Ohio Finds PBMs Increase Costs, CVS Accused of Fueling Opioid Crisis, & RPM Abuse Analysis

Hey all,

Happy Monday! I was reading the Peterson Center’s RPM analysis and wasn’t at all surprised by the abuse they uncovered. This is one area where President Trump’s China tariffs might help, since most RPM devices are made in China—cutting into, or even wiping out, the margins for offending RPM providers. Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX)

(Ohio Capital Journal) Ohio Medicaid Reform Saves Millions While Boosting Pharmacy Pay

A new report from the Ohio Department of Medicaid reveals that cutting out major pharmacy benefit managers (PBMs) led to $140 million in net savings over two years—even after drastically increasing dispensing fees to support local pharmacies. The reform, launched in 2022, created a state-run PBM system focused on transparency and fairness, replacing a model previously dominated by conglomerates like CVS and OptumRx that were accused of overcharging the state and underpaying pharmacies. The revamped system signed up 99% of pharmacies statewide, enhanced patient access, and reduced administrative overhead by $333 million. Apparently, the big PBMs’ idea of “cutting costs” meant keeping more of the money for themselves. Full Article

(USA TODAY) DOJ Lawsuit Accuses CVS of Fueling Opioid Crisis

The U.S. Department of Justice has filed a lawsuit against CVS, alleging the company filled unlawful opioid prescriptions and defrauded federal healthcare programs by seeking reimbursement for them. Citing internal evidence and whistleblower claims from former employee Hillary Estright, the DOJ accuses CVS of ignoring clear signs of “pill mill” practices in order to meet performance targets and boost profits, contributing to overdose deaths and the broader opioid epidemic. CVS disputes the allegations, claiming it always follows the law—which is an interesting defense from a company that, in 2015, paid $22 million and acknowledged it failed to monitor and report suspicious opioid prescriptions, effectively turning a blind eye to red flags. Full Article

(HealthLeaders) Remote Patient Monitoring Reimbursement Policy Reset

A new report from the Peterson Center on Healthcare highlights that CMS spent nearly $200 million on remote patient monitoring (RPM) in 2023, yet current reimbursement policies are outdated and not aligned with the clinical value of these services. As more providers adopt RPM for conditions like hypertension and musculoskeletal disorders, the report emphasizes the need for payment models that prioritize evidence-based, time-limited monitoring and condition-specific billing to ensure effectiveness and cost-efficiency. It recommends aligning coverage with clinical outcomes, expanding access to high-impact services, and improving data collection—because too many RPM programs seem focused on improving financial outcomes, not patient ones. Full Article