many clinical factors contribute to ASCVD, and many interventions exist to help lower the risk. Aside from encouraging patients to change their habits and behaviours (i.e. to stop smoking, eat healthier, incorporate more exercise in their lifestyle), pharmacological interventions mostly involve generic drugs with a low budget impact for healthcare systems. However, there remain patients who develop fatal or non-fatal myocardial infarction or strokes despite treatment, leading to a high burden on healthcare systems. Hence there remains a clinical need for interventions to successfully identify and treat these patients at very high risk to develop ASCVD events. After years of limited new product launches, there are currently a wealth of products in clinical trials, with new modes of action to tackle ASCVD-related conditions. New treatments give hope to physicians and patients alike, to be able to prevent this deadly condition. But, what about payers? •What will it take to gain approvals and funding, and even premium pricing in a world where drug expenditure continues to increase? •What evidence do payers need to see to make positive pricing and reimbursement decisions? •Will there be an appetite for innovative contracting and if so, what could it look like? •What will be impact be of the IRA in the US on price pressures? •Will the JCA in EU influence evidence needs in some markets? • If these questions resonate with you, our new ASCVD syndicated payer study can help you find the answers. Our study delivers a report that talks to your situation and gives you actionable recommendations. Contact me to find out more about our syndicated payer research into ASCVD in US, EU4 + UK (other markets possible on request) we can help you solve your problems. #IpsosHealthcare #payer #marketaccess #ASCVD