PBMs are the Gatekeepers to Managing Employees’ Drug Abuse

In 2018, the opioid epidemic cost the country $179 billion in mortality related expenses, health care expenses, lost productivity, criminal justice expenses, and assistance. The opioid epidemic is a preventable and complex public issue that arises from a myriad of causative factors. Because of this, the solutions needed to effectively end the opioid epidemic require multiple stakeholders, including healthcare providers, pharmacies, drug manufacturers and employers. Highlighted among the participants in ending this crisis is the pharmacy benefit manager (PBM).  PBMs...

PBMs Lower Health Costs, Improve Outcomes for Patients

266 million consumers are fighting to keep prescription drugs accessible and affordable. PBMs are advocating for them. By using advanced tools to manage pharmacy benefits, negotiating price concessions from drug manufacturers, improving patient adherence to prescriptions, encouraging generic drug use, managing high-cost specialty medications, and offering more affordable pharmacy channels, PBMs are vying to achieve overall stability for the cost of prescription drugs.  It is estimated that in the next decade, PBMs efforts will save plan sponsors and consumers over...

Assessing the Clinical Utility of Patient Requested Lab Tests

Due to skilled and sometimes aggressive marketing that enthusiastically directs patients and labs towards new, proprietary tests, laboratorians must be diligent about assessing the evidence-based clinical utility of the tests.  A large part of the difficulty in this task lies in the fact that often patient requested testing is a response to clinical conditions that involve profound patient suffering. Naturally, the patient wanting to understand more about their condition in the face of their own suffering is understandable. This increases...

340B Savings Programs Imperative to Hospitals Maintaining Levels of Care

When interviewed about how they were able to use their 340B savings, hospitals ranging in size from eighteen to five-hundred beds reported that they would not be able to continue to provide the same level of care to low-income patients without the 340B program. Hospitals reported they would not be able to maintain the services they currently provide without the 340B program. Hospitals around the country were interviewed and all reported the difference the savings had made in the quality...

2.1 Billion Genetic Testing Fraud

The Department of Justice (DOJ) charged 35 people for fraudulently selling unnecessary medical tests to thousands of elderly patients who were using Medicare. This ultimately cost Medicare 2.1 billion. Those charged worked for a variety of telemedicine and cancer genetic testing laboratories (CGx). MedTechDive reported that CMS took administrative action against CGx testing companies and providers who filed more than $1.7 billion in Medicare claims.  The HHS Office Of Inspector General put out a warning to the public back in...

A Cry For Industry Reform: $760+ Billion Dollars Wasted Annually

For every $4 spent on healthcare, it is estimated that $1 is being wasted. When put to scale, that 25% equates to a tremendous sum of $265 billion dollars annually. Spearheaded by the health insurance company Humana, these numbers shed light on how dire nationwide reform is for this industry.  As healthcare costs continue to rise, the last thing that the American people want to hear is that their dollars spent on health insurance are being wasted, but in many...

CMS To Raise Fees For The First Time In 20 Years

For the first time in nearly two decades, CMS is having to raise their fee in order to remain self-sustaining as required by the law. This fee will apply to all laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA). Labs will be required to obtain CLIA certification prior to being able to perform testing.  With significant growth being experienced since 1992, this fee increase will help maintain CMS through the year 2021, allowing them to continue to offer leading...

Raise And Restructure Your Lab’s Position For System-Wide Success

The health industry has been placing more importance on value over volume, and patient outcomes are overriding revenue as an indication of achievement. To keep up with the shift, lab leaders need to broaden the lab’s ability to support value-based strategic objectives, according to Becker’s Hospital Review. By creating value across all programs, the lab can be positioned as a leader of the health system.  To do this, it is important to understand how the lab impacts the system’s strategic...

Ohio is Leading the Charge in Successful PBM Integration Through the State Medicaid Program

House and Senate leaders in Ohio are establishing a system that has the potential to offer a significant change in the state’s Medicaid program. They are leading the charge in this change by hiring a pharmacy benefit manager, also known as a PBM. The PBM was chosen by the state’s Medicaid department with the hopes of cutting out the middleman and providing a more transparent view of the state's current financial landscape in terms of drugs, pharmacies, reimbursements, and more....