#Caremark

[mostlysignssomeportents]

What the fuck is a PBM?

TOMORROW (Sept 24), I'll be speaking IN PERSON at the BOSTON PUBLIC LIBRARY!

Terminal-stage capitalism owes its long senescence to its many defensive mechanisms, and it's only by defeating these that we can put it out of its misery. "The Shield of Boringness" is one of the necrocapitalist's most effective defenses, so it behooves us to attack it head-on.

The Shield of Boringness is Dana Claire's extremely useful term for anything so dull that you simply can't hold any conception of it in your mind for any length of time. In the finance sector, they call this "MEGO," which stands for "My Eyes Glaze Over," a term of art for financial arrangements made so performatively complex that only the most exquisitely melted brain-geniuses can hope to unravel their spaghetti logic. The rest of us are meant to simply heft those thick, dense prospectuses in two hands, shrug, and assume, "a pile of shit this big must have a pony under it."

MEGO and its Shield of Boringness are key to all of terminal-stage capitalism's stupidest scams. Cloaking obvious swindles in a lot of complex language and Byzantine payment schemes can make them seem respectable just long enough for the scammers to relieve you of all your inconvenient cash and assets, though, eventually, you're bound to notice that something is missing.

If you spent the years leading up to the Great Financial Crisis baffled by "CDOs," "synthetic CDOs," "ARMs" and other swindler nonsense, you experienced the Shield of Boringness. If you bet your house and/or your retirement savings on these things, you experienced MEGO. If, after the bubble popped, you finally came to understand that these "exotic financial instruments" were just scams, you experienced Stein's Law ("anything that can't go forever eventually stops"). If today you no longer remember what a CDO is, you are once again experiencing the Shield of Boringness.

As bad as 2008 was, it wasn't even close to the end of terminal stage capitalism. The market has soldiered on, with complex swindles like carbon offset trading, metaverse, cryptocurrency, financialized solar installation, and (of course) AI. In addition to these new swindles, we're still playing the hits, finding new ways to make the worst scams of the 2000s even worse.

That brings me to the American health industry, and the absurdly complex, ridiculously corrupt Pharmacy Benefit Managers (PBMs), a pathology that has only metastasized since 2008.

On at least 20 separate occasions, I have taken it upon myself to figure out how the PBM swindle works, and nevertheless, every time they come up, I have to go back and figure it out again, because PBMs have the most powerful Shield of Boringness out of the whole Monster Manual of terminal-stage capitalism's trash mobs.

PBMs are back in the news because the FTC is now suing the largest of these for their role in ripping off diabetics with sky-high insulin prices. This has kicked off a fresh round of "what the fuck is a PBM, anyway?" explainers of extremely variable quality. Unsurprisingly, the best of these comes from Matt Stoller:

https://www.thebignewsletter.com/p/monopoly-round-up-lina-khan-pharma

Stoller starts by pointing out that Americans have a proud tradition of getting phucked by pharma companies. As far back as the 1950s, Tennessee Senator Estes Kefauver was holding hearings on the scams that pharma companies were using to ensure that Americans paid more for their pills than virtually anyone else in the world.

But since the 2010s, Americans have found themselves paying eye-popping, sky-high, ridiculous drug prices. Eli Lilly's Humolog insulin sold for $21 in 1999; by 2017, the price was $274 – a 1,200% increase! This isn't your grampa's price gouging!

Where do these absurd prices come from? The story starts in the 2000s, when the GW Bush administration encouraged health insurers to create "high deductible" plans, where patients were expected to pay out of pocket for receiving care, until they hit a multi-thousand-dollar threshold, and then their insurance would kick in. Along with "co-pays" and other junk fees, these deductibles were called "cost sharing," and they were sold as a way to prevent the "abuse" of the health care system.

The economists who crafted terminal-stage capitalism's intellectual rationalizations claimed the reason Americans paid so much more for health care than their socialized-medicine using cousins in the rest of the world had nothing to do with the fact that America treats health as a source of profits, while the rest of the world treats health as a human right.

No, the actual root of America's health industry's problems was the moral defects of Americans. Because insured Americans could just go see the doctor whenever they felt like it, they had no incentive to minimize their use of the system. Any time one of these unhinged hypochondriacs got a little sniffle, they could treat themselves to a doctor's visit, enjoying those waiting-room magazines and the pleasure of arranging a sick day with HR, without bearing any of the true costs:

https://pluralistic.net/2021/06/27/the-doctrine-of-moral-hazard/

"Cost sharing" was supposed to create "skin in the game" for every insured American, creating a little pain-point that stung you every time you thought about treating yourself to a luxurious doctor's visit. Now, these payments bit hardest on the poorest workers, because if you're making minimum wage, at $10 co-pay hurts a lot more than it does if you're making six figures. What's more, VPs and the C-suite were offered "gold-plated" plans with low/no deductibles or co-pays, because executives understand the value of a dollar in the way that mere working slobs can't ever hope to comprehend. They can be trusted to only use the doctor when it's truly warranted.

So now you have these high-deductible plans creeping into every workplace. Then along comes Obama and the Affordable Care Act, a compromise that maintains health care as a for-profit enterprise (still not a human right!) but seeks to create universal coverage by requiring every American to buy a plan, requiring insurers to offer plans to every American, and uses public money to subsidize the for-profit health industry to glue it together.

Predictably, the cheapest insurance offered on the Obamacare exchanges – and ultimately, by employers – had sky-high deductibles and co-pays. That way, insurers could pocket a fat public subsidy, offer an "insurance" plan that was cheap enough for even the most marginally employed people to afford, but still offer no coverage until their customers had spent thousands of dollars out-of-pocket in a given year.

That's the background: GWB created high-deductible plans, Obama supercharged them. Keep that in your mind as we go through the MEGO procedures of the PBM sector.

Your insurer has a list of drugs they'll cover, called the "formulary." The formulary also specifies how much the insurance company is willing to pay your pharmacist for these drugs. Creating the formulary and paying pharmacies for dispensing drugs is a lot of tedious work, and insurance outsources this to third parties, called – wait for it – Pharmacy Benefits Managers.

The prices in the formulary the PBM prepares for your insurance company are called the "list prices." These are meant to represent the "sticker price" of the drug, what a pharmacist would charge you if you wandered in off the street with no insurance, but somehow in possession of a valid prescription.

But, as Stoller writes, these "list prices" aren't actually ever charged to anyone. The list price is like the "full price" on the pricetags at a discount furniture place where everything is always "on sale" at 50% off – and whose semi-disposable sofas and balsa-wood dining room chairs are never actually sold at full price.

One theoretical advantage of a PBM is that it can get lower prices because it bargains for all the people in a given insurer's plan. If you're the pharma giant Sanofi and you want your Lantus insulin to be available to any of the people who must use OptumRX's formulary, you have to convince OptumRX to include you in that formulary.

OptumRX – like all PBMs – demands "rebates" from pharma companies if they want to be included in the formulary. On its face, this is similar to the practices of, say, NICE – the UK agency that bargains for medicine on behalf of the NHS, which also bargains with pharma companies for access to everyone in the UK and gets very good deals as a result.

But OptumRX doesn't bargain for a lower list price. They bargain for a bigger rebate. That means that the "price" is still very high, but OptumRX ends up paying a tiny fraction of it, thanks to that rebate. In the OptumRX formulary, Lantus insulin lists for $403. But Sanofi, who make Lantus, rebate $339 of that to OptumRX, leaving just $64 for Lantus.

Here's where the scam hits. Your insurer charges you a deductible based on the list price – $404 – not on the $64 that OptumRX actually pays for your insulin. If you're in a high-deductible plan and you haven't met your cap yet, you're going to pay $404 for your insulin, even though the actual price for it is $64.

Now, you'd think that your insurer would put a stop to this. They chose the PBM, the PBM is ripping off their customers, so it's their job to smack the PBM around and make it cut this shit out. So why would the insurers tolerate this nonsense?

Here's why: the PBMs are divisions of the big health insurance companies. Unitedhealth owns OptumRx; Aetna owns Caremark, and Cigna owns Expressscripts. So it's not the PBM that's ripping you off, it's your own insurance company. They're not just making you pay for drugs that you're supposedly covered for – they're pocketing the deductible you pay for those drugs.

Now, there's one more entity with power over the PBM that you'd hope would step in on your behalf: your boss. After all, your employer is the entity that actually chooses the insurer and negotiates with them on your behalf. Your boss is in the driver's seat; you're just along for the ride.

It would be pretty funny if the answer to this was that the health insurance company bought your employer, too, and so your boss, the PBM and the insurer were all the same guy, busily swapping hats, paying for a call center full of tormented drones who each have three phones on their desks: one labeled "insurer"; the second, "PBM" and the final one "HR."

But no, the insurers haven't bought out the company you work for (yet). Rather, they've bought off your boss – they're sharing kickbacks with your employer for all the deductibles and co-pays you're being suckered into paying. There's so much money (your money) sloshing around in the PBM scamoverse that anytime someone might get in the way of you being ripped off, they just get cut in for a share of the loot.

That is how the PBM scam works: they're fronts for health insurers who exploit the existence of high-deductible plans in order to get huge kickbacks from pharma makers, and massive fees from you. They split the loot with your boss, whose payout goes up when you get screwed harder.

But wait, there's more! After all, Big Pharma isn't some kind of easily pushed-around weakling. They're big. Why don't they push back against these massive rebates? Because they can afford to pay bribes and smaller companies making cheaper drugs can't. Whether it's a little biotech upstart with a cheaper molecule, or a generics maker who's producing drugs at a fraction of the list price, they just don't have the giant cash reserves it takes to buy their way into the PBMs' formularies. Doubtless, the Big Pharma companies would prefer to pay smaller kickbacks, but from Big Pharma's perspective, the optimum amount of bribes extracted by a PBM isn't zero – far from it. For Big Pharma, the optimal number is one cent higher than "the maximum amount of bribes that a smaller company can afford."

The purpose of a system is what it does. The PBM system makes sure that Americans only have access to the most expensive drugs, and that they pay the highest possible prices for them, and this enriches both insurance companies and employers, while protecting the Big Pharma cartel from upstarts.

Which is why the FTC is suing the PBMs for price-fixing. As Stoller points out, they're using their powers under Section 5 of the FTC Act here, which allows them to shut down "unfair methods of competition":

https://pluralistic.net/2023/01/10/the-courage-to-govern/#whos-in-charge

The case will be adjudicated by an administrative law judge, in a process that's much faster than a federal court case. Once the FTC proves that the PBM scam is illegal when applied to insulin, they'll have a much easier time attacking the scam when it comes to every other drug (the insulin scam has just about run its course, with federally mandated $35 insulin coming online, just as a generation of post-insulin diabetes treatments hit the market).

Obviously the PBMs aren't taking this lying down. Cigna/Expressscripts has actually sued the FTC for libel over the market study it conducted, in which the agency described in pitiless, factual detail how Cigna was ripping us all off. The case is being fought by a low-level Reagan-era monster named Rick Rule, whom Stoller characterizes as a guy who "hangs around in bars and picks up lonely multi-national corporations" (!!).

The libel claim is a nonstarter, but it's still wild. It's like one of those movies where they want to show you how bad the cockroaches are, so there's a bit where the exterminator shows up and the roaches form a chorus line and do a kind of Busby Berkeley number:

https://www.46brooklyn.com/news/2024-09-20-the-carlton-report

So here we are: the FTC has set out to euthanize some rentiers, ridding the world of a layer of useless economic middlemen whose sole reason for existing is to make pharmaceuticals as expensive as possible, by colluding with the pharma cartel, the insurance cartel and your boss. This conspiracy exists in plain sight, hidden by the Shield of Boringness. If I've done my job, you now understand how this MEGO scam works – and if you forget all that ten minutes later (as is likely, given the nature of MEGO), that's OK: just remember that this thing is a giant fucking scam, and if you ever need to refresh yourself on the details, you can always re-read this post.

The paperback edition of The Lost Cause, my nationally bestselling, hopeful solarpunk novel is out this month!

If you'd like an essay-formatted version of this post to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:

https://pluralistic.net/2024/09/23/shield-of-boringness/#some-men-rob-you-with-a-fountain-pen

Image: Flying Logos (modified) https://commons.wikimedia.org/wiki/File:Over_$1,000,000_dollars_in_USD_$100_bill_stacks.png

CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0/deed.en

[caremarkliverpool]

Providing Compassionate Care: A Look into Caremark Liverpool, Your Trusted Care Agency in Liverpool

In a bustling city like Liverpool, where life moves at a fast pace, there arises a need for compassionate care services to support individuals in various stages of life. This is where Caremark Liverpool shines as a beacon of reliability and compassion in the realm of caregiving.

Introduction:

Care Agency Liverpool: Meeting the Needs of the Community

As one of the leading care agency in Liverpool, Caremark Liverpool stands out for its unwavering commitment to providing high-quality care services tailored to the unique needs of each individual.

Dedicated Caregivers:

At the heart of Caremark Liverpool are its dedicated caregivers who go above and beyond to ensure the well-being and comfort of their clients. Trained extensively in caregiving techniques and equipped with empathy and compassion, our caregivers form meaningful connections with those under their care.

Comprehensive Services:

From elderly care to disability support and everything in between, Caremark Liverpool offers a comprehensive range of services designed to meet the diverse needs of the community. Whether it's assistance with daily tasks, companionship, or specialized care, our team is here to provide support every step of the way.

Tailored Care Plans:

Recognizing that each individual has unique requirements, Caremark Liverpool takes a personalized approach to care planning. Our team works closely with clients and their families to develop tailored care plans that prioritize comfort, dignity, and independence.

Conclusion:

Choose Caremark Liverpool for Compassionate Care You Can TrustWhen it comes to finding a reliable care agency in Liverpool, look no further than Caremark Liverpool. With a team of dedicated caregivers, comprehensive services, and personalized care plans, we are committed to providing compassionate care that makes a difference in the lives of our clients. Trust Caremark Liverpool for all your caregiving needs.

[nationallawreview]

Caremark Liability Following the SEC’s New ESG Reporting Requirements

Caremark Liability Following the SEC’s New ESG Reporting Requirements

Recent developments in the Court of Chancery concerning a corporate board’s duty to monitor and provide oversight over a corporation’s operations, so-called Caremark claims, are likely to intersect with the Securities and Exchange Commission’s (“SEC”) proposed new ESG disclosure obligations to create a new category of corporate risk.  In this article, we discuss the recent trends in Delaware law��

[lesbianralzarek]

you know those airplane mechanics who are good at their jobs and keep them in top condition because they wanna fuck the plane so bad? thats me with ethical practices in medicine. yes i WILL sit with you running prior auths and adjudicating insurance claims for an hour until i can get that drug below 1k for you. i know all pertinent hipaa policies by heart. is this needle size working for you? i bet i can get you a 72-hour emergency supply of that blood pressure med while your prescriber is out of office. i wont say anything weird. but. dear tumblr followers, i am being a sicko about it internally

[newpathwrites]

My insurance finally approved my biologic (that I’ve been taking for almost 10 years…)!

[vixvaporub]

Working in healthcare reminds me on the daily that the US medical system is fucked up but a recent example that hasn't escaped my mind for weeks is that a patient with a new diagnosis for HIV was trying to get his medication... but his insurance rejected it and said that they don't cover any HIV meds

[14raweggs]

my red flag is that I get Irrationally Pissed when people don't understand the pharmacy industry at all but still act like they're cracking some code over discount cards

like baby come here, let's talk about pbms, let's talk about how discount cards are profitable, let's talk about your local pharmacy's abysmal profit margins

[rodspurethoughts]

CVS Caremark® defines future of pharmacy benefit management

CVS Caremark pledges to accelerate transparency, drive to lowest net cost prescription drugs, strengthen pharmacy relations, and deliver the best clinical care in pharmacy WOONSOCKET, R.I. /PRNewswire/ — CVS Caremark®, the nation’s leading pharmacy benefit manager and a CVS Health® (NYSE:��CVS) company, today announced a renewed pledge to American businesses, unions, and health plans — building…

[chillyfeetsteak]

sign into the patient portal to make an appointment! enter the six digit confirmation code we texted! make an account to view health providers near you! log in with your google account! please use our online portal to manage your healthcare! download our app for virtual appointments! use mychart to track your labs! this is a different medical facility from your last doctor so you need a different mychart account! answer this 80 question survey each time before you are seen! download the cvs app to manage your prescriptions! download the cvs caremark app to manage your other prescriptions! these apps are not compatible. scan this generated barcode at the pharmacy to pick up your prescriptions! must be logged in. what if i jeff the kill you

[screamingay]

finally FINALLY got antibiotics for my 2.5 week uti bc i was worried at that point it would become a kidney infection and i legit forgot how it felt to pee normally.. moral of the story is always pee after sex & stop holding it for no reason & for the love of god do something abt it if it doesnt go away in like 5 days

[acetoneperoxyde]

caremark sucks my ass. fuck caremark and the horse it rode in on.

[numerousenbees]

because of my new insurance, i just payed 60 dollars for a 12 count (only 12 pills) of migraine meds. that you take on onset, and dissolve on ur tongue…

i constantly have the headache. it never goes away. its been here for 6 years. and if this also triggers a worse headache like its cousin suma triptan then its going to just fuck over my day more

[an-sceal]

I really don't dwell in this headspace much, but I wasn't expecting to spontaneously burst into tears as I was trying to fall asleep. I can't fucking live like this. And I didn't fucking have to, before they decided to deny me the medication that was WORKING.

Seeing the rheumatologist on Wednesday. I ache in every joint, I can barely make it up and down the stairs, and I keep falling over. I'm worse than I ever was before I started getting treated for this. I also have to sit down every half hour or so if I'm walking, because that's the time limit on actually being able to feel my legs and move them in an ambulatory manner.

I think I scared my sister with how much I can't do right now.

I feel like the embodiment of that old Garth Brooks song. I am much too young to feel this damn old.

[newpathwrites]

Anyone here suffer from sacroiliac joint pain? I’ve long suspected I have SI joint inflammation related to autoimmune stuff, and it’s gotten so bad recently, likely because my insurance is denying my biologic, so I’ve been without for too long now. It feels like my lower back is in a vice and about to break, so hard to get comfortable. Tylenol and heat are minimally helpful, and I’m not allowed to take NSAIDS. Stretching seemed to have made it worse?

I finally relented and took a free sample of Humira from my doctor to hold me over until this insurance thing is sorted out (I just feel like free samples should be reserved for people with financial difficulties, but I’m dying here). I hope it helps because this really sucks.

[follow-up-news]

The Federal Trade Commission said Friday that it is suing three drug middlemen, accusing them of inflating insulin prices. The FTC accused the "Big Three" pharmacy benefit managers (PBMs) — UnitedHealth Group's Optum Rx, CVS Health's Caremark and Cigna's Express Scripts — of "engaging in anticompetitive and unfair rebating practices that have artificially inflated the list price of insulin drugs, impaired patients’ access to lower list price products, and shifted the cost of high insulin list prices to vulnerable patients." Around 8 million Americans rely on insulin in the U.S., per the FTC. PBMs work with insurance companies to negotiate discounted prices from drug companies in exchange for including the drugs in their coverage. In theory, they are supposed to save patients money. Also included in the lawsuit are the PBMs' group purchasing organizations, which include Zinc Health Services, Ascent Health Services and Emisar Pharma Services. The "Big Three" oversee around 80% of all prescription drug plans in the U.S., according to the complaint, which alleges that they created a rebate system prioritizing high rebates from drug manufacturers, which led to the inflated insulin prices.

[tacosaysroar]

I’m currently reading 40+ pages on pharmacy benefit managers (PBMs — so like Optum and Caremark and Express Scripts, etc) for a thing at work and it is somehow simultaneously *Viciously Boring* and *The Most Fury-Inducing Garbage on Earth*.

Slow clap for that accomplishment, I guess?

I just finished the section on utilization management (or how they’re able to accomplish limiting or denying drugs people truly need) and I want to barf. The section on chronic illness and cancer treatment? Dark, stomach-churning stuff.

I know — we ALL know — the US healthcare system is fucked up and that PBMs are a huge, HUGE part of that, but the details. Oof. How they make those denial calculations. The number of people who abandon drugs because they aren’t covered — drugs they really and truly need to live comfortably or even to stay alive.

Again, this wasn’t news to me and I know it’s not news to you — US healthcare has been on the “this is the bad place” list for at least as long as I’ve been on the planet (and exponentially worse every decade since) — but having to read 40 pages of this shit parsed out in an impartial, matter-of-fact way is a lot. Like A LOT a lot.