Insurers Ax Coverage Over a Nickel, PBMs Face Being Legal Fiduciaries (The Horror), and the FTC Settlement Somehow Makes Pharmacies’ Lives Worse

Hey all, 

Happy Tuesday! Welcome to the peak of healthcare automation, where the same high-tech systems that can’t find a live human to answer a medical question are perfectly calibrated to terminate your coverage over the terrifying financial threat of a single, stray nickel. It is truly a marvel of modern engineering that we’ve built a digital gauntlet where patients are at the mercy of "efficient" algorithms that treat a five-cent rounding error like a federal crime while regulators "fix" the system by inadvertently giving PBMs more data to squeeze out of independent pharmacies. Apparently, the only thing more automated than our insurance cancellations is the industry’s uncanny ability to prioritize its own bottom line over the actual humans who are just trying to get a person—any person—on the phone.

Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX)

[KFF Health News] Insurer Cancels Coverage Over Five-Cent Debt

A Florida teacher’s aide had her health insurance terminated and was left with thousands of dollars in medical debt because a plan recalculation resulted in an unpaid premium balance of only five cents. While federal flexibility rules once allowed insurers to ignore debts under $10, recent policy shifts and automated billing systems have led to tens of thousands of subsidized ACA plans being canceled over negligible amounts. It’s truly heartening to know that in our modern age of medical innovation, the entire American healthcare safety net can be successfully dismantled by the terrifying financial might of a single nickel.

Full Article

[STAT News] Washington is on the verge of true PBM reform

New legislative initiatives like the FAIR Act and Department of Labor rules aim to reclassify Pharmacy Benefit Managers (PBMs) as fiduciaries, finally forcing these middlemen to prioritize patient savings over their own bottom lines. Research indicates that PBMs have long exploited opaque rebate structures to drive up drug list prices, and these federal mandates seek to impose the same transparency that successfully reined in hidden fees within the retirement plan industry. If these industry giants are truly the "cost-saving heroes" their lobbyists claim to be, they should be absolutely delighted to finally have a legal obligation to prove it rather than continuing their championship-level performance in the sport of financial hide-and-seek.

Full Article

[Modern Healthcare] Express Scripts-FTC deal making matters worse, pharmacies say

Pharmacists warn that a recent FTC settlement intended to curb anticompetitive behavior by Express Scripts is actually resulting in new contract terms that are "untenable" and economically unsustainable for independent drugstores. The agreement’s shift toward acquisition-cost reimbursement and its specific data-sharing requirements may inadvertently give the PBM a competitive advantage while offering loopholes that limit the reach of its consumer protections. Apparently, the only thing more efficient than a PBM at extracting profit is a federal regulator "fixing" the problem by accidentally handing the monopoly a more detailed map of its victims' wallets.

Full Article