All posts by Micah Crittenden

Follow all of my thoughts and posts on Twitter at @thatgingerish

ALERT! YOUR CO-PAY HAS BEEN CLAWED BACK

How Does Prescription Drug Insurance Work?

Every insurance plan has preferred drugs, brand name drugs and drugs that are either not covered or have a high co-insurance cost.  These are often arranged into Tiers.

  • Tier 1 – Generic Drugs

    • Once a drug has been on the market for 20 years (25 in some circumstances), the patent held by the company which created the drug expires.  This allows other companies to create the exact same drug (chemically and in delivery) for a tiny fraction of the price.
    • Lowest copay amount
  • Tier 2 – Non-Preferred Generic Drugs

    • Same as above just more complex or expensive ingredients.  Could also be generics purchased by new companies trying to drive profits.
    • Slightly higher copay amount
  • Tier 3 – Preferred Brand Name Drugs

    • These drugs are less expensive than the Non-Preferred list, but are still under patents and therefore significantly more expensive than a generic.
    • Often have a higher copay than a generic drug
  • Tier 4 – Non-Preferred Brand Name Drugs

    • These are expensive drugs which are still under patent.  They are often the brand name drugs for the generics in Tier 1.  Considered an unnecessary insurance expense.
    • These drugs are often susceptible to a copay and having to pay the cost difference between the Brand Name and the Generic version.
  • Tier 5 – Specialty Drugs

    • These drugs are expensive, new and used to combat complex diseases.
    • They are often not covered at all or require heavy co-insurance payments and restrictions on access.

So…how do tiers become tiers?  Why is a drug covered under one insurance plan and not another?  Who controls this system?

Pharmacy Benefit Managers

Insurance Companies and Employers contract PBMs (Pharmacy Benefit Managers) to organize and negotiate plans with pharmacies and drug companies.  These folks are super important to understanding the cost of pharmacological medicine.

BCBS uses Prime Therapeutics from Irving, TX, as their PBM for many of their plans.  According to Prime Therapeutics’ website:

“Prime Therapeutics’ NetResults is one of the most aggressive formularies in the industry. And it works. Our clients are seeing an estimated savings of more than $10 per member per month.

So being aggressive pays off — we get people the medicine they need without the use of high-cost drugs.

Go bold or go home.”

So wait.  You do this formulary thing and we avoid high-cost drugs and everyone wins?  Cool.  

What’s a formulary?

A formulary is a tiered list of drugs covered by a prescription plan.  The “NetResults” formulary can be accessed here.  It uses a “p” for Tier 1, “np” for Tier 2, “P” for Tier 3 and “NP” for Tier 4.  The copay assigned to each of those tiers depends on how much your insurance company/business wants to pay for prescription coverage.

The average copay for a three-tier system (usually combines tiers 1 and 2 from above and excludes all drugs from tier 5) are $11 for Tier 1, $31 for Tier 2 and $53 for Tier 3.

So how do Wal-Mart and Target offer $4 generics WITHOUT INSURANCE? (They totally do.  Check out their lists here and here)

Average Wholesale Price

The Average Wholesale Price is the price a pharmacy buys the drug for in bulk.

It is considered the industry’s average price paid by a pharmacy to a drug manufacturer per 30/day or traditional supply.  You can find the federal government’s ACA payment AWP list here.

Let’s use Meloxicam 15mg as an example.  Target offers it for $4 without insurance.  The FDA says its AWP is about 1 cent a pill.  That’s a wholesale cost of 33 cents per 30 day supply.  With my insurance it is $4.18/30 day supply at Walgreens (as mine is a percent, not a copay).  The average cash price for the same amount is $13.78.  Priority Health will charge you $7 after you meet their $75 deductible.

NOTE:  The pricing isn’t even this simple as it is what the manufacturer reports to the government.  It doesn’t include all of the standard rebates and coupons given as incentives to PBMs and Pharmacies in the form of checks after our collective purchases.

Has it ever occurred to you that pharmaceuticals are like a grocery store without price tags?  Everyone pays a different amount and no one knows exactly why.  But more importantly, does Walgreens keep all of the 1,250% markup on my Meloxicam?

The Clawback

A PBM clawback occurs when an insurance company assigns expensive copays to a drug, a price that may be significantly higher than the actual value and acquisition cost of the drug.

Clawbacks occur when your pharmacy submits a claim for a prescription drug, and you’re directed to collect a specific dollar amount for the copay. The amount will likely be excessive and unrelated to the acquisition cost of the drug. – pbahealth.com

So for example, if you paid that $7 co-pay for 30 days of Meloxicam and Walgreens paid 33 cents, the PBM would clawback over $6 of that copay YOU PAID after paying your deductible and monthly premiums.  The amount of clawback to these PBMs has skyrocketed the cost of medication.

  • The PBM negotiates with drug companies to decide which drugs will be part of their formulary and on which tier.
  • The PBM establishes a rebate program for themselves based on purchases made by member of their formulary.
  • The PBM then sets the copay amount (often far above the actual price of the drug).
  • When the copay is more than the pharmacy charges, the PBM claws back all of the copay paid beyond the cost of the drug.

On top of this, you could have gotten the prescription cheaper by paying cash and not using your insurance.  But, if you’re a pharmacy, telling a customer not to use their insurance is asking for big-time PBMs to make your pharmacy a persona non grata under all plans they administer.  That would be a huge loss.

What Did We Learn?

There is a lot about pharmaceuticals that needs overhaul and transparency.  When the pharmaceutical rep shows up in a short skirt to your doctor’s office talking about the next big drug, she’s bringing with her a list of PBMs who have tiered that very medication.  The whole system revolves around a few key players who negotiate the prices, set the premiums, set the copays, choose the drugs, tell the doctors what scripts to write, tell the pharmacies what to charge and then collect back huge sums of cash from your family’s bank account.  We need transparency so that we can reform this broken system.  The only thing that can fight darkness is the light of day.

Further reading on other relevent pharma shenanigans

Micah Crittenden is a Senior Writer for American Research and is on Twitter at @thatgingerish

 

 

One Day in the Life of a Private Payer

The Backstory

We were in between insurance plans.  My husband had changed jobs and his new insurance would kick in on May 1st.  By the time we realized all of this, we had about 14 days to go.  We were faced with a decision – pay $1,800 for COBRA or take the risk and hope our family’s care for two weeks would cost less.  We took the risk.

With seven days to go, I developed a really ugly cough and fever.  I’ve had pneumonia a couple of times and the intensity seemed similar.  I had to go in.  We decided on Care Now, a “doc in a box” clinic which does Urgent Care.  I knew their fees would be standard and up front while my doctor’s office’s would be based upone many variables.

I have visited Care Now in the past for treatment on a weekend or during the evening when I didn’t want to miss work.  With insurance, they normally cost about $75 ( co-pay flat rate) and are able to do x-rays, blood work, urinalysis on site.  This is an affordable way to get rapid care for more intense illnesses – Pneumonia, Kidney Infections, Bronchitis, Pertussis – without having to do a stop at the doctor, then a lab, then an x-ray technician and wait for results.  Additionally, in the latter scenario, I often get a co-insurance bill from the x-ray tech and the lab for the cost of the testing.  This isn’t the case with Care Now.  One price to the patient — if you have insurance.


One Day as a Private Payer

Returning back to my day as a private payer, I used the mobile app to call ahead.  They usually call you back and let you know your wait will be 1 1/2 to 2 hours and they’ll call you when they are almost ready.  When they called me and I explained that I was going to be a private payer, they told me it would be about an hour or so.  Within 5 minutes they called me back and told me they were ready to see me.

Normally, even though they call you when they’re “ready” they’re not really ready.  I expect to spend a half hour sitting in their lobby with sick kids watching Moana on repeat anytime I want to see a doctor at Care Now.  I even brought my phone charger.  Within 5 minutes I had checked in, filled out their questionnaire and was called back to a room to be seen.  I was blown away.

My nurse was unexpectedly prompt as well, popping into the room to assess my condition.  She took basic vitals and then told me the doctor would see me soon.  She wasn’t kidding.  Within 3 minutes, the doctor was in my room to listen to my lungs and talk about my symptoms.

After she finished with the stethoscope, I asked what she thought.  She said, “well, I would recommed blood work and an x-ray to check for any possible infection – just to be safe.”  Then she looked down at the chart.  “But I see you’re a private payer, so I’ll leave that decision up to you.”

I think my jaw fell on the floor.  I have never had a healthcare professional let me make my own testing decisions.  I said, “well, you listened to my lungs…how did they sound?”

She thought for a moment.  “They sounded a little strained.  But that could be because you weren’t breathing all the way in – probably because it hurts.  Because of that, I wasn’t able to tell how well they were functioning.”

Jaw-on-floor-again.  “I could try harder, if you want to listen again?”

She agreed and we repeated the breathe-in breathe-out routine.

“Your lungs actually sound pretty clear.  It seems to me that you have sinusitis and it isn’t infecting your lungs yet.”

Excited by the new medical conversation I’m able to have I ask, “so then why am I coughing so hard?”

“Because the drainage from your sinuses is irritating your throat.  Its hard to tell.  Your lungs could be a problem.  I can never know for sure without testing.”

“But as it stands right now, you would be willing to treat me for sinusitis and then, if it didn’t improve in a couple days, we could explore doing the blood work and x-ray?”

“Absolutely.  If that’s the course you decide to go, I think I would also prescribe you a cough syrup to help as we fight off the sinus infection.”

“Sold.”

I sailed out of Care Now within 5 minutes of that moment paying only $150 for the visit.  I left with an antibiotic and a cough syrup.

Next up was Walgreens.  Certainly this would hurt, right?  Prescriptions with ZERO coverage have gotta be EXPENSIVE.  I dropped the scripts off and explained again that I would be a private payer.  She took the time to give me an estimate of my prescriptions before I left the window so I would know what they were going to cost.  $116.41 for my antibiotic and syrup combined.  Not too bad.

When they were ready for pick up, I walked up to the window.  The clerk said “I noticed you’re a private payer, so I hope you don’t mind, but I looked up some coupons for you.  Instead of $116.41, your total is $68.42.”  I thanked her and collected my medicine in awe.  Since when has Walgreens tried to save me money?

The doctor was right.  I was better within 48 hours of treatment and had spent a total of $218.42.


The Takeaway

 

If I had used insurance on that day in April the total bill paid by my insurance company would have been higher than what I paid as a private payer.  They would have charged for the visit, the blood work and the xray.  In addition, my copay would have been subject to The Clawback.  All of these costs would have resulted in a net cost increase for the coverage across the board.

This is the long term result of allowing doctors and pharmacies to bill our insurance companies whatever they think could be necessary.  While the cost to patient appears less with insurance, the cost to the system is greater due to the freedom afforded to perform tests and prescribe at will.  If we begin to work with our doctors as collaborators on our health instead of as flat-rate consumers, we can decrease costs to the system and lower the burden on the flawed American insurance system.

Think of it like managing data on a cellular plan.  If we all agree to only stream netflix when we are on wifi, there’s more to go around for everyone.  Hell, with collective cost savings in mind, we could make single payer dreams affordable for our nation without sacrificing quality or skyrocketing cost.  We just need doctors to join us in our fight.

Georgia’s 6th Special Election:  A Referendum on Trump

Today (Tuesday, June 20th) the voters in Georgia’s 6th congressional district go to the polls in a special election to choose their new representative in the US House.  This election is incredibly important for many reasons:

 

1.  This is a traditionally conservative district in a conservative state.  

district-6-map

Georgia’s 6th congressional district, just north of Atlanta, was Newt Gingrich’s home district from 1979 to 1999.

In 2016, the Republican incumbent won this district with 61.7%.  In 2014, it was 66.04%.  In 2012, Price won with 64.5%.  This trend can be traced all the way back to 1978 when Newt Gingrich won the seat for the GOP by 7,500 votes.  (https://ballotpedia.org/Georgia%27s_6th_Congressional_District_election,_2016)

The current polling between Democratic candidate Ossoff and Republican candidate Handel is within the margin of error.  That means they are in a statistical tie.  Come rain or shine, turn out will determine the outcome of the election.  

The simple fact that the race is in a statistical tie is, to quote Joe Biden, “a big f***in’ deal”.  This seat has been a guaranteed Republican seat since 1979.  If guaranteed conservative seats are up for grabs in 2018, this will send a shockwave through all members of the Republican controlled House of Representatives.

 

2.  If this district swings from being a GOP stronghold to being a Democrat-held seat, it will concern all members of congress up for election in 2018.

Certain congressional seats are considered guaranteed Republican holdings.  These seats often breed the most conservative members of the House of Representatives as they have no need to be moderate, Democrats will simply never win.

Georgia’s 6th isn’t the only seat like this.  Texas-26, the seat held by Michael Burgess, is another inherited Republican “guaranteed” seat.  Michael Burgess is the author of the disastrous AHCA and a vocal advocate for big Pharma.  From places like Georgia’s 6th and Texas’s 26th we find the most partisan, divisive rhetoric.  They can say what they want about women and their bodies, about African Americans, about LGBTQ without reproach because the Democrats in their districts will never get loud enough to say “THIS IS NOT AMERICA.”

If Ossoff wins, every red district will be considered a toss-up for 2018.  The rhetoric will become less extreme.  The Democrats will nominate stronger candidates.  The people will have a choice across the country that isn’t based on identity politics, but instead, based on issues and trust.

This means, the Republicans in congress will be afraid to push far right-wing agendas from now until election day in 2018.  They will back peddle on the AHCA.  They will avoid tax breaks for the rich.  They will be more inclined to investigate into the cyber war propagated by the Russian Government.  They will hold town halls.  They will listen to our phone calls.  They have to or, for the first time in many years, they could lose the House Majority.

 

3.  If Ossoff wins, conservatives will blame Trump.

In mid-term elections where the President has an approval rating over 50%, his party loses an average of 14 seats in the House.  In mid-term elections where the President has an approval rating below 50%, they lose an average of 38.  That is a massive gulf.

The investigation into collusion with Russia has been stalled by Republican members of the House (remember Devin Nunes) in an effort to wait it out and hope it goes away.  If Ossoff wins, it will show the GOP that the public not only supports an investigation into Trump Team’s collusion with Russia, but that defending Trump is a dangerous political decision.

97% of voters who strongly disapprove of Trump say they’re voting for Ossoff.  If he wins, that will indicate that the public disapproval of Trump is so strong that it will harm Republicans in 2018 mid-terms.  The coat-tails will be bad.

 

4.  Dark posts are back.

The same team (Giles-Parscale) that engineered the dark posts in the November 2016 election are back to disenfranchise African American voters.  They have sent out ads mis-quoting President Obama yesterday morning.  On Sunday, Handel’s husband shared this post on Facebook:

Aviary Photo_131423619876787802

The goal is to get the 13.4% of Georgia’s 6th that is African American to stay home.  If you are in the 6th district and see an ad on Facebook, Twitter, Instagram today that is disparaging about African Americans regarding Democrats, Obama or Ossoff – SAY SOMETHING.  This type of advertising is not intended to help democracy, its intended to dissuade voters from going to the polls.

Statistically, Democrats vote earlier than Republicans.  That means all information that comes out in the next 12 hours will affect Republican turnout more than Democratic.  Expect extreme rhetoric.  Expect lines.  Expect disenfranchisement.  Stand up against it.

handel-ossoff

In conclusion, if Georgia’s 6th is won by the Republicans, nothing changes.  We continue on with the division in our country and with no check or balance against the Obstructionist policies of the House and Executive Branch.  Trump is emboldened.  House Republicans feel safe to spew extremist rhetoric.  Strong Democratic candidates will stay out of “red district” races.  We get more of the same for the next year and a half.  Maybe longer.

But, if Ossoff wins tonight, it changes everything.

Micah Crittenden is a Senior Writer for American Research and is available on Twitter at @thatgingerish

Obstruction of Justice

What is Obstruction of Justice?  According to 18 U.S.C. § 1503, “whoever . . . corruptly or by threats or force, or by any threatening letter or communication, influences, obstructs, or impedes, or endeavors to influence, obstruct, or impede, the due administration of justice, shall be (guilty of an offense).”

In light of James Comey’s prepared remarks (which can be found here:  https://www.intelligence.senate.gov/sites/default/files/documents/os-jcomey-060817.pdf) we need to evaluate whether President Trump has committed the aforementioned offense.

1.  “Whoever corruptly or by threats or force” — this indicates that force or threat of force is not necessary for one to be guilty of Obstruction of Justice.  It is enough to be acting corruptly.

2.  “by any threatening letter or communication” — This indicates the offense does not need to be in writing but can be verbally or by direct action.

3.  “influences, obstructs, or impedes, or endeavors to influence, obstruct, or impede, the due administration of justice, shall be (guilty of an offense).” — Indicates that it is not necessary for the crime to be successful, but rather, the attempt to obstruct justice is sufficient for conviction.

Information we have received from the Comey statement:

Second Meeting (page 3):



From this section we can infer that the President was using Director Comey’s desire to stay in his position as a bargaining chip for “loyalty”.

Second Meeting (page 4):


Through this we see a specific aim voiced – to “let Flynn go”.  In every aspect of the definition of Obstruction of Justice, this fits. This statement alone is a clear instance of the aforementioned crime.

Final Meeting (page 7):


This is a clear request for the Director to have acted to benefit Trump in the middle of the investigation.  This was his final conversation with the President before being terminated on May 9, 2017.
Based on the prepared testimony and before we have the opportunity to hear what other issues will be brought to light tomorrow, it is clear that President Trump at least committed Obstruction of Justice in relation to the Michael Flynn case.  He also appears to have attempted to influence justice on his own behalf on at least two separate occasions listed by Director Comey.  For this reason, we must begin impeachment proceedings.
“It is almost always the cover up rather than the event that causes trouble.” – Howard Baker

Micah Crittenden is a writer for American Research and is also on twitter at @thatgingerish

Blending Truth and Propaganda

The harms of “fake news” are all too often overlooked.  We search for trustworthy news purveyors, those that provide us information about the world around us without intentionally ignoring parts of the situation’s reality.  When we can’t find a source that simply provides information without hiding/dismissing the parts that complicate the intended conclusion, we search for a source that agrees with our own understanding of the world.  This is called an echo chamber.

Technology has increased our access to the world.  We can, in an instant, see life through the eyes of a 50-year-old in Pakistan or a 33-year-old in Lufkin, Texas.  We can see the newborn of our college roommate across the globe within minutes of its birth.  The connectivity is awe-inspiring and world-changing.

In this same light, we have greater access to unfolding news stories across the globe.  If a child goes missing in Georgia, it shows up on our Twitter feeds within seconds of the story breaking.  If you allow it, the inundation with these local stories you never had access to beforehand will lead to a misguided fear that we are less safe than we once were.  When your Facebook feed is filled with friends sharing sad/scary stories from their own communities it causes one to believe that crime, fear, violence, war and hate are more prevalent today than they were before the internet.

Statistics say this isn’t so.  According to U.S. News & World Report (https://www.usnews.com/news/articles/2016-09-26/us-crime-rate-rises-slightly-remains-near-20-year-low), violent crime has decreased by almost 50% since 1996.  Pew Research echoes and expands upon the statistics cited in U.S. News & World Report (http://www.pewresearch.org/fact-tank/2017/02/21/5-facts-about-crime-in-the-u-s/).  We are simply not becoming less safe.  Yet, it feels differently, doesn’t it?

That’s the problem with an echo chamber.  If we use our own gut feelings based on the aggregation of internet information we access we begin to doubt facts.  This is the direct cause of alternative factsfacts that feel true regardless of their support by independent verification.  These facts begin with a whisper between friends – “I don’t let my kids play outside anymore because the world is so dangerous now” and lead to online opinion posts about the same subject matter.  Add in enough likes, enough re-tweets, enough shares and these posts take on a life of their own as alternative facts.

Anecdotal evidence has always been an argument used against scientific facts.  This is prevalent enough that there is a logical fallacy of the same name (http://rationalwiki.org/wiki/Anecdotal_evidence).  However, if enough people have the same anecdotal evidence, it becomes a group theory.  Before the internet, most folks didn’t know enough people to build past their own feeling that a fact is incorrect.  Today, you can find a thousand people who agree with your feelings simply by typing your theory into google search.

These pods of people with the same feeling begin by affirming their original theory to one another.  They look for others who think similarly and link out to their anecdotal posts about the subject matter.  Once the network becomes broad enough, it begins to echo back.  New feelings emerge and are sent to the group.  Since the group has bonded over the mistrust of scientific fact, they trust each other wholeheartedly as the only true source of information.  If my friend online also thinks Obama was born in Kenya, when they tell me he is going to invade Texas, I listen.

The far right has courted these feelings via AM radio for decades.  Today, they court them via online media.  These posts are shared between pod members, reaffirming their own belief sets and expanding the areas where they distrust facts.  This grows and grows until the readers no longer trust any other source for news.  If you, an outsider, tell them the Mayor of Detroit says crime is down, they’ll ask about your source.  If you say it is anything other than a far right alternative facts blog (or sometimes Fox News), they’ll declare your facts skewed and therefore invalid.

Oddly enough, the readers of these blogs are grateful.  In the face of complex and constantly evolving internet information, their worlds have become simple again.  Their feelings are real and valid and everything else is false.  Fake News.  Just like a wolf in sheep’s clothing, talk show hosts like Sean Hannity, Bill O’Reilly and Tucker Carlson all state they are not journalists.  Not a single one of them has done investigative work on anything on which they report.  Their only job is to digest and define the issues for their viewer.  To be frank, they’re glorified Maury Povich/Jerry Springer types, trying to be the most extreme for ratings.  Yet, they’re called news.

So, what’s the harm?  Why are alternative facts so dangerous?

When we cannot trust the media, we begin placing all of our trust in demagogues.  Their words are the truth.  They have no need to independently verify.  They aren’t interested in debate.  Their opinion is the the only way to think, to feel.

We were warned against demagogues by our founding fathers.  In the Federalist Papers #1, Alexander Hamilton warns “… of those men who have overturned the liberties of republics, the greatest number have begun their career by paying an obsequious court to the people; commencing demagogues, and ending tyrants.”   To give any person command of truth is to give them the power to become a tyrant.  The DPRK is an excellent example of this fact.  In a post-fact society, the ruler becomes God.

Across the globe today, people joined in the March for Truth.  We must continue to rise up against the falsities in our feeds, the fallacy of anecdotal evidence and the belief that any one person has a firm hold on what is real.  We must fight for universal, scientifically proven truth in all areas of life.  Real patriots stand on the side of justice.  Real patriots stand on the side of truth.

Micah Crittenden is a writer for American Research and is also on twitter at @thatgingerish