Thread by @NeuCare

1/ If y'all want to know why health care costs are high in America, pull up a chair & pour a stiff drink...

My patient is 67 yo lady (call her Sue) w/ newly diagnosed COPD. She is very reluctant to take meds but I convinced her to at least try an inhaler for relief of symptoms.

2/ In addition to general stubbornness, Sue is also understandably concerned about the cost of the med. I had some Dulera samples so gave her 2 months of that.

Follow-up visit: Sue reports it's working well so wants to continue.

Great! (wish that was the end of the story)

3/ I don't have unlimited samples, so suggested she get could get a similar med from the pharmacy. (Sue didn't even know she had a Part D med plan.) So, being a cost-conscientious doctor, I prescribe her an AirDuo inhaler to Walgreens.

4/ AirDuo is an inhaled combo med, a generic equivalent of Advair. very similar to Dulera. For most people, these are clinically the same. AirDuo currently my go-to med in the category because "cash" price is ~$50/mo using @GoodRx at several pharmacies--by far cheapest option.

5/ Within 24 hrs, Walgreens notifies me her Part D plan (which she didn't know existed until then) doesn't "cover" AirDuo, but prefers Advair, Breo, or Symbicort.

<MY HEAD EXPLODES>

The preferred meds are $200-400/mo--4-8X the cost of what I prescribed! What is going on here?!

6/ This makes no sense..."Why would her insurance plan prefer to pay MORE $ for medication for the same condition?" They are trying to spend less $, right?

Well, it's more complex than that.

There is a little (actually, multiple billions--with a B--of $) industry called PBMs.

7/ What are these "PBMs"? (Different than PB&J, so glad you asked)

Pharmacy benefit managers (PBMs) are yet another middleman in our insane medical billing industry. They are not insurance plans; rather a company that administers many aspects of Rx coverage for insurance plans.

8/ PBMs choose which meds are on the preferred list (the formulary). According to them, they "reduce prescription drug costs and improve convenience and safety for (everyone)"...which is awesome & thankfully they do this for 266 million (75%) Americans w/ insurance!

<plot twist>

9/ Other than being self-described as awesome, how do PBMs themselves make money?

PBMs claim they save insurance plans (including govt-funded plans) money by helping them spend less on meds; then share in that "savings" (profit for them).

Win-win, right? Not so fast.

10/ Other than the math of "savings" being convoluted, another revenue source for PBMs are "rebates". (Or, as we call them in the real world "kickbacks")

Kickbacks, I mean "rebates", are $ paid to PBMs by med manufacturers whenever a patient gets a particular med at a pharmacy

11/ <I need a refill 🥃 >

So, what does this all mean for Sue?

I told Walgreens to go ahead & fill Advair if the plan "preferred" it-- stupidly presuming it would a cheaper co-pay (than $50) for her. Recalling Sue's cost concern, I called back the pharmacist to confirm...

12/ Boy, I was wrong!

Sue's portion for the Advair was going to be $189/mo for the foreseeable future!

That was just her portion...the Rx plan total "discounted" price was nearly $350/mo.

I have no idea how much of a kick-back the PBM was getting but likely more than pennies.

13/ I don't blame the pharmacist here. He was actually just as perturbed! Also, pharmacies are busy places with most patients demanding to use their insurance plans. (And, until recently, many PBM contracts had "gag clauses" prohibiting pharmacy disclosure of this info!)

14/ Back to Sue...

She smartly told her Rx plan to shove it & paid $50 for the AirDuo. (she'll be fine)

But this isn't just about Sue: Millions of Americans who are unknowingly being ripped off like this every damn day. You might be one of them!

& it's not just Rx meds...

15/ While the effect of PBM kick-backs is perhaps the most egregious example, this type of inflation happens at almost every level; multiple layers of billing admin and middlemen are involved in everything-- doctor visits, labs, radiology, procedures, etc.

Even crazier...

16/... is that the vast majority of people, including policymakers, strongly believe these third-parties are "controlling" costs; protecting patients from unscrupulous medical providers who would, without them, try to overcharge them.

After all, these are "benefits", right?

17/ Perhaps, you are screaming the trendy political slogan, "Medicare for All!".

Remember, Sue is a "beneficiary" of Medicare--the real program, not a unicorn, imaginary version. Furthermore, PBMs are huge power players, in large part, due to Medicare itself!

18/ I don't have a simple or political fix for this mess, but my best advice for individuals is to find a primary care physician (PCP) to help navigate this insane system, including watching out for your pocketbook where feasible.

Imo, the best PCP options are typically...

19/ ...those independent from a large hospital/health system. (another thread for another day).

Better yet, find a PCP who operates in the #DirectPrimaryCare (DPC) model who works exclusively for you and isn't rushed--can take time to care about all aspects of your care.

20/ There are now over 1000 DPC clinics around the nation. Us rebels even have a base now @DPCAlliance.

You can search for a DPC clinic at DPCAlliance.com/directory or DPCFrontier.com/mapper.

21/ (I'm an idiot...blame it on anger!)

It is DPCAlliance.org/directory