Marilyn Heine Profile picture
May 27, 2022 6 tweets 4 min read Read on X
🔥A must-read: ⁦@oncologyCOA⁩ report on #PBMs

Some takeaways:

“…PBMs make up an oligopoly of rich, vertically integrated conglomerates that routinely prey on health care practices, providers, and their patients.”
2/ “PBMs have done this by overwhelmingly abusing their responsibility to protect Americans from this country’s drug pricing crisis, instead exploiting the opacity throughout the nation’s drug supply chain to enrich themselves.”
3/ “[The report] explores how the recent levels of consolidation among PBMs and health insurers is adversely impacting #cancer care, fueling drug costs, all while allowing for massive profits for #PBMs and health insurance companies.”
4/ “Examining the most pervasive and abusive #PBM tactics, each section highlights the adverse impact of PBMs on #patients, health care payers (including #Medicare, #Medicaid, employers, and taxpayers), and providers, while also detailing potential solutions.”
5/ “[Solutions] include legislative efforts at both the state and federal levels…regulators (both state and federal) have tremendous tools available to them, that up until this point, have not been widely utilized.”
6/ To read the @oncologyCOA report, “Pharmacy Benefit Manager Exposé: How PBMs Adversely Impact Cancer Care While Profiting at the Expense of Patients, Providers, Employers, and Taxpayers.” please see:
communityoncology.org/wp-content/upl…

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More from @MarilynHeineMD

Aug 6
🚨As AMA’s representative to the HL7 Da Vinci Project Clinical Advisory Council (CAC), I ask that you please take urgent action.

Your participation could be the difference between meaningful improvements to prior authorization (PA) and little change.

Details in🧵

#FixPriorAuth Image
2/ **ISSUE OF CONCERN:

🔥On the PA and burden reduction use-case calls, some payers and EHR vendors are advocating that PA users should be back-office staff only, not clinicians based on their understanding and experiences.
3/

❗️Reliance on back-office is not the original intent of Da Vinci PA use-case design.

The goal was to have a clinician-oriented process that renders real time coverage information at the time of clinical decision and ordering to inform more timely and efficient PA workflows.
Read 8 tweets
Jul 31
🚨New AMA report analyzes the #pharmacybenefitmanager (#PBM) market concentration & its impact.

The report reviews the structure of the PBM industry, its deep ties to insurers, low level of competition, & high level of vertical integration.

👉 Report: 🧵 spr.ly/6047fnzfVImage
2/ AMA reports on the 10 largest PBMs & drug insurers nationally, summarizes concentration levels (HHIs) in their markets, & describes the extent of vertical integration of insurers with PBMs.

With ⬇️ competition & ⬆️ consolidation, patients could face ⬆️ costs & ⬇️ choices. Image
3/ The largest PBMs dominate a critical part of health care.

📍The 4 largest PBMs have a collective national market share of 67%.

📍OptumRx is the largest PBM (22.2% market share), followed by CVS Health (18.9%), Express Scripts (15.5%), & Prime Therapeutics (10.6%). Image
Read 9 tweets
Jul 21
🚨@AmerMedicalAssn conveyed to CMS concerns regarding the recently announced WISeR Model.

Read full letter:

Details “…key areas of concern where clarification and safeguards are needed to protect physicians and patients…”

Excerpts in 🧵 tinyurl.com/46msnsk8Image
2/ Wasteful and Inappropriate Service Reduction (WISeR) Model is a “…substantial shift in the traditional Medicare program’s approach to utilization management (UM) and prior authorization (PA)…potential for unintended consequences that could harm both patients and physicians.”
3/“…pathways represent significant departures from current standards & seem to conflict with CMS’ recent, highly laudable achievement of securing a commitment from the health insurance industry to fix the broken PA process, to include [⬇️] the overall volume of PA requirements.”
Read 28 tweets
Jul 16
🚨On 7/14/2025, CMS released the proposed rule for the 2026 Medicare Physician Fee Schedule Proposed Rule:

AMA identifies items for immediate attention as staff analyzes and develops a detailed summary of the nearly 2,000-page proposal. tinyurl.com/2p9t7w9xImage
2/🔹Conversion Factors (CF): Effects of MACRA, H.R. 1, Budget Neutrality

👉 MACRA Effect:

•Permanent 0.75% update for Medicare payments to QPs in advanced APMs

•Permanent 0.25% update for Medicare payments to all physicians who are not QPs, including MIPS-eligible clinicians
3/ Conversion Factors

👉 MACRA Effect:

•Physicians who are qualifying participants (QPs) in advanced APMs will receive a slightly ⬆️ CF update and, thus, slightly ⬆️ Medicare payments in 2026 compared to physicians who are not QPs.

tinyurl.com/3w48a8hfImage
Read 34 tweets
Jul 11
🚨CMS issued updates to its Risk Adjustment Data Validation (RADV) audit process aimed at strengthening oversight of Medicare Advantage (MA) payments to ensure accurate reflections of enrollees’ health status.

AMA has concerns about potential administrative burden on physicians. Image
2/ 🚨If you experience any new challenges related to increased RADV audit activity, the AMA encourages you to share your feedback with AMA to ensure they properly represent your concerns with the administration. Contact: Jamal.Bowleg@ama-assn.org
3/ Under the updated RADV framework, CMS will now audit all eligible MA contracts (approximately 550) annually.

Additionally, CMS aims to increase the number of records audited per plan from 35 to up to 200 per year.
Read 7 tweets
Feb 25
🔥 From AMA:

“Many physicians fear the #healthinsurance industry’s use of unregulated #artificialintelligence (#AI) automation and predictive technologies will increasingly override good medical judgment and systematically deny #patients coverage for necessary #medicalcare. “🧵 Image
2/ “According to a new survey from @AmerMedicalAssn, 3️⃣ in 5️⃣ physicians (61%) are concerned that health plans’ use of AI is increasing prior auth denials, exacerbating avoidable patient harms and escalating unnecessary waste now and into the future.”

👉 tinyurl.com/mt2h7dedImage
@AmerMedicalAssn 3/ “Burdensome #priorauthorization requirements that conflict with evidence-based clinical practices & create hurdles to patient access to safe, timely, & affordable treatment have been a major impediment to patient care for decades.”

Read @PresAmerMed statement⤵️

#FixPriorAuth Image
Read 6 tweets

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