Linda Lawyer Insurance

10/09/2024

California Insurer Experiments With Drug Giveaway, Bypassing Secret Fees

October 8, 2024 | Source: Los Angeles Times, by John Tozzi

A major California health insurer is set to offer one of the world’s top-selling drugs for free in a bid to show the medicine can reach Americans affordably without going through the middlemen that typically control its flow.

Blue Shield of California struck an unusual deal to buy a lower-cost version of Humira directly from a manufacturer, bypassing the giant pharmacy benefit managers that normally determine which maker’s drug will go to tens of millions of Americans.

AbbVie Inc.’s Humira has been a prime example of how drug prices can stay high even after drugmakers lose patent protection. Sales of Humira, at one point the world’s top-selling drug, were $14 billion last year even after low-cost versions hit the market.

Pharmacy benefit managers, known as PBMs, typically agree to pay drugmakers higher prices upfront in exchange for payments described as rebates. The Federal Trade Commission recently alleged in a lawsuit that rebates illegally drive up patients’ costs. In the case of Humira, drug plans initially favored the brand-name drug and higher-priced copycats that came with higher rebates. The three largest PBMs say they’re now removing the brand version of Humira from their lists of preferred drugs in favor of cheaper versions.

Blue Shield said it was trying to call out the dysfunction in the existing system. “We don’t want rebates. We don’t want middlemen. We don’t want people dipping their hands in,” said Matt Gibbs, vice president of pharmacy transformation at Blue Shield of California. “We want to be able to present the price to our membership so that they can make the choice.”

There’s also a profit motive: Blue Shield of California currently spends more than $100 million a year on Humira, Gibbs said, more than any other drug. The new lower prices and lack of fees for middlemen should result in a savings of $20 million over three years, executives said, adding that the figure might be a low estimate.

Beginning next year, Blue Shield will pay $525 per monthly dose for the drug. That’s about a quarter of what the company currently pays for Humira after rebates, according to a person familiar with the pricing who asked not to be named discussing private information.

Blue Shield provides pharmacy benefits for about 2.5 million people and fills about 40,000 prescriptions a year for Humira, which treats inflammatory diseases like rheumatoid arthritis, Crohn’s disease and psoriasis.

The $525-a-month price is notable because it’s lower than the best prices available from the nation’s largest pharmacy benefit managers, units of CVS Health Corp., Cigna Group and UnitedHealth Group Inc. Those companies have faced intensifying pressure in Washington over how they purchase prescription drugs and whether they favor medicines with higher upfront prices that raise patients’ costs.

The FTC sued the three largest PBMs last month, alleging they used rebates to steer patients to higher-priced insulins and profited at patients’ expense. An FTC official not authorized to speak publicly said the agency is witnessing similar patterns in the market for Humira and cheaper copycat versions known as biosimilars.

PBMs have disputed the FTC’s characterization and said they intend to fight the lawsuit. The companies maintain they pass most of the rebates they get from drugmakers back to their clients — employers, unions and health insurance companies — that then use them to lower the prices people pay for drugs or to offset other medical expenses.

Rebates aren’t the only PBM practice under scrutiny in Washington. Lawmakers have recently started bashing PBMs, including CVS and Cigna, for forming divisions outside the U.S. that are partnering with drugmakers to sell their own biosimilar versions of Humira.

Sens. Mike Braun (R-Ind.) and Elizabeth Warren (D-Mass.) wrote to the FTC in August, urging the agency to investigate the matter.

“By preferring private labeled biosimilars,” the senators wrote in a letter viewed by Bloomberg News, PBMs “are protecting their own profits even as the drug’s price has fallen dramatically.”

Democratic Sens. Ron Wyden of Oregon and Sherrod Brown of Ohio released a separate letter to the FTC on Tuesday calling the deals “a veiled attempt by PBMs to control additional parts of the supply chain,” leading to fewer choices and higher costs for consumers.

The prices the PBMs currently charge health plans for their brands of biosimilar Humira are well above the $525 a month that Blue Shield is now paying.

CVS’ Ireland-based unit Cordavis offers its version for about $1,315 a month. Cigna says biosimilars will be available through its Cayman Islands-based subsidiary Quallent Pharmaceuticals with a list price of about $1,038. And UnitedHealth’s Optum Rx’s lowest price for its Humira copycat is about $1,177 a month.

The companies cite different reasons for the higher prices, but pointed to rebates that get prices down for clients. All three said many patients can get the drug for no out-of-pocket costs.

A CVS spokesperson also said its price isn’t lower because it sought a combination of low cost, stable supply and a formulation that it says is closer to Humira than some competitors’.

A Cigna spokesperson said that with rebates, its PBM offers Humira biosimilars for “less than $1,000” a month to its clients, with no cost to most patients.

Blue Shield isn’t the only company working to show how rebates are contributing to higher drug costs. The Mark Cuban Cost Plus Drug Co. sells a version of Humira for $584 for people paying cash as part of a broader effort the celebrity businessman has mounted to expose how drug prices can be inflated by middlemen. Another smaller player, GoodRx, offers a Humira biosimilar for $550 for people paying cash, undercutting the prices that the largest PBMs charge their clients.

A UnitedHealth spokesperson said comparing manufacturers’ list prices to cash prices for consumers is “not a fair comparison.”

For its new Humira pipeline, Blue Shield struck the deal through a company called Evio Pharmacy Solutions, which is owned by it and other Blue-branded health plans. Unlike a PBM, Blue Shield of California pays Evio a flat fee to negotiate with drug manufacturers rather than a fee based on the drug’s price. A division of German manufacturer Fresenius is making the drug for the insurer.

Blue Shield sent the stock prices of major pharmacy benefit managers sinking last year when it unveiled a plan to break with the conventional PBM model. Instead of outsourcing drug benefits to one firm, it would split up the business among many vendors, including CVS, Amazon Pharmacy and Cuban’s company.

At the time, the insurer said it would save as much as $500 million a year by gaining more control over its drug purchasing. The company’s chief executive, Paul Markovich, said Blue Shield of California is on track to save more than $100 million in the first year.

“How quickly we get to the rest of it depends on how quickly we can do more deals like this one where we are directly contracting for the lower-cost alternative,” he said.



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10/04/2024

Companies will be looking for ways to offset the cost of the drug cap, says author Philip Moeller, so look for other changes in Part D plans.

09/26/2024

09/26/2024

It's that time of year again too!
I can help you navigate the labyrinth of Medicare Insurances.

04/08/2024

Have you ever thought about it? ❤️
When you are alone and have a heart attack, what are you gonna do then?
A really good post that can't be shared often enough:
1.
Take a 2 minute break and read this:
Let's say it's 5:25 pm and you're driving home after an unusually hard day's work.
2.
You are really tired and frustrated.
All of a sudden your chest pains. They are starting to radiate in the arm and jaw. It feels like being stabbed in the chest and heart. You're only a few miles away from the nearest hospital or home.
3.
Unfortunately you don't know if you can make it..
4.
Maybe you've taken CPR training, but the person running the course hasn't told you how to help yourself.
5.
How do you survive a heart attack when you're alone when it happens? A person who is feeling weak and whose heart is beating hard has only about 10 seconds before losing consciousness.
6.
But you can help yourself by coughing repeatedly and very strongly! Deep breaths before every cough. Coughing should be repeated every second until you arrive at the hospital or until your heart starts to beat normally.
7.
Deep breathing gives oxygen to your lungs and coughing movements boost the heart and blood circulation. Heart pressure also helps to restore a normal heartbeat. Here's how cardiac arrest victims can make it to the hospital for the right treatment
8.
Cardiologists say if someone gets this message and passes it on to 10 people, we can expect to save at least one life.
9.
FOR WOMEN: You should know that women have additional and different symptoms. Rarely have crushing chest pain or pain in the arms. Often have indigestion and tightness across the back at the bra line plus sudden fatigue.
Instead of posting jokes, you're helping save lives by spreading this message.
❤️ COPY (Hold your finger on the text, click on it the word COPY, go to your own page, and where you normally want to type, hold your finger in the box and click on the PASTE❤️

10/12/2022

Health Care News for Insurance Brokers

02/23/2022

There’s a flood of do-it-yourself healthcare apps, gadgets and home tests. Here’s how to navigate the options—and tell what’s useful, reliable and safe.

More people are taking their health into their own hands as the Covid-19 pandemic has made it more difficult to see a doctor and get tests done, but taking the do-it-yourself approach requires navigating a lot of technology.

The tech industry has raced to fill consumer demand. A flood of new health-tracking wearables, monitors, tests and apps—more than 350,000 apps, according to health research firm IQVIA—promise to help people screen, monitor or flag all sorts of maladies and conditions, with or without a doctor’s orders.

Some of these healthcare tools have proved helpful, but consumers also report experiences with at-home lab tests that have been disappointing, confusing or misleading. Tools like sleep-tracking apps and blood testing kits aren’t always regulated by the U.S. Food and Drug Administration, and the regulations are so complicated that often it is unclear to consumers which ones should be.

The availability and convenience—not to mention the marketing—of tests like Everlywell’s at-home test kits are prompting people to give them a try.

Lauren Harris thought it would be simple to test herself for food sensitivities. She ordered an Everlywell test kit from Amazon and watched the instructional video. When she pricked her finger to get blood for the test, “there was blood everywhere,” says Ms. Harris, who runs a food and recipe website out of her home in Middletown, Del. “It was very painful.”

When she did another home test—for thyroid levels because of fatigue and trouble losing weight—the results didn’t tell her anything she hadn’t already heard from doctors: that her levels were borderline.

A spokeswoman for Everlywell, maker of both tests, acknowledged a slight risk of excessive bleeding when performing its tests, but says that it is “exceptionally rare.” More commonly, she says, consumers have trouble getting enough blood to complete the tests.

For those who have turned to a growing number of do-it-yourself tools to handle more of their healthcare at home during the pandemic, or those who are curious to try, here are some tips from doctors and consumers.

There are limitations
Some apps and monitors can give you instant information about a concern when you can’t get in to see a doctor. But doctors caution against using data or at-home lab tests to diagnose yourself, because they say DIY tools cannot give all the information you would get in an office exam.

A home eye test, for instance, may be sufficient for a glasses prescription, depending on your age and health of your eyes, doctors say, but the tests cannot detect signs of glaucoma or macular degeneration.

While numerous dermatology apps are designed to help identify cancerous lesions and moles, many use artificial intelligence to analyze the problem and may not be accurate, says John Whyte, chief medical officer of WebMD. If you suspect cancer, consult a doctor, he says.

DIY apps and monitors can also help determine whether in-person care is needed. For instance, apps that come with over-the-counter smartphone attachments allow parents to take and share digital images with a pediatrician or nurse, who can tell if the child needs to come in.

DIY can require more effort, and money
Home tests can also be tougher than you think to administer.

Sruthi Ramaswami, an investor and co-founder of a nonprofit for South Asian professional women, wanted to know more about her reproductive health to aid in family planning, but says such testing wasn’t routinely done though her gynecologist’s office. When she tried an at-home test to check fertility hormone levels, she passed out as she watched the blood drip from her finger. She ended up going to a clinic for a fertility assessment.

Some DIY companies, like at-home testing company Everlywell, list the out-of-pocket cost of a test clearly on its website, but others aren’t so clear. Some tests are covered by insurance, depending on the plan.

Do your homework

Activity trackers and monitors generally aren’t regulated by the FDA because they are considered consumer products, not medical devices designed to be used in the diagnosis, cure, treatment or prevention of disease.

At-home lab tests are subject to overlapping regulations by the FDA and the Centers for Medicare and Medicaid Services, but the FDA doesn’t necessarily review lab tests, software or gadgets if they are intended to promote wellness and don’t make medical claims. So it is hard for consumers to know whether the do-it-yourself products are subject to regulation or ought to be.

“Tests that are not FDA-approved use phrases like ‘not a medical device. It cannot prevent, treat or cure any medical problem,’” says James Nichols, professor of pathology, microbiology and immunology at Vanderbilt University School of Medicine.

Don’t base a decision on whether to use a DIY test or gadget on something you read online, doctors say. Tech startups that are making many of the DIY offerings also put lots of money into content and marketing. Consult your pharmacist or a healthcare provider and get their advice.

Look up the advisory boards on websites of the companies that make a test or device you are considering. The boards should include qualified scientists, says Shantanu Nundy, chief medical officer of digital healthcare firm Accolade Inc.

The fine print on the box or in the package should disclose the accuracy of an at-home lab test and clearly explain how to perform it. On some tests, such as at-home screenings for colon cancer, those instructions say when and whether to repeat the test. “If a test is negative, it isn’t a Get Out of Jail Free card,” says Dr. Whyte.

Talk with your doctor
When you want a doctor’s feedback—on home app data especially—present it in a way that works for them. Don’t just hold up your smartphone and expect your doctor to decipher a spreadsheet of your heart rates or glucose levels. Ask first whether they are willing to review the data, then distill the information on a piece of paper that the doctor can look at while talking to you, says Dr. Nundy.

Practical advice for when and how to use apps, tracking devices and at-home test kits.

02/21/2022

Something we never think about... but should!

Amy Goyer is AARP’s family and caregiving expert. She has written two books on the subject and has her own consulting business.

“I am a caregiving expert. How did I end up in bankruptcy?” she says.

Ms. Goyer depleted her savings and ended up relying on credit cards after being financially drained by costs related to caring for her parents. After more than a decade of caring for her mom, who had a stroke, and her dad, who had Alzheimer’s, Ms. Goyer filed for bankruptcy protection in 2019.

Ms. Goyer started a consulting business, which gave her more flexibility to care for her parents.
She describes the bankruptcy experience as humiliating and embarrassing. But she says it shows how the unexpected costs of daily caregiving can accumulate over time and overwhelm even the most experienced of the nation’s 53 million family caregivers.

Family caregivers are the backbone of the nation’s long-term care system and provide an estimated $470 billion worth of free care—often at great personal cost. On average, caregivers spend 26% of their personal income on caregiving expenses, according to a 2021 AARP study, with most personal spending going to housing, including home modifications. A third of caregivers dip into their personal savings, like bank accounts, to cover costs, and 12% take out a loan or borrow from family or friends.

“I don’t think people understand how expensive caregiving is,” says Jean Chatzky, founder of HerMoney.com, a digital media company focused on women and personal finance.

Ms. Chatzky and others say family members incorrectly assume Medicare will pay for long-term care in nursing homes or in-home help, only to be surprised when a relative falls ill or needs that kind of care. Private long-term-care insurance picks up some of those costs, but the amount varies depending on the plan.

Caregiving is becoming more expensive because people are living longer with more complicated medical needs and hiring help costs more. The median annual cost of in-home care rose to $54,912 in 2020, an 18.5% increase from 2016, according to Genworth, a long-term-care insurance company.

The financial strain is widespread. Although the average caregiver is 49, about 23% percent are millennials, who have had less time in the workforce to build financial security. Concerns about the toll on family caregivers led to a recently introduced bipartisan Credit for Caring Act that would provide a tax credit of up to $5,000 to eligible working caregivers.

Ms. Goyer began her caregiving from a distance. Her parents lived in Phoenix. She lived in Alexandria, Va., and worked in Washington for the AARP. While her sisters pitched in, Ms. Goyer, who was single, childless and had a background in aging, managed their care and ultimately financed a large part of it.

At first, she would fly to Arizona several times a year, but began coming monthly as her parents’ health declined. Her mother, Patricia, who had a stroke at the age of 63, had frequent hospitalizations, and her dad’s cognitive abilities began slipping. In 2009, the doctor said that he had Alzheimer’s and that he should stop driving.

“That is when everything changed. I picked up my life and moved,” says Ms. Goyer.

Costs start to mount

She left her full-time position at AARP and started a consulting business, which gave her more flexibility to care for her parents but also meant added costs for things like health insurance.

She found a continuing-care community for her parents and moved into their house, taking over the mortgage and bills, while maintaining her Washington-area apartment to be close to her clients and boyfriend.

Her parents had long-term-care insurance, which along with Social Security and her dad’s pension, covered the monthly $4,000 fees at their independent living apartment. Personal-care services, including someone to help her mother bathe and dress, were extra. She paid for the extra care when it exceeded her parents’ budget.

When her parents needed 24-hour care, Ms. Goyer moved them back home, and took out a home-equity line of credit to install grab bars and a safe shower in the bathroom.

Ms. Goyer hired caregivers to watch her parents while she worked, but took over during evenings and weekends. One sister lived in Arizona and helped, but also had a child with special needs. Another sister flew from Ohio to cover when Ms. Goyer had to travel. Ms. Goyer personally paid for her flight.

As her parents’ savings dwindled and their needs increased, Ms. Goyer assumed more expenses, relying on credit cards to buy equipment, like special folding wheelchairs, and pay veterinary bills for Mr. Jackson, a service dog that had become her dad’s constant companion and source of comfort. The air-conditioning units died and had to be replaced. She paid with credit cards.

Her boyfriend, Bill Carter, who lived in Alexandria, came out and helped with small house projects. On occasion, she borrowed money from him to get through the month. “I know it was very hard for her to ask for that kind of help,” says Mr. Carter. “She was trying so hard to keep everything going.”

By 2013, she had $25,000 in credit-card debt. That year, her mother died. A year later, her oldest sister died. Ms. Goyer, her sister’s power of attorney, incurred additional expenses going to Maryland to help with her sister’s care.

Devastated by the losses, her dad, Robert, declined. She hired someone to help him exercise for his physical health and well-being. She tried alternative treatments, including acupuncture and Chinese medicinal herbs, which helped reduce his anxiety more than any other therapies and treatments.

“When you care for someone with dementia and love them so much, you get to the point that you do anything you can that works,” she says.

Overwhelmed by expenses

Her father’s medical and in-home care expenses reached $10,000 a month in the last two years of his life, exceeding his $8,000 monthly income from Social Security, pension, long-term care-insurance payments and Veterans Affairs benefits. Ms. Goyer, whose personal income from her consulting business ranged between $35,000 and $74,999 annually, picked up the $2,000 monthly shortfall, while also paying for the Phoenix house and her apartment in Alexandria.

In 2018, the year her dad died, her credit-card debt topped $120,000, with a large amount representing high interest rates on unpaid balances. She went to consumer-credit counselors and called credit-card companies trying unsuccessfully to get lower interest rates.

“I was just so overwhelmed financially, I couldn’t figure out how to dig out,” she says. She consulted lawyers and financial advisers, who recommended that she file for bankruptcy, which she did in 2019.

Mr. Carter, her boyfriend, says he felt relief. “I worried all the time about the tremendous strain Amy was under,” he says. “I felt that her debt had spiraled out of control that last year of her father’s life and bankruptcy was her only option.”

Bankruptcy was demoralizing. “I feel like even friends judge me,” says Ms. Goyer. She has no savings and must rebuild her credit rating. She is fortunate, she says, that she could continue working for the AARP and others, and plans to meet with a financial adviser, something she wishes she had done sooner.

She has no regrets about the care she gave to her parents or its cost.

“I made my choices and did my best for my parents,” she says. “If it can happen to me, it could happen to anyone.”

The unexpected costs can accumulate over time and overwhelm even the most experienced of the nation’s 53 million family caregivers.

06/28/2021

How do I get parents in 80s to accept help?

Q My parents are in their 80s and live in a one-story condominium. My dad is OK. I am concerned about my mother, who has ankle problems and is unstable on her feet. Her balance is poor and she moves at a slow pace, using a cane for assistance. I feel she can fall with the least provocation.

Given this, my parents have housekeeping help only once every two weeks. How can I convince them to have more help?

Money is not an issue. Note: Mentally, they both are sharp as a tack! Many thanks.

— A.L.

A You have described an important problem and you certainly are not alone. A study by Penn State University found that 77% of adult children believe their parents are stubborn in taking their advice, and that includes advice about getting help with daily tasks.

As aging parents face challenges, so do adult children who worry and wait for an accident to occur that possibly could be prevented. Our society values self-determination, as each of us can decide how to live our lives as long as we are not harming anyone. The reality is that even with good intentions, we have limited power and influence over an older adult who refuses to get additional help. And yet, it is worth giving it a try.

Here are some approaches.

Try to understand reasons for refusal. Most older adults want to keep control over their lives and fear the possible eroding of independence. In a Forbes article, Carolyn Rosenblatt suggests that using logic to combat this fear is useless unless there is a crisis. Rather, Rosenblatt suggests asking parents not to burden you whenever possible. In other words, do it for your children.

Here is another approach that I recently used in a situation similar to what you’ve described that appealed to logic and fear. The daughter of an 84-yearold friend wanted me to help her mother agree to get more help for household tasks in her home.

When my friend made a welcomed and unexpected visit to my home, I witnessed her frailty as she moved slowly with hesitation. I asked how things were going. My friend replied that she is having some mobility and balance problems but was OK. I asked if she had any help.

She replied, “Once a month.” That was my opportunity to make some suggestions in a caring yet strong way.

My first response was, “My dear friend, that is not enough.” Here are a few facts that I shared with her.

According to the Centers for Disease Control and Prevention, more than 1 in 4 four older people fall each year, and less than half tell their doctor.

Among older adults, about 95% of hip fractures are caused by falls. Women experience about three-quarters of them.

Nearly 25% of hip-fracture patients will die within one year of the fracture; 50% will have a major decline in their independence.

There’s more bad news. Adults 75 or older have the highest rate of traumatic brain injury-related hospitalizations and deaths. Over half are caused by falls.

And falling once doubles your risk of falling again.

I then reviewed some basics of housekeeping that require mobility and balance such as doing the laundry, changing sheets, cleaning floors, vacuuming and more. I ended our conversation with the fact that at our age, the consequences of falling are serious. Fortunately, my friend heard me and is planning for more help.

I share this with you to emphasize the importance of a third party as a potential influencer. This is similar to a work setting where an employee makes a suggestion to the boss who does not acknowledge the value of the suggestion.

That is, until an outside paid consultant is hired to deliver the same message. The conversation we did not have was the importance of making her condominium age-friendly by installing grab bars, removing throw rugs and clutter, ensuring proper lighting and more. We also did not discuss the many reasons an older person can fall, including medications, lack of sleep, poor footwear and vision problems.

A.L., thank you for your important questions. If all else fails, know that you did everything you could to support the safety of your mother. She is lucky to have you as a caring and concerned daughter. Stay safe and be well.

Helen Dennis is a nationally recognized leader on issues of aging, employment and the new retirement, with academic, corporate and nonprofit experience.

Contact Helen with your questions and comments at Helendenn@gmail.

com. Visit Helen at HelenMdennis.

com and follow her on facebook.com/ SuccessfulagingCommunity

Q My parents are in their 80s and live in a one-story condominium. My dad is OK. I am concerned about my mother, who has ankle problems and is unstable on her feet. Her balance is poor and she moves at a slow pace, using a cane for assistance. I feel she can fall with the least provocation.

06/03/2021