Employer↔PBM > Biggest Syndicate Swindle

Federal Agents, here are your present day mob bosses hiding in plain sight.

Contrast to recent pandemic, “When the Great Depression hit, almost every hospital in the country saw its patient load disappear.” Industry key players were fast to capitalize on crises and design their Racket.

Job shortage due to WWII raised the demand for workers. As an incentive, Employers offered healthcare coverage to attract workers. Inadvertently, this produced a growing number of prospective patients facilitated by the doctor.

The U.S. health system is a century in the making. Accidental or by design? Alex Blumberg’s NPR 2009 article “Accidents Of History Created U.S. Health System” offers relevant viewpoints about the system from economic historians who “see it as the profound result of historical accidents.” This may be partly correct.

In “the advent of effective medicines, especially antibiotics, along with a revolution in medical schools” few cures were discovered. Yet, a rising health management system effectively organized. In spite of Blumberg’s argument, I find that the Biggest Syndicate Swindle came about by design.

Insurance Companies & Hospitals ↔ Blueprints for Life, Death, and Bankruptcy

Insurance companies are the gatekeepers tailoring coverage around the insured’s age, gender, health record and how much one is looking to insure. For a growing number of people it has become cost prohibitive leaving the public to rely on an employer; assuming of course one is working.

Typically, company plans do not insure all as a whole; insurance is tailored differently across various employee classes within the company (i.e. executive, top-level management, administration, etc.). Depending on the classification one falls under will determine coverage percentage and/or deductible amounts for services and medicine. And whether your prescribed medicine is covered.

It is important to note that “Before the birth of modern medicine, hospitals were poorhouses where the indigent went to die” according to Blumberg. It appears that the business of hospitals, like hospitality, grew from not having vacant beds and so it marketed itself to those who did not necessarily need urgent care.

However, “by the late 1920s, hospitals noticed most of their beds were going empty every night. They wanted to get people who weren’t deathly ill to start coming in. Suddenly, says economic historian Melissa Thomasson, ‘hospitals are marketing themselves as places to have babies.’” Once rooms were occupied, it was a matter of time before costs and idea of insurance arose.

In the U.S., after the war, “The Baylor idea became hugely popular. It eventually got a name: Blue Cross.” Reportedly, “An official at Baylor University Hospital in Dallas noticed that Americans, on average, were spending more on cosmetics than on medical care.” He said, “We spend a dollar or so at a time for cosmetics and do not notice the high cost.” Idea of being insured was in the works. 

Blumberg notes “The Baylor hospital started looking for a way to get regular folks in Dallas to pay for health care the same way they paid for lipstick — a tiny bit each month.” Blue Cross may have created a template for what followed: Referrals for excessive unnecessary costly exams or denials for urgent ones. And denying physician prescribed medicine but approving experimental drugs.

Blue Cross recent ad reportedly reads “racism and hate is a virus”.  Blue Cross, what does that make you? Stick to your hypocrite crosses and not “add insult to injury” by manipulating social crises to sell your costly and deadly service. Dangerous social constructs have bred hate crimes for which there are penalties.

Viruses get “vacked.” How does one penalize systemically viral corrupt insurance companies and hospitals?  Seems this type of virus needs to be “hacked” to neutralize it.

CVS ↔ Cartel Venue Systems

PBMs Exclusive Drug Deals→ PBMs have become the Negotiator and Closer of your drug. Brian S. Feldman’s March 17, 2016 article, “Big pharmacies are dismantling the industry that keeps US drug costs even sort-of under control” points to its beginnings and administrations “greenlighting” deals.

Feldman adds, “When a pharmacy owns a PBM, explains Bob Zebroski, a professor at the St. Louis College of Pharmacy, “it’s a sweetheart deal—the two entities no longer have an incentive to negotiate with each other.”  Sounds like Cartel Venue Systems or CVS.

A German company Merck KGaA, (NOT to be confused with the American Merck & Co.), appears to have been give the “green light” to contract with an American PBM.

A PR Newswire 2016 news release headline reads, “EMD Serono Takes on Exclusive Promotion of Rebif® (interferon beta-1a) in the US.”

Two questions: Who is EMD Serono and who is the deal with?

→“EMD Serono, the biopharma business of Merck KGaA, Darmstadt, Germany”

→“Rebif, the number one prescribed interferon for relapsing MS in patients new to therapy in the US*, is now the exclusive interferon beta-1a on CVS Caremark™ National Formulary and will also continue to be covered on most major national formulary plans.”

WHY IMPORTANT? For employers not contracted with CVS, it means zilch. For employers who are, it may mean patients with physician prescribed formularies will be required to take Rebif. Family and friends in Europe may have no choice in what their state run health system prescribes, but they’ll likely not pay high drug prices.

As I noted in my September 2020 paper, “PBM: What Doesn’t Kill You Makes Us Money,” pharma company of originally prescribed formulary may supply it. They could arrange to have their product shipped via their contracted pharmacy at a discount or free of charge, assuming patient meets three criteria: Disclose income, send the PBM denial letters to their financial assistance program, and conduct a phone screening to confirm eligibility.

IT BEGS THE BIG QUESTION. WHY WOULD A PBM DENY A PHYSICIAN PRESCRIBED DRUG WHEN THE MANUFACTURER OF THE DRUG CAN SUPPLY IT FOR FREE?

Aside from collecting data, it appears people are being forcibly put in the position of taking part in clinical experiments required to use biosimilar products. In access data clinical studies are highlighted in FDA drug comparisons. PBMs or Cartels facilitate the process.

How Some PBMs Work

PBMs are made up a sleuth of health networks, service providers and pharmacies which I’ll term A, H2, M, and C. For example, Employer X contracts A who is partnered with H2 and M.

Health insurance company plans are typically offered to new employees or presented to current employees yearly during open enrollment. Employee choses a health insurance plan network. Let’s call it Plan Network “A.” A mails members a card with the names of service providers H2 and M.

H2 provides “health assistants and registered nurses ready to help you with your health or benefit questions.” Yet, H2 “does not practice medicine or provide patient care.”  It simply acts as an “independent resource to support and assist you as you use the healthcare system.”

M uses “A” Network Providers. M partners with H2 to help coordinate patient care. M verifies eligibility and functions as a “Claims Administrator.”

Basically H2 and M operate similarly to the traditional HR and insurance company also known as the “hand holders.” They explain your benefits, answer questions and tell you if your meds are covered or not so your Employer doesn’t have to.

C is a pharmacy. C acquired “Insurance Company Network A.” C provides the services of a healthcare company, H2 and M.

C is a PBM – Pharmacy Benefits Manager.  

C is a Cartel – Supplier and Dealer

Cartel Set Up: Scoring the Drug

Employee makes appointment with Doctor. Employee requests drug X. Doctor faxes prescription to Pharmacy C. Pharmacy C requests doctor fill out pre-authorization form including patient clinical notes and medical necessity to be faxed to pharmacy.

Pharmacy C denies request in a Notice of Adverse Determination based on “Employer’s chosen plan” and offers alternative drugs.

Option to file an appeal is offered to the Employee. Employee and/or doctor mail/fax appeal request. If Pharmacy denies appeal, the option of a second appeal, an “External Review,” may be offered to Employee. Employee is required to send request online or by mail.

If “External Review” is conducted, Pharmacy C contracts with medical association. A “medical expert” is selected to contact doctor and review patient’s records and assess “medical necessity.” If second appeal is denied, a Second Level Appeal – Notice of Final Determination, is sent to Employee via email or by Postal mail within 45 days.

Employees, what good is paying for Plan “A” if by denying your doctor’s and yours preferred medication they also deny you access to their sleuth of services? Unless, of course, you take the Cartel’s choice of drugs.

Quacks: If they look, walk and sound like…

According to Blumberg “the evolution of the American health care system began in the 1920s, when choices boiled down to which crazy cure you preferred.” It appears that quacks and quackery still exist today. The difference is it comes in the guise of so called reputable insurance companies, doctors, pharma, and hospitals that are effectively “working the system.”

Yep, it seems the Employer and PBM Negotiator are running this deadly syndicate. So what do you do? Face your boss and say, Hey, I don’t want any part of this racket!