Pharmacy Benefit Managers Are Not Much More Than “Complex Well-Greased Algorithmic Human Scoring Machines” That Deny or Allow Access To Drugs To Create/Substantiate Big Corporate Profits

<p>So let’s get down to what’s really happening here.  Once upon a time the PBM models were a different type of creature but as time moved on they became less about a better and affordable price for prescriptions and more about and algorithmic machine to create profits, hidden for the most part as we can’t see the transactions written in computer code where every execution comes along and takes their<a href="https://lh3.googleusercontent.com/-cPuBknPJnJI/WqQR9-82JAI/AAAAAAABNMo/9BxoYmYEPDAeO2VeUBanKlAoH7tehHiYwCHMYCw/s1600-h/image%255B3%255D"><img align="right" alt="image" border="0" height="268" src="https://lh3.googleusercontent.com/-xbwHhvTEeAo/WqQSDg_2GoI/AAAAAAABNMs/E_i8H8PUsT4fEPyQ_XZKR5otSvSnyMC4QCHMYCw/image_thumb%255B1%255D?imgmax=800" style="float: right; display: inline; background-image: none;" title="image" width="395"></a> chunk of money.  United Healthcare created the PBM model back in 1976 under the name of <a href="https://en.wikipedia.org/wiki/Diversified_Pharmaceutical_Services">Diversified Pharmaceuticals</a>, which ended up ultimately being purchased by Express Scripts via SmithKline Beecham.  Express Scripts also purchased another PBM a few years back called <a href="https://en.wikipedia.org/wiki/Medco_Health_Solutions">Medco</a>, so combine all the algorithms with both companies and you end up with a massive collection of algorithmic computer code, there to create profits.  </p><p>It was the feeling that too much corruption and price setting would occur if pharmaceutical companies owned pharmacy benefit managers so they divested themselves of the pharmacy benefit business and it got worse as the PBM businesses moved into the arena of the health insurance companies.  Initially the PBMs were supposed to work as a partner to help insurance companies control costs, but it’s far from that today.  Today all we see is a consumer “scoring” business that found out how to score you by mining and selling all your data to make big profits for the most part.  Sure there’s still drug pricing in the picture, but it’s more about what the market will bear than it is affordability.  What we have ended up with is more of a digital caste system with drugs that goes way beyond negotiating price and helps substantiate a digital caste system that is growing every year in the US.  We don’t have the algorithms and the formulas to fight back and thus as consumers and small businesses we are just mowed under by what’s taking place and we have a Congress that is flat out both too stupid to see it or has been sufficiently bought off by the big conglomerate, or both. </p><p><a href="http://ducknetweb.blogspot.com/2015/09/excess-scoring-of-us-consumers-us.html"><strong>Excess Scoring of US Consumers, US Citizens-Scored into Oblivion By Proprietary Algorithms and Formulas, Never Duplicated or Tested for Accuracy-Profits of Big Business And A White House Executive Command To Continue the Abuse..</strong></a></p><p>It’s hard today to even find really good journalism with the big media as they are all starving for revenue since Facebook came along with all their algorithms and functioned like a PBM to rob them of their advertising revenue so they are hanging on to what’s left on who pays for ads, and it circles right back to big pharma and health insurance companies, and nobody’s going to disturb what left of the golden goose that helps keep their doors open with new stories that give you the real picture today as they will not publish anything that will reduce what advertising revenue that they have left with anything detrimental reported about big pharma and health insurance companies.  As I wrote a while back, news rigging is here, and done with algorithmic models that write the news for them today as well.  It’s like your day trading software, you just plug in what you want and the software will write it up with a focus that you specify, or knock off news is also done this way, taking existing news and putting the bot to work t re-arrange an article (s) that’s already been written to create a new one with a bot that is smart enough to avoid any references that would create any plagiarism.  It’s the way it works, with 60% of what you read today being produced in this fashion.  </p><p><a href="http://ducknetweb.blogspot.com/2015/04/news-rigging-has-arrived-astroturf-and.html"><strong>News rigging Has Arrived! Astroturf and Manipulation of Media Messages-TED Video About “The Fake Grass Roots” Of Big Pharma and Other Campaigns That Fool and Fool Again…</strong></a><p>Coming back around to the PBM machines, these are all automated processed and you can’t see what’s really going on and it’s hard to make changes as they keep adding more layers of hidden computer code and then create a story that will dupe you into thinking that some new algorithmic processes are going to save the day for consumers, and that’s not true, the machines are there to create more profits, not a better world for us with getting our medications we need, they have a captive audience and they know it.  If thing were really working the way they said they were, we wouldn’t have news stories and legal cases like this. You take the receipts, the cost as it’s been done many times on what you pay for your prescriptions, and you end up with the same thing, algorithms that lie to you and a big media service today that supports the algorithms that lie and cheat.  It’s in your face and you can choose to look at reality or go off into a little virtual world where you convince yourself that this is just not happening, which many people do and then wonder why things are not getting any better. <p><a href="http://ducknetweb.blogspot.com/2016/10/cigna-united-healthcare-face-class_16.html"><strong>Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store</strong></a><p>It’s what I call a “One Trick Algo” world out there for consumers and the PBM business clearly leads the way in all of this with trickery used with computer code to make you think this is not the case.  It’s all about selling, mining and scoring your data to rapidly increase the rate of inequality in the US and if you think that putting another layer top will fix things, you’re back in that virtual fantasy world as you can’t keep layering computer code and algorithms on top of bad models and expect anything to change, it will only get worse, more complex and that benefits corporate America when consumers have no clue about understanding the systems we are forced to deal with today, and you are told “just keep clicking” for those miracle fixes, which of course do not exist.<p><a href="http://ducknetweb.blogspot.com/2017/04/one-trick-algo-world-needs-to-be.html"><strong>“One Trick Algo World” Needs to be Licensed and Indexed–Spurious Correlations “For Profit” Are Out of Control</strong></a><p>So there’s coupons out there for saving on your prescriptions, but did you know it’s just another pharmacy benefit manager financing the coupon?  Why do they do it?  They do it for money and data.  So as an example if your PBM is Express Scripts let’s say and you have a coupon from one of those discount card deals that will give you a better price, well it’s probably OptumRX (a wholly owned subsidiary of United Healthcare) that gives you the discount, so you’re still in the PBM game, just not the one that comes with your insurance plan to get your meds.  <p>These coupons too all have what is called a “bin” number on them just like your insurance plan has and you can easily do a “bin” number search on the internet to see who’s financing the discount of your prescription.  Drug stores have to pay a fee for the privilege of filling your prescription when a PBM card or discount is used and it’s called a DIR fee, and these get big as they do not all occur at the time of your transaction either.  When you ask for a “cash” discount from an independent pharmacy the drug store gets to avoid this fee and can keep more of the revenue and not have to give it to the PBM.  The DIR fees are yet another profit producing algorithmic machine of their own accord.  Recently it was discovered that Caremark was charging their own CVS drug stores a much smaller fee than what was being levied on other drug stores where Caremark is the patient’s PBM, so this gets very involved with quants and analysts figuring how much profit they can make with these fees.  Recently it was reported that the auditors at Publix Warehouse asked about the $25 Million<img align="right" height="208" src="http://lh3.googleusercontent.com/-XHSvyCC6Ly0/Vi7i2iz25hI/AAAAAAABMkY/pP9kI46N7qE/image%25255B8%25255D.png?imgmax=800" style="float: right; display: inline;" width="182"> Dollar DIR fees they had to pay, they didn’t know what they were and that’s a big charge so even the big corporations are getting screwed by the PBMs with these fees just to be able to fill your prescription.  What a big profit making algorithmic machine, is it not?<p>So if you have one of those cards, the one getting the big profits are the company names attached to that “bin” number folks.  A lot of pharmacists if you give them the chance will match that price or even give you a better price with cash, as both you and the pharmacist win that way versus having the PBM monster algorithms charging in to get their cut.  Now we have Cigna wanting to buy Express Scripts so they can be liked United Healthcare and keep all that money, but there’s only one problem with Cigna being late to the dance here and that’s the fact that Cigna had a 10 year PBM agreement with PBM Catamaran which was bought by OptumRX (UNH) and there’s 5 years left, so no Express Scripts for those insured by Cigna, you have 5 more years of OptumRX unless they cut some kind of a deal and pay United Healthcare a boat load of money.  Right now Cigna needs a bond sale to be able to buy Express Scripts as they don’t have enough money, so when’s that going to take place?  I wrote this article back in 2015 when OptumRX bought Catamaran and few folks seem to be aware of this as they are too busy with their little virtual worlds of Facebook Follies and playing games I think. <p><a href="http://ducknetweb.blogspot.com/2015/10/if-you-are-insured-by-cigna-guess-what.html"><strong>If You Are Insured by Cigna, Guess What You Have a New Pharmacy Benefit Manager Named United Healthcare</strong></a><p><a href="http://ducknetweb.blogspot.com/2015/03/united-healthcare-buys-catamaran.html"><strong>United Healthcare Buys Catamaran Pharmacy Benefit Manager Just As the PBM Gets Hit With A Class Action Lawsuit For Low Balling Pharmacy Reimbursements..And More Patient Data to Sell and Analyze For Profit</strong></a></p><p>Actually Express Scripts uses a lot of OptumRX algorithms already and has since 2010 with their bogus<img align="right" src="http://lh3.googleusercontent.com/-WTU_WavuGLg/VYjYaFce1MI/AAAAAAABMZA/DCNNtafnZm8/image%25255B8%25255D.png?imgmax=800" style="float: right; display: inline;"> black box scoring metrics, so yeah they’re already connected at the algorithms you could say.  <p><a href="http://ducknetweb.blogspot.com/2010/10/express-scripts-new-program-to-contact.html"><strong>Express Scripts- New Program to Contact and Predict Patients Who May Not Be Taking Their Medicine Based On Ingenix Algorithms–We Want the Revenue Please Don’t Stop</strong></a></p><p>And here it is a few years later, revisited to see what kind of a bogus data selling/mining business Express Scripts created with those Ingenix (Optum) algorithms, quite the deal when you are scored on bogus metrics every time you fill a prescription.  Are you a man seeing a female MD, whoops that’s bad and do you have kids at home, that’s bad too as they will distract you from taking your meds.  These companies get away with this crap and sell those scores to insurers right and left.  So the choice is yours to start reading up and not being so stupid and speaking out and realize it’s an algorithmic computer code service that is running all of this. <p><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html"><strong>Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</strong></a></p><p>Did you know FICO buys all this scoring data from PBMs and sells it too?  Sure they want to cash in and mix t<img align="right" height="282" src="http://lh3.googleusercontent.com/-U0fHNHM3Vvo/VYjYc7peUgI/AAAAAAABMZI/N5v7HrnJd2c/image%25255B3%25255D.png?imgmax=800" style="float: right; display: inline;" width="340">his crap in with your credit scores!  Please get angry about this and start speaking up as the well greased algorithmic machines are taking over your meds every way they can.  Big pharma buys these scores too and if they can show that folks aren’t really taking their meds with a bunch of bogus stats, it helps them keep the prices high with their political campaigns for profit as they come back with arguments that patients are not taking their meds so why should they offer them for less!   Look at the image from Express Scripts, they want to make the patients the problem!  Non-adherence is not a disease to be cured, it’s the price of the drugs that adds to people not taking their drugs, wake up to the scam for bigger profits.  <p><a href="http://ducknetweb.blogspot.com/2014/06/fico-medication-adherence-scoring.html"><strong>FICO Medication Adherence Scoring Should Be Banned As It’s Quantitated Justifications for Profit That Hurts US Consumers Using Proprietary Algorithms That Cannot Be Replicated For Accuracy or Audited</strong></a></p><p><strong>It’s pretty wild is it not that Express Scripts decided to turn medication adherence into a disease!  It’s not a disease at all.</strong>  They want you to think of it like you have cancer, diabetes, etc.  Beware of PBM marketing for profit.  <p>Be aware too of the next step of the PBM algorithms for profit, connecting coupons to your medical records.  This is promoted to doctors to provide you with an e-coupon that goes directly to the pharmacy in lieu of using your PBM discount.  When this is done electronically, you cannot ask for a cash discount from the drug store as the price is locked in and the drug store is electronically stuck with the DIR fee to pay that I discussed above.  If you are offered one of these, have the doctor print it out and give the drug store a chance to match it with a cash discount instead of sticking it to the drug store.  See how these algorithms for profit work and you had no idea at all.  It’s PBM wars you could say as if you don’t use your PBM for your script, or you don’t have one, by using a coupon, a DIR fee is created for the drug store to pay down the road and cha ching, cha ching they make some money. <img align="right" src="https://lh3.googleusercontent.com/-3vUPXlYry8E/WUtNkuod6xI/AAAAAAABM5U/RBTZvIgihuwzV9mJkE-v1WQA66bHnFg4wCHMYCw/image_thumb%255B5%255D?imgmax=800" style="float: right; display: inline;"> <strong>PBMs  want no prescription filled without a PBM getting a DIR fee attached in the overall performance standards levied on the pharmacy. </strong><p><a href="http://ducknetweb.blogspot.com/2017/06/pharmacy-benefit-managers-invade.html"><strong>Pharmacy Benefit Managers Invade Medical Records and Electronically Connect Cash Patients to RX Discount Cards-OptimizeRX-to SingleCare to OptumRX</strong></a><p>Actually if you pay cash the PBMs come knocking at the door of the drug stores in time as well if they can’t track a credit card transaction or one of these coupon things, along with any other data supporting a purchase and you’ll be labeled a non compliant outlier if you use cash as well.  Get a load of that as the pharmacists at the drug stores get presented with lists of patients who are not compliant, only because they pay cash.  See how these black box analytics are really bogus!  PBMs are right in there pushing the war on cash.  Too many cash clients make the drug store look bad, which is ridiculous!  <p><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html"><strong>Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</strong></a><p>I have quite a few more posts in the archives of this blog that explain a lot of this as well, read them and learn up as when you hear laws and rules are being created to control the costs of medications today, just laugh like I do at those attempts as they are fruitless and Congress is way too stupid to understand how the well greased PBM algorithmic machines work, as you can’t change the machines with verbiage and expect any changed outcome, corporate America just codes around the verbiage and cheats if they want as the code and algorithms are all locked up in black boxes which nobody except the PBM has access to, so as long as they can tell a story that their code is complaint with verbiage, the nightmare lives on and nothing gets changed and they’ll keep telling you to go hang out in your little virtual worlds of the Facebook Follies and the likes to speak out.  Nobody listens to any of that anymore as well, it’s just a place to vent and you get trapped in their well greased algorithmic machines as well.  Here’s a big part of the problem. </p><p><a href="http://ducknetweb.blogspot.com/2015/06/virtual-world-values-and-real-world-we.html"><strong>Virtual World Values and The Real World, We Have A Big Problem: People Can’t Tell the Difference Anymore as Perceptual Madness Grows to Further Accelerate Inequality…</strong></a></p><p><a href="http://ducknetweb.blogspot.com/2015/05/privacy-duping-of-america-intangible.html"><strong>Privacy Duping of America-The Intangible Threat Model Has Changed Significantly-Companies Hide The Code On the Web, $180 Billion Dollar A Year Business, Welcome to The Duperville World of Inequality..</strong></a></p><p>So in closing I hope helped make the case and explained a bit more about the well greased PBM algorithmic machines that are in control out there, and the only way to do anything is to dump some of these black boxes and furthermore get to see their code that’s patented and running everything.  Until something is done is, no laws, rules, etc. will have much impact, they just call in their quants and code around it.  You can hear more of that from a presentation I did a few months ago where I spoke and spelled a lot of this out at a big doctor convention.  Here’s a spoiler screen to the right…how do you like that patent?  Time to wake up dupes and speak up. BD<p><strong><a href="http://ducknetweb.blogspot.com/2017/11/algorithms-scoring-metrics-privacy-and.html">Algorithms, Scoring Metrics, Privacy and more in today’s Healthcare business world–The Healthcare Algo Cartel</a></strong>

Pharmacy Benefit Managers Are Not Much More Than “Complex Well-Greased Algorithmic Human Scoring Machines” That Deny or Allow Access To Drugs To Create/Substantiate Big Corporate Profits

So let’s get down to what’s really happening here.  Once upon a time the PBM models were a different type of creature but as time moved on t...

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Algorithms, Scoring Metrics, Privacy and more in today’s Healthcare business world–The Healthcare Algo Cartel

<p>This is a video of a recent presentation I did at the 74th Annual AAPS (American Association of Physicians and Surgeons) meeting.  I don’t do too much blogging anymore as I don’t want to be confused with all the “junk” news out there but thought this is worth a look and listen for all.</p><p>The presentation was initially intended for a physician crowd, but after I thought about it, consumers can learn a lot from this as well.  We have too many folks today <a href="http://ducknetweb.blogspot.com/2015/06/virtual-world-values-and-real-world-we.html">choosing “virtual” values and getting lost in the real world and don’t realize</a> what goes on behind the scenes, and it’s a lot, things you can’t see rising from corporate America to gain control of us lesser valued serfs it seems.<a href="https://lh3.googleusercontent.com/-x9TT-P6Qjsc/WhHuVDVWncI/AAAAAAABM6k/xN1ufLdHrMM8gaJiMxDf4aNpcDKifKFoACHMYCw/s1600-h/Optum_moneyball%255B4%255D"><img align="right" alt="Optum_moneyball" border="0" height="149" src="https://lh3.googleusercontent.com/-NMTC07Amu2I/WhHuVoIroiI/AAAAAAABM6o/74SyRudsU7IGGN1PBCMVEbp4DoYGFY9sACHMYCw/Optum_moneyball_thumb%255B2%255D?imgmax=800" style="border: 0px currentcolor; border-image: none; float: right; display: inline; background-image: none;" title="Optum_moneyball" width="207"></a></p><p>Every direction you turn today, somebody is <a href="http://ducknetweb.blogspot.com/2015/09/excess-scoring-of-us-consumers-us.html">mining up some behavior data and scoring you today, so we have so many scores</a>, and many of them secret, who knows what value some big corporation or government is putting on our head today?  I’ve been writing about this for years and unfortunately we have gone beyond just good production software that helps us in life and in doing our jobs into a somewhat digital caste system.  I used to write software and this is my attempt here to let the average consumer know more about what’s really taking place out there.  I thought the Obama administration was getting way too virtual, but it seems the new Trump administration is just as bad with not seeing the real world and embracing virtual world values as well, so I guess it doesn’t matter which person or party is in control out there today, <strong>they don’t like the ugly real world </strong>and keep pushing virtual values on all of us to keep consumers in the dark.</p><p>I call it a <a href="http://ducknetweb.blogspot.com/2017/04/one-trick-algo-world-needs-to-be.html">“One Trick Algo” world</a> and that’s what you’re getting too often out there today, some algorithms and computer code, written by corporate America to profit that tricks you into things you would rather not do if you knew the whole story.  I call this <a href="http://ducknetweb.blogspot.com/2015/06/operation-perception-deception-into.html">“Operation Perception Deception”,</a> which was a post I wrote back in 2015 and sadly it’s getting bigger every day.  So take a look and see what’s going on behind the scenes in healthcare, and don’t deceive yourself too badly with virtual values as people can’t seem to be able to tell the difference anymore.  BD</p><p><iframe width="560" height="315" src="https://www.youtube.com/embed/vKBMXQXWvvs?rel=0" frameborder="0" allowfullscreen=""></iframe></p>

Algorithms, Scoring Metrics, Privacy and more in today’s Healthcare business world–The Healthcare Algo Cartel

This is a video of a recent presentation I did at the 74th Annual AAPS (American Association of Physicians and Surgeons) meeting.  I don’t d...

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Pharmaceutical Wholesalers Inc. File Legal Complaint Against OptumRx “Aligning Its Interests” with the Big Three Drug Distributors in US, Thus Acting as an Agent of the Government With Accreditation Processes

<p>This is a pretty interesting lawsuit and it includes named invidituals at HHS and CMS as well as participants.  You can view all the defendants included in the <a href="https://www.law360.com/cases/581cff6a5270e84d59000001">filing here.</a>   Being we are at the end of the Obama administration, the named directors Burwell and Slavitt in this case involvement once out of office may or may not still be included, but OptumRX portion looks like it won’t go away.</p> <p>This is basically collusion with the government giving exceptional regulation controls to OptumRX on <a href="https://lh3.googleusercontent.com/-nTq7yCVQmIU/WDHZppI5bzI/AAAAAAABM2o/Di60u0eZQ1Y/s1600-h/image%25255B3%25255D.png"><img align="right" alt="image" border="0" height="126" src="https://lh3.googleusercontent.com/-lTdcxFwJdc8/WDHZqc4qZgI/AAAAAAABM2s/C4HFa3C1W-Q/image_thumb%25255B1%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="240"></a>the accredited distribution of drugs distribution of drugs in the US with basically setting up shop with only the 3 major distributors, and thus so it is making it harder for the secondary or smaller drug distributors to function and operate.  We know what less competition probably means, even higher prices at the drug store.  </p> <p>The lawsuit also points out that United Healthcare is a Medicare Part D insurer and with that fact it appears to be an “agent of the government” will also having the OptumRX subsidiary, the PBM manager having the authority to use the accrediting program called VAWD to basically let other smaller drug distributors in the game.  It would seem to make more sense to have pharmacies be accredited than distributors since they are the ones selling the drugs. </p> <p>OptumRX might be working to drive independent pharmacies out of business to and convert those customers to their mail order pharmacy or to Walgreens, their preferred pharmacy partner.  Recently there was a big partnership created there as well to allow higher profits via Walgreens.</p> <h5><a href="http://ducknetweb.blogspot.com/2016/03/walgreens-signs-agreement-with-pbm.html">Walgreens Signs Agreement With PBM OptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts</a></h5> <p>The fear is that secondary drug distributors will be pushed out of business.  Effective October 1st, all prescription claims not not filled via a VAWD distributor could be denied.  There’s a long list of VAWD credited distributors.  Wholesalers in most states are already subject to inspection by state and/or federal regulators to ensure compliance so what’s the action with OptumRX to act as a 3rd party regulator of sorts?  All pharmacies who fill prescriptions are required to sign a contract with Optum, which I have read in some instances includes the pharmacists not being able to offer a cheaper cash price to the customer as they would be in violation of the contract.  </p> <p>Here’s an interesting tidbit on how OptumRX makes a ton of money from diabetes test strips, take notice of this and the <a href="http://www.pharmacychoice.com/news/article.cfm?Article_ID=1608884">entire article can be read here.</a>  Look at how this winds around with insurer United making big deals on test strips, but does this savings get passed on to the consumers, apparently not. </p> <p><em>“Tackling OTC supplies was the logical next step for OptumRX. OptumRX has a booming mail-order pharmacy business and diabetic test strips play a big role in their profitability. They champion one brand, Roche’s Accu-Chek, and by pooling their purchasing power get manufacturers to compete against each they secure steep discounts. To put this in real world terms: from a retail pharmacy, these <strong>test strips cost about $90 per 50 test strips to the consumer</strong> and is then adjudicated with<strong> insurance companies for about $95</strong>. However, with their steep discounts, it is <strong>estimated that OptumRX pays only about $10 per box of 50 test strip</strong>s because <strong>Roche only charges Medicare about $5 for that same box</strong>. </em></p> <p><em>This means that<strong> OptumRX stands to make up to $85 in gross profit per box, per month</strong>; multiplied by the diabetic population of their 65 million members, OptumRX is playing with real numbers. It sheds a lot of light onto American’s high insurance premiums and the resources they can call on to fight the legal action brought against their new bold policies in court.”</em></p> <p>If noting else, when you look at the big money that the OptumRX subsidiary of United is making, the paragraphs above shed some light on how this is happening and it’s all done with algorithmic business models with a series of algorithms for distributors and drug stores to jump through.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p>Again states have regulations but now OptumRX in fact is becoming a 3PL regulation enforcer via the government on some of this?  I have read that OptumRX is giving folks some extended time to become VAWD certified before cancelling payments here and there, and wholesalers must already comply with the Drug Supply Chain Security Act (DSCSA) which requires the FDA to issue regulations regarding wholesale distributor and third-party logistics provider licensure.</p> <p>So basically smaller distributors who provide better drug prices might be edged out completely.  So again with more certification policies and adherence, is this going to fix any</p> <p> </p> <p>thing other than to allow OptumRX to charge more a the drug store counter and really accomplishe much?  Here’s the lawsuit on the “clawbacks” that are taking place when you arrive to get your prescription at the drug store with the OptumRX algorithms “front running” the script cost via the pharmacy software networks in place all over the US before you can physically even get there to fill your prescription too. </p> <h5><a href="http://ducknetweb.blogspot.com/2016/10/cigna-united-healthcare-face-class_16.html">Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store</a></h5> <p>I’ve often said it would be of real interest to have a video of a pharmacist filling a prescription via the software of the pharmacy benefit management systems in place at pharmacies today so the public can see what the process is for the pharmacist just to get you your bottle of pills, and maybe involving a call or two to the dreaded PBM pharmacy tech.  <p>Don’t forget that Optum 360 is now taking care of all your Quest Diagnositics lab bills too as their outsourcer.  Pay attention to the “too big to fail” health insurer, United with close to 300 subsidiaires that do all kinds of things out there outside of just insurance.  BD <h5><a href="http://ducknetweb.blogspot.com/2016/09/quants-of-optum-carve-out-new.html">Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries</a></h5> <p>They’re buying up your doctors too, another reason you can’t keep your doctor as they own and manage physicians groups all over the US today.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/08/optumcare-doctors-to-get-allscripts.html">OptumCare Doctors to Get Allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own</a></h5> <p>By thew way, if you have never seen how the automated prescription services work, take a look at this…complete audit trails that also feed <a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">medication compliance software data systems.</a>  That is yet another topic for conversation with flawed data using metrics about us that are flawed.  BD  </p> <p><iframe height="315" src="https://www.youtube.com/embed/SfXoQWnpIb4" frameborder="0" width="560" allowfullscreen></iframe></p> <p> <hr> WASHINGTON (Legal Newsline) - A not-for-profit trade association that represents independently-owned pharmaceutical wholesalers is suing a pharmacy benefit manager and the federal government over a new accreditation policy, arguing it violates various state and federal laws. The Association of Independent Pharmaceutical Wholesalers Inc., based in Pine Brook, N.J., filed its complaint in the U.S. District Court for the District of Columbia Nov. 4. </p> <p>The named defendants include OptumRx Inc., based in Irvine, Calif.; the U.S. Department of Health and Human Services; Sylvia Burwell, secretary of the DHHS; the Centers for Medicare and Medicaid Services; and Andrew Slavitt, acting administrator of the CMS.</p> <p>“OptumRx’s business relationships with the Big Three have resulted in the implementation of bad faith policies designed to steer market share away from the Secondary Wholesale Market and toward the Big Three,” AIPW alleges. </p> <p>For instance, AIPW claims OptumRx, in August, informed its participating pharmacies that effective Oct. 1, participating pharmacies were required to purchase all medications being dispensed to OptumRx members from a VAWD. VAWD, an accreditation offered by the National Association Boards of Pharmacy, essentially eliminates the secondary wholesale market, AIPW argues.</p> <p>“Plaintiff’s members have already been informed by their pharmacy customers that the pharmacies will cease ordering medications and supplies from Plaintiff’s members due to OptumRx’s VAWD-Accreditation Policy,” the association alleges. “This is because the pharmacy customers face PBM audits from OptumRx, whereby OptumRx actively threatens to ‘recoup’ 100 percent of funds paid to the pharmacy arising from the purchase of drugs from wholesalers such as Plaintiff’s members that are not VAWD accredited.”</p> <p><a href="http://legalnewsline.com/stories/511045586-pharmaceutical-wholesale-group-says-accreditation-policy-will-irreparably-damage-the-nation-s-prescription-drug-delivery-system" title="http://legalnewsline.com/stories/511045586-pharmaceutical-wholesale-group-says-accreditation-policy-will-irreparably-damage-the-nation-s-prescription-drug-delivery-system">http://legalnewsline.com/stories/511045586-pharmaceutical-wholesale-group-says-accreditation-policy-will-irreparably-damage-the-nation-s-prescription-drug-delivery-system</a></p>

Pharmaceutical Wholesalers Inc. File Legal Complaint Against OptumRx “Aligning Its Interests” with the Big Three Drug Distributors in US, Thus Acting as an Agent of the Government With Accreditation Processes

This is a pretty interesting lawsuit and it includes named invidituals at HHS and CMS as well as participants.  You can view all the defenda...

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Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store

<p>Here we go again.  If you haven’t figured this out yet, when you buy a Cigna Health insurance policy you get a two for one with 2 insurers.  Cigna provides the insurance benefits and then it’s pharmacy benefit manager, PBM OptumRX (biggest revenue sector subsidiary of United Healthcare) that runs all their formulas via the computer and tells the pharmacist what to charge you.  (Video at the break below-watch it!)</p> <h5><a href="http://ducknetweb.blogspot.com/2015/10/if-you-are-insured-by-cigna-guess-what.html">If You Are Insured byCigna, Guess What You Have a New Pharmacy Benefit Manager Named United Healthcare</a></h5> <p><strong>I call this “front running” the consumer at the prescription counter if you will,</strong> as that’s a term we hear used in stock trading all the time and it’s somewhat a very similar model with providing the drug stores advance information before you can even physically get there to ask for a cash price<a href="https://lh3.googleusercontent.com/-q-UPZgdLZ_c/WAPNzlK3WoI/AAAAAAABM1o/Ujtb-Zpcwds/s1600-h/Clawback-Cigna2.png"><img align="right" alt="Clawback-Cigna" border="0" height="154" src="https://lh3.googleusercontent.com/-QhPJyRFePt8/WAPN0Pb6L0I/AAAAAAABM1s/2x_J2Gm4Ij8/Clawback-Cigna_thumb.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="Clawback-Cigna" width="244"></a> from the pharmacist.  Markets work the same way with dealing on advance information provided by their brokers and investment analysts, before their clients get a chance to see it.  <strong>Less than a month ago, United Healthcare received the same type of lawsuit for doing the same thing.</strong>  Below are a couple links with some videos that explain how this works in the words of the pharmacists.</p> <h5><a href="http://ducknetweb.blogspot.com/2016/06/the-truth-about-pharmacy-benefit.html">The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2016/05/be-aware-of-prescription-claw-backs-as.html">Be Aware of Prescription “Claw Backs” as Pharmacy Benefit Management Profit Centers Continue to Evolve</a></h5> <p>In my own observations, Cigna is kind of living under the thumb of United Healthcare right now anyway and if I were them I would not be too happy having a competitor meddling in various areas of customer data that probably goes beyond prescriptions as United is the second largest healthcare data seller out there, behind IMS.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/06/cigna-launches-new-company-careallies.html">Cigna Launches New Company, CareAllies To Manage Patient Care, Doing Same Things as Does Optum</a></h5> <p>Actually the data selling algorithms provided mostly by United Healthcare/OptumInsights even goes beyond prescriptions and such algorithms were sold to a subsidiary of Quest Diagnostics called Exam One and they use the same formulas to score you and sell that data as well.  Also, in case you missed it, United Healthcare will be preparing your Quest Labs bill as well.  Another United Healthcare company, Optum 360, to which Dignity Healthcare is a partner will be doing their billing for them.  Over 2000 Quest employees were let loose and rehired under the Optum 360 name, and we kind of all know what that represents for the employees with reductions in pay, benefits, etc. in order to save money as that’s why they outsource.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/09/quants-of-optum-carve-out-new.html">Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries</a></h5> <p>So how did this marriage occur?  <strong>United Healthcare under their “Optum” subsidiary bought a pharmacy benefit management company named Catamaran,</strong> who was the exclusive PBM (pharmacy benefit manager) for Cigna.  In addition, Catamaran was in a bit of hot water and partially responsible for getting Cigna sanctioned by CMS with denying drugs and access to care. <strong>Cigna was around 2 years into a 10 year contract with Catamaran </strong>and I assume that was a big lure for United Healthcare as with buying the PBM, they increased their OptumRX revenue by around 25% and there were about 8 years left on this agreement.  This sanction has been in place since January of this year (seems like a long time) and<strong> none other than former United Healthcare Executive CMS Andy Slavitt makes the call on when to allow Cigna to sell Medicare D policies again</strong>.  If you look at how this all came about and the competition with health insurers, it certainly gives the appearance that CMS Slavitt could very well be making sure his former employer, United Healthcare benefits.  </p> <p>Remember that<strong> HHS Secretary Burwell was able to provide pardons for Slavitt (so he could do his job, the reason) to discuss policy and healthcare business with United </strong>(to include the CEO) any time he wants, so who knows how often the two might get together for lunch and chew some healthcare policy and some fat.  Here’s the story on the sanctions levied against Cigna in January of this year.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/01/cms-sanctions-cigna-no-more-selling-any.html">CMS Sanctions Cigna-No More Selling Any New Medicare Advantage Policies Until Algo Problems Denying Medical Coverage and Prescription Denials Are Fixed</a></h5> <p>Cigna is also still saddled with yet another Ingenix lawsuit that has not completed and that goes back to the days when CMS Andy Slavitt as CEO of Ingenix was caught using algorithmic formulas to short pay doctors on out of network payments.  This was discovered by Andrew Cuomo and there were multiple class action lawsuits filed, including the big case from the AMA on the fraudulent activity in 2010.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/05/cigna-legal-case-with-ingenix-flawed.html">Cigna Legal Case With Ingenix Flawed Formulas for Out of Network Payments Allowed to Proceed Under ERISA, Can’t Avoid the Claims…</a></h5> <p><strong>United Healthcare had a $10.5 Billion dollar bond sale to acquire Catamaran PBM</strong> and wrap into OptumRX in record time with importing customers.  It was well stated all over the web outside of this blog that <strong>both companies were using “like” technologies</strong> so the process would be quick and easy.   Being a former developer and what I have seen over the years, there’s probably a good chance that Catamaran was licensing the old Ingenix or OptumInsights algorithms, as all the pharmacy benefit management software seems to come back to that being the tech or algorithms being used.  It’s not uncommon as for another example you have Cerner as  a reseller of Ingenix/Optum Revenue Cycling technologies with their medical records systems.  The link below gives you more information on the acquisiton of the Cigna Catamaran PBM by United Healthcare/Optum.  <h5><a href="http://ducknetweb.blogspot.com/2015/03/united-healthcare-buys-catamaran.html">United Healthcare Buys Catamaran Pharmacy Benefit Manager Just As the PBM Gets Hit With A Class Action Lawsuit For Low Balling Pharmacy Reimbursements..And More Patient Data to Sell and Analyze For Profit</a></h5> <p>In addition last year United is getting into the workman’s comp area of pharmacy benefit management with buying Helios and the largest customer serviced by Helios is the US Post Office.  <h5><a href="http://ducknetweb.blogspot.com/2016/01/united-healthcare-buys-helios-workmans.html">United Healthcare Buys Helios Workman’s Comp PBM and Their Other Related Businesses</a></h5> <p><a href="http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash">The link at the bottom of this page</a> from the story reported (the source) has copies of the actual court documents filed against Cigna and United Healthcare and it’s called racketeering.  Be sure and check it out.  Most all the links in this post are prior posts from the Medical Quant that give you additional information relative to what’s going on.  Pharmacists are being told to not disclose the cash price unless you ask so be sure to ask. <p><strong>Pharmacists in this whole scheme are also required to use software to input data so PBMs can produce a  predictive secret score,</strong><a href="https://lh3.googleusercontent.com/-ygEDmyDQtho/WAPN0hN7ouI/AAAAAAABM1w/5I3HGXrY51Y/s1600-h/EQUIPP4.png"><img align="right" alt="EQUIPP" border="0" height="293" src="https://lh3.googleusercontent.com/-Yhjo_rObwDQ/WAPN01XTkCI/AAAAAAABM10/LliBi2CGen4/EQUIPP_thumb2.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="EQUIPP" width="288"></a> than can also be sold to predict if you will take your meds.  Read up on that one as well.  Most consumers have no clue they are being secretly scored with software that does produce flawed and bias data every time you fill a prescription.  One of the programs is called EQUIPP and recently Rite-Aid has rolled out this software to their drug stores and current users include Wal-Mart and more.  <h5><a href="http://ducknetweb.blogspot.com/2015/12/rite-aid-pharmacies-are-latest-to-begin.html">Rite Aid Pharmacies are the Latest to Begin Used Flawed Data Provided by the EQuIPP Platform Relative to “Scoring” Patients for Predictive Medication Adherence–The “Outlier” Patients…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p><strong>Do pay cash when you can at the drug store for your own privacy benefits when you can, even though you risk being coded at an Outlier by the software, it’s less other data that can get linked to you.</strong> </p> <h5><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to FixOutliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> <p><strong>You can click on the image to read a short screenshot on what they do and if you as a patient are not in the 80% percentile, your pharmacist is required to hammer you to bring their numbers</strong> up so they can meet their goals and sometimes even keep their jobs, as the culling effect on pharmacist performance is out there as well as what doctors put up with today. <strong>If you are a diabetic and your pharmacy uses the EQUIPP program, the pharmacists are required to hit you up to tell you to ask your doctor about statins so more drugs can be sold</strong>.  Of course this is where the pharma business comes into play here as well to boost their sales.  <p>It’s to the point now where there are way too many consumers getting hit with the “co-pay” algorithms of the pharmacy benefit managers and the health insurers, so lawsuits have been filed.  As a matter of fact the pharmacy benefit management business is so profitable it’s the #1 revenue stream for United Healthcare, ahead of their insurance groups and we’ll see if Q3 is yet another barn burner for them with PBM revenue.  OptumRX also just secured a 5 year contract with CALpers to manage all of their drug programs worth about $5 billion.  <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p><strong>There seems to be some rotten algorithmic eggs out there slinking around in the pharmacy benefit management business</strong> and they all do it to some degree but some are much worse than others. <strong>With the recent CMS 5 Star ratings of Medicare D insurers, it’s starting to stink over there too.</strong>  CMS has been running models created by United Healthcare for years and now some of them are either failed in concept creation or are failing as time are failing.  Humana is now being hit with a loss of CMS money for not providing “quality” care.  We all know these surveys CMS uses are a joke and now the algorithms compiling all of this are at the point to where they are hurting the stock of Humana and Cigna, who again is sitting under the thumb of United Healthcare with the PBM OptumRX.  </p> <p>If I were Humana, and this is just me speaking I would consider suing CMS and Slavitt on this point, and Humana has already put out a press release contesting the 5 Star ratings.  What you are seeing here is a diminish of available insurance for consumers, using flawed and evil algorithms <a href="https://lh3.googleusercontent.com/-hnSHs9PwzoY/WAPN1Q-laQI/AAAAAAABM14/otqoznra0Lw/s1600-h/CAP3.png"><img align="right" alt="CAP" border="0" height="84" src="https://lh3.googleusercontent.com/-it-CR4E6LBE/WAPN1nZn-YI/AAAAAAABM18/BOXPg2y7vjQ/CAP_thumb1.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="CAP" width="240"></a>with United flexing their power where they can to gain an edge. It’s getting to be pretty visible if you look as that’s how they grew their business, math and algorithms.  Watch the 4 videos in the footer of this blog to understand how this works as there’s not a ton of difference between some financial models and tweaked health insurance models today. I saw this evolving way back in 2009, but it takes a while for more to clue in, I get that.</p> <p><strong>The incest of United Healthcare with HHS/CMS began years ago when Lois Quam, a former big VP at United Healthcare took a leave of absence from United and worked at the White House as the senior advisor to Hillary when “Hillarycare” was created.</strong>  You can also see a lot of this incest over at the John Postesta created CAP (Center for American Progress) with several former and current United Healthcare executives as “fellows”, some even earning the name of a distinguished fellow.  Currently former Senator Tom Daschle, a big lobbyist for Aetna is one of the CAP’s distingushed members, along with others such as Larry Summers as with their financial interests.  <a href="http://ducknetweb.blogspot.com/2016/01/zeke-emanuel-joins-venture-capital_14.html">Zeke Emanuel</a> and Jonathon Gruber can also be found at the CAP, writing US Healthcare policy as contributors. <h5><a href="http://ducknetweb.blogspot.com/2015/11/hhs-joins-optum-labs-as-research.html">HHS Joins Optum Labs as Research Partner–Back Peddles Support of FDA Sentinel Program That Does the Same Thing-More Impact from the Six Degrees of Bob Rubin Running Healthcare in the US</a></h5> <p>Here’s another good read written by a former CMS analyst and Tillman pretty much lines up every player in the ACA and their connections to United Healthcare along with their actions in turning healthcare in the US in to a “Cottage Industry”.  I would guess she should know after many years spent on the inside track involved in ACA policy.  It’s along read but worth it.  </p> <h5><a href="http://hardnoxandfriends.com/2016/01/10/hillarys-obamacare-fraud/">Building the Infrastructure of the Affordable Care Act: Hillary Clinton, UnitedHealth Group/ Optum, and the Center for American Progress</a></h5> <p>Good luck getting any real anti-trust action going here as our head of the Department of Justice is also a former United Healthcare anti-trust lawyer during the time she worked at Hogan Lovells (current lawfirm name).  If you <a href="https://lh3.googleusercontent.com/-XOP8Lxs0BLg/WAPN2c40UOI/AAAAAAABM2A/kaODx1jwYbU/s1600-h/Zeke8.png"><img align="right" alt="Zeke" border="0" height="64" src="https://lh3.googleusercontent.com/-hgWpC4FyWAE/WAPN2uX_9FI/AAAAAAABM2E/iLrV5UZX5lc/Zeke_thumb3.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="Zeke" width="263"></a>look over there you will find a few former Untied Healthcare lawyers working there today, including the one who wrote this letter of recommendation to Grassley to approve her nomination.  In addition with the expansion of the large number of urgent care clinics that United/Optum has opened or purchased (MedExpress) they have even more outlets to push their OptumRX pharmacy benefits to patients to gain more revenue.  <h5><a href="http://ducknetweb.blogspot.com/2015/05/optum-clinics-holdings-new-subsidiary.html">Optum Clinics Holdings, New Subsidiary Incorporated In 2015 Raises Over 36 Million (Exchange of Shares) From Investors Unknown-Form D Used to Maintain Secrecy Of Who They Are For Now…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2016/08/optumcare-doctors-to-get-allscripts.html">OptumCare Doctors to Get Allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own</a></h5> <p>So here we have it, two insurers, Cigna and United Healthcare both using the same OptumRX (owned by United Healthcare) <img align="right" src="http://lh3.googleusercontent.com/-dclAvjnezyI/Vi7i3HcWjII/AAAAAAABMkc/j5mxORCgLmA/image%25255B4%25255D.png?imgmax=800" style="float: right; display: inline">PBM management company, both front running consumers at the pharmacy counter.  I always tell people, pay attention to what’s going on with the  subsidiaries of big insurers and follow the data algorithms to really see what’s going on out there today as you see very little mention in major  news today as insurers are some of their biggest advertisers, so we know what that means…<a href="http://ducknetweb.blogspot.com/2015/04/news-rigging-has-arrived-astroturf-and.html">news rigging</a> (grin).  Don’t think because you fill your prescription at Walgreens that the OptumRX data is not there on the pharmacist’s computer, as it is, they are connected everywhere.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/03/walgreens-signs-agreement-with-pbm.html">Walgreens Signs Agreement With PBMOptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts</a></h5> <p><strong>It doesn’t stop there either as “co-pays are in your veins” too with CVS buying Omni-Care and OptumRX with buying AxelaCare.</strong>  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">OptumRX (United Healthcare) Buys Home Infusion Company AxelaCare-Using Algorithms To Determine Your Care With Being Financed By A “Too Big to Fail” US Health Insurance Company…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/05/cvs-buys-omnicareselling-drugs-to.html">CVS Buys Omnicare–Selling Drugs to the Elderly Via Nursing Homes and Assisted Living Homes And Pays Over $2 Million Dollar Fine In California for False Advertising</a></h5> <p>Here’s another trick that is used to get more co-pay money from you from CVS.  <h5><a href="http://ducknetweb.blogspot.com/2014/10/cvs-to-charge-consumers-higher-co-pays.html">CVS To Charge Consumers Higher Co-Pays With Prescriptions Filled at Drug Stores That Still Sell Tobacco Products–Killer Algorithms Attacking Once Again To Make SureCVS Gets the Prescription Revenue And Your Data To Score And Sell</a></h5> <p>The data selling and predictive flawed modeling scores in healthcare and pharmacies needs an over haul indeed as today, it’s once again the consumer having to stay one step ahead of the “front running” of drug prices out there with the PBM algorithms that are there to test you and get more money from you every step of the way.  <p><strong>We just want fair drug prices and a stop to the<em> “tricky front running </em><a href="http://www.ducknet.net/attack-of-the-killer-algorithms/"><em>killer algorithms</em></a><em>”</em> that soak us for more money when we fill our prescriptions!</strong>   <p>Be sure and ask your pharmacist every time for the “cash” price and circumvent some of algo duping taking place out there today for profit.  BD <p> <hr> <script type="text/javascript" src="http://WVUE.images.worldnow.com/interface/js/WNVideo.js?rnd=703235370;hostDomain=www.fox8live.com;playerWidth=630;playerHeight=355;isShowIcon=true;clipId=12820629;flvUri=;partnerclipid=;adTag=News;advertisingZone=;enableAds=true;landingPage=;islandingPageoverride=;playerType=STANDARD_EMBEDDEDscript;controlsType=fixed"></script><a href="http://www.fox8live.com" title="FOX 8 WVUE New Orleans News, Weather, Sports, Social">FOX 8 WVUE New Orleans News, Weather, Sports, Social</a> A spreadsheet given to FOX 8 News by a pharmacist in the Midwest shows Cigna Health Insurance overcharged at least 70 customers for prescription medication in one month, at just one community pharmacy. The spreadsheet details how the insurance company paid the pharmacist $25 for an acne cream. But Cigna instructed the pharmacist to collect a $187 copay, overcharging the customer $167. That money went right back to Cigna. <p>"One of the claims that we brought in the case is a RICO case, a racketeering case," says plaintiffs' attorney Craig Raabe. "And part of the racketeering case is a scheme to defraud - essentially an entity is engaging in fraud use through interstate commerce. And that creates the racketeering. So, it's a term of art in what we do, but in common sense terms it's fraud - saying one thing and doing another." A Massachusetts woman filed the class action lawsuit against Cigna at a federal court in Connecticut, where Cigna's corporate headquarters is based.</p> <p><a href="http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash" title="http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash">http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash</a></p>

Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store

Here we go again.  If you haven’t figured this out yet, when you buy a Cigna Health insurance policy you get a two for one with 2 insurers. ...

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The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!

<p>One thing we all hate is the high prices we pay in the US today for our prescriptions.  Sure we do get some discounts, but that too has become an effort in algorithmic shopping to click here and click there to get the best price.  It shouldn’t have to be that way,<a href="https://lh3.googleusercontent.com/-03KxuGam6CU/V2VweidWtYI/AAAAAAABMxA/bSF-WShHFqw/s1600-h/image%25255B3%25255D.png"><img align="right" alt="image" border="0" height="194" src="https://lh3.googleusercontent.com/-XeddxZrW3uQ/V2VwfOv-7PI/AAAAAAABMxI/QbtqtRipr-U/image_thumb%25255B1%25255D.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="image" width="285"></a> but it is as that’s how the systems have been built.  There are a ton of discount prescription cards floating around out there and they all vary in one way or another, but the big thing to remember about all of them is that they are a marketing firm that can and will sell your data to make money.  In addition, the discount cards act just like a pharmacy benefit manager with getting all your information when you use them to fill a prescription.  In addition, some of them offer referral fees so they can increase the size of their data base of patient information.  Data means money today and it can be repackaged and resold over and over, and yes, that’s us.</p> <p>I found a video on YouTube done by a pharmacist that very well in detail describes how the whole process takes place and how these discount cards work.  He tells you what to expect and how the pharmacist reacts and uses them for their required input when filling your prescription.  He uses some real life examples on a couple commonly prescribed drugs with a brand name and a generic drug.  Yes indeed some of this information makes its way to the big pharmacy benefit managers as well.  </p> <p>What is interesting too is that the pharmacist points out with one example, the patient is getting charged the normal “cash” price the pharmacy would have given anyway with an additional $4.00 as a fee added on, so before jumping into any of the discount cards, be sure and ask the pharmacist for the “cash” price first as you may not even need the card at all.  It all depends and you have to really check each time.  Again the pharmacist makes the point to where they have to send the discount card company information about you so you can get a discount when you use one of them to include the name of your doctor, medication name, etc. so the company now knows who you are, who your doctor is, date of birth, and more.  The data is resold to market you for something else, or to compile lists of people taking certain drugs (sold to pharma as an example) </p> <p><iframe height="315" src="https://www.youtube.com/embed/bUVbX3-gOWc" frameborder="0" width="560" allowfullscreen></iframe></p> <p>When it comes to privacy policies, you get stuck with the same old legal routine with a policy written by lawyers to be interpreted by lawyers basically that has a lot of “double talk” in the verbiage.  This is one big reason I have my campaign and have had it out there for a few years now to get Congress to pass a law to require all data sellers to be licensed-who are they and what are they selling!  This really comes in to play when the data about you being sold is flawed and frankly the data sellers don’t care as bad data gets the same price as good data as nobody looks at the data.  Why do you think t<img align="right" src="http://lh3.googleusercontent.com/-WTU_WavuGLg/VYjYaFce1MI/AAAAAAABMZA/DCNNtafnZm8/image%25255B8%25255D.png?imgmax=800" style="float: right; display: inline">here’s referrals promoting these cards-to get more data to sell!</p> <p>Again ask the pharmacist for the “cash” discount first as you may not need one of those cards, so find out first.  Some pharmacies will refuse to take the cards if the cost of the prescription causes them to lose money as well.  I read somewhere that Wal-Mart with their $4.00 generic drug plans being pretty large, no longer will accept the cards.  So again using the prescription cards, all comes back around to data for a discount and companies marketing such end up selling or giving the information back to pharma, other marketing companies or even companies like IMS, the largest data seller of health information in the country, making so much money they had an IPO last year and a lot of folks got wealthy from it.</p> <h5><a href="http://ducknetweb.blogspot.com/2014/06/ims-health-buys-cegedim-information.html">IMS Health Buys Cegedim Information Systems to Include CRM and Intelligence Software - Data Selling Business Gets Healthier and Wealthier But Can’t Say the Same for the Health of US Citizens - It’s All About Making Money Selling Data, The Epidemic</a></h5> <p>So yes in short, the big pharmacy benefit managers work in one way or another with the big pharmacy benefit managers and can add to the their bases of prescriptions filled using these cards as the card folks sell it to them.  I wrote about how pharmacies and insurers are now doing what is called “medication prediction scores” on everyone, and be aware it’s a secret and you cannot get your score, but your insurer can. <strong>FICO does this and thinks that everyone should run around with a “score” on medication just like we do with credit, but the big problem is that the data is so flawed</strong> everywhere you turn for their prediction scores.  It’s a rip on consumers.  See what Express Scripts tells you about these scores, and worse yet, they “brag” about these scoring algorithms! <h5><a href="http://ducknetweb.blogspot.com/2014/06/fico-medication-adherence-scoring.html">FICO Medication Adherence Scoring Should Be Banned As It’s Quantitated Justifications for Profit That Hurts US Consumers Using Proprietary Algorithms That Cannot Be Replicated For Accuracy or Audited</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p><a href="http://www.ejovi.net/goodrx-make-money/">I found a review on GoodRX,</a> who does provide a listing of current drug prices on their website and they too are “doing data”.  All you have to do is take a look at their job listings, and you get the picture of what’s going on over there with looking for Channel marketing director, email marketing director and from the data side a python developer (python is the choice of computer languages for the financial firms), and a java script contractor.  With someone doing a review of the company it saves me the time of having to say a lot more about their card, and they focused on the same gray privacy policy you are starting to see templated on most web sites anymore.  <p>They make their money charging the pharmacy a fee for the referral, and do reserve the right to sell data.<a href="https://lh3.googleusercontent.com/-tfP_3JJPGgk/V2Vwf-tSsTI/AAAAAAABMxQ/ec0957ZOiGQ/s1600-h/image%25255B6%25255D.png"><img align="right" alt="image" border="0" height="162" src="https://lh3.googleusercontent.com/-fFREgbfEaNo/V2VwgWFBAMI/AAAAAAABMxY/t8tmC1OqJak/image_thumb%25255B2%25255D.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="image" width="244"></a>  It’s crazy that we have to jump through all kinds of hoops anymore with shopping for prescriptions, but that’s what the insurance and pharmacy business had created with their business models and contracts.  Here’s another post below on what pharmacists call “clawbacks” with using a pharmacy benefit price with either your PBM or even one of the discount cards.  <strong>You can end up paying more, so always ask for the “CASH” price first as pharmacy benefit managers are now telling the pharmacists they can’t volunteer this information, you have to ask.  The RX Bin number tells the pharmacist who to bill.  The discount card folks all have your data to do whatever they please with it as well as the pharmacy benefit managers and transaction records are accumulated. </strong> <h5><a href="http://ducknetweb.blogspot.com/2016/05/be-aware-of-prescription-claw-backs-as.html">Be Aware of Prescription “Claw Backs” as Pharmacy Benefit Management Profit Centers Continue to Evolve</a></h5> <p>Here’s another good video done with a taste of humor that explains the role of the Pharmacy Benefit Manager, the middleman cashing in big!  It’s done well and the Pharmacy Benefit Manager is jumping all over the counter during the video, getting in the middle. </p> <p><iframe height="315" src="https://www.youtube.com/embed/UXq2FetUu60" frameborder="0" width="560" allowfullscreen></iframe></p> <p>So in short, we are all getting ripped one way or another and have to “play this game” instead of just a simple process of filling a prescription.  The government has their hands in this till as well as now pharmacists are seeing patients with the use of another prescription monitoring program called EQUIPP to see your “star” rating if you are on Medicare as far as medication adherence goes.  Yes indeed, before you even show up data has already calculated a score about you that shows how they predict you will be with compliance.  It’s a real nasty game, and oh yes, those folks who use cash to pay for prescriptions, well they are now called Outliers as they can’t track enough data on you, so if you like and want privacy, pay cash.  Rite-Aid is the latest to announce using the data mining compliance software from EQUIPP.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/12/rite-aid-pharmacies-are-latest-to-begin.html">Rite Aid Pharmacies are the Latest to Begin Used Flawed Data Provided by the EQuIPP Platform Relative to “Scoring” Patients for Predictive Medication Adherence–The “Outlier” Patients…</a></h5> <p>The flawed prediction scores are indeed a dangerous business as they will end up denying you access at some point as well.  “Give old Jane the cheap stuff as our numbers predict she won’t take the expensive meds”…as a simple example.  <h5><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to FixOutliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> <p>As a matter of fact, take a look at the first quarter revenue from United Healthcare, as their OptumRX revenue is exceeding that of the revenue produced by their insurance groups, more money made by United Healthcare with their OptumRX pharmacy benefit management company<a href="https://www.healthylife.optumhealthallies.com/ha/public/indexDtc.jhtml;sessionid=BR23TQVTSZWV0CW5GZIBQBY?_requestid=13686"><img align="right" alt="image" border="0" height="287" src="https://lh3.googleusercontent.com/-NK9BJ_g2_LA/V2Vwg4MvlNI/AAAAAAABMxg/rULTllfkSO4/image%25255B16%25255D.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="image" width="387"></a> than Medicare Part D policies..the world is changing and they are chasing the money.  Within the last few weeks, OptumRX has secured a few large contracts, like CalPers retirement system, Texas employee retirement system, etc. so they do want to control what drugs you can get and when.  Don’t forget the clawback video above as they are the pharmacy benefit manager featured in the news report, although they are all doing it.  <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p>Look what else gets involved with OptumRX pharmacy benefit management, infusion drugs so they may show up to provide that service for you as well.  The link below about OptumRX buying the infusion company has a<strong> side listing of a lot of government cronyism in healthcare</strong> too if you want to read about it.  </p> <p>There’s a company that’s a subsidiary of United Healthcare, <a href="https://www.healthylife.optumhealthallies.com/ha/public/indexDtc.jhtml;sessionid=BR23TQVTSZWV0CW5GZIBQBY?_requestid=13686">HealthAllies</a>  that was created by current CMS Adminsrator Slavit and Elizabeth Warren’s daughter (funded by Soros these days with her think tank) both former McKinsey consultants that will <strong><u>sell you a card to</u></strong> get both care and prescription discounts at the cost of $25.00 a month too.  It’s very dirty and corrupt these days in healthcare to say the least.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">OptumRX (United Healthcare) Buys Home Infusion Company AxelaCare-Using Algorithms To Determine Your Care With Being Financed By A “Too Big to Fail” US Health Insurance Company…</a></h5> <p>The discount card business has become very complex with just trying to get a prescription filled today and it’s done with complexities on purpose as everytime we don’t check something, we get fooled and pay more.  This is what I call the world of the <a href="http://www.ducknet.net/attack-of-the-killer-algorithms/">Attack of the Killer Algorithms</a> as it is math models and computer codes that run everything so be aware, be very aware as it’s a game of being able to click for the right price anymore to the extremes and it shouldn’t be that way.  BD  </p>

The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!

One thing we all hate is the high prices we pay in the US today for our prescriptions.  Sure we do get some discounts, but that too has beco...

Read more »

Be Aware of Prescription “Claw Backs” as Pharmacy Benefit Management Profit Centers Continue to Evolve

<p><script type="text/javascript" src="http://kfda.images.worldnow.com/interface/js/WNVideo.js?rnd=344707067;hostDomain=www.newschannel10.com;playerWidth=530;playerHeight=355;isShowIcon=true;clipId=12412460;flvUri=;partnerclipid=;adTag=News;advertisingZone=;enableAds=true;landingPage=;islandingPageoverride=;playerType=STANDARD_EMBEDDEDscript;controlsType=overlay"></script>If you have watched the news of late, drug prices that we pay are a big item as the price of drugs keeps<a href="https://lh3.googleusercontent.com/-B_ianRfzEgY/Vy6FmQlLxFI/AAAAAAABMvA/WM5j5vYFwO8/s1600-h/image%25255B2%25255D.png"><img align="right" alt="image" border="0" height="143" src="https://lh3.googleusercontent.com/-zgkJ-LQAdLg/Vy6FnKRc3SI/AAAAAAABMvE/G63cfrKoPig/image_thumb.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="image" width="244"></a> going up.  The pharmacy benefit management company is the middle man in between the pharmacy and you.  Their computers connect to the PBM and they are given the price to charge you according to your  agreement and insurance under which your prescriptions fall.</p> <p>Worth a mention here is that OptumRX last quarter became the biggest revenue producer of their 4 revenue categories.  That’s right they are making more here than any of their insurance groups when compared, more at the link below.  OptumRX gets a double whammy in revenue as their OptumRX, through the acquistion of Cigna is also the pharmacy benefit manager for those insured by Cigna.  Cigna is currently sanctioned by CMS though and and their former benefit manager, Catamaran, which was acquired and integrated into OptumRX was denying patients too many drugs and care. </p> <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-hits-bottom-of-barrel.html">United Healthcare Hits the Bottom of the Barrel Linking Doctor Information to Healthgrades Flawed Data</a></h5> <p>Of course in this video, which pharmacy benefit management company is heavily connected to claw backs?  United Healthcare, aka OptumRX. You may have wondered why we have the Walgreens and OptumRX agreement right?  There’s claw back money potential here as they state that patients can pay the same at Walgreens as they would getting a 90 day supply via the mail.  Well, when you watch the video, the computers talk to each other and the patient may receive a higher cost than what the Walgreens “no insurance-cash” rate would be.  So what do they do, split the difference with a profit?  More at the link below on how this happens.  Anthem is suing Express Scripts as well on the pharmacy kick backs that the pharmacy benefit management company Express Scripts receives on the sale of drugs.  That’s another avenue in which pharmacy benefit management companies make money,<a href="https://lh3.googleusercontent.com/-knR2byNEz5s/Vy6Fny6KkZI/AAAAAAABMvI/h1UiyX4ZnWM/s1600-h/image%25255B5%25255D.png"><img align="right" alt="image" border="0" height="172" src="https://lh3.googleusercontent.com/-ufxZJXQqv-Y/Vy6FoXrazRI/AAAAAAABMvM/3bkI2KAimvI/image_thumb%25255B1%25255D.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="image" width="244"></a> they get a kick back from the drug company on the dollar amount of the drugs that were sold.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/03/walgreens-signs-agreement-with-pbm.html">Walgreens Signs Agreement With PBM OptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts</a></h5> <p>Some day if you need infusion drugs, there’s a good possibility a subsidiary of OptumRX, the subsidiary of United Healthcare might pay you a visit for that too as the company they bought operates in 38 states.</p> <h5><a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">OptumRX (United Healthcare) Buys Home Infusion Company AxelaCare-Using Algorithms To Determine Your Care With Being Financed By A “Too Big to Fail” US Health Insurance Company…</a></h5> <p><strong>When you really want to throw off the entire pharmacy patient “scoring” system, just pay cash for your prescriptions</strong> and you’ll be scored by default as an outlier who doesn’t take their meds.  Before you walk in to most pharmacies today, the pharmacists already have you sized up with 300 metrics that have zero to do with taking your prescriptions on predicting whether or not you will.  I think it’s a big farce, costs a lot of money and they sell all of this data to insurers and other people who want to calculate any type of risk assessment on you.  The problem is, the numbers are flawed.  <h5><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Nonmedication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> <p>Do always ask for the “cash” no insurance price is the moral of this story to avoid pharmacy benefit managers getting a claw back of your money and charging more when they find you could be asleep at the wheel if you will.  In the video they ask what kind of company is that which is supposed to negotiated cheaper prices for you and ends up charging you more?  That’s a good question and of course some of that probably goes to pay for all the software and algorithms that score you on predictions and risk, right? <p>Sometimes customers are paying more than the drug is worth as well.  Claw Backs don’t occur on every prescription but ask to avoid one happening with you is the best advice.  I had a person tell me they have a son who needs some expensive drugs due to some serious conditions he has and due to the pricing, he has to go to three pharmacies to get all the prescriptions for the best price.  That’s wild when that occurs but that shows how different the contracts are and how the pharmacy benefit management contracts work.  BD  <p><a href="http://www.newschannel10.com" title="KFDA - NewsChannel 10 / Amarillo News, Weather, Sports">KFDA - NewsChannel 10 / Amarillo News, Weather, Sports</a></p> <p> <hr> One source for our investigation, a New Orleans-area pharmacist, asked us to hide his identity.  Contracts with pharmacy benefit managers, or PBM's, prevent him from talking publicly. <p>But documents that multiple pharmacists provided to FOX 8 News show, in some cases, companies are charging copays that exceed the customers' costs for their drug.   <p>Pharmacists call it a clawback - the company is essentially clawing back money from you and, our source tells us, you probably don't even realize it's happening. <p>“They have no idea,” the pharmacist says.</p> <p>“Whatever the insurance company/PBM tells us to charge as a copay, we have to charge the patient for that,” our source says.  “We cannot discount it, we cannot forgive it. Our computer calls their computer. They tell us charge the patient this much money.”</p> <p>But many pharmacists, who asked that we not reveal their identities, gave us dozens of examples. They include <a href="http://ftpcontent.worldnow.com/wvue/documents/HOPCpg24.jpg">a $22 clawback</a> on a nasal steroid, fluticasone; <a href="http://ftpcontent.worldnow.com/wvue/documents/HOPCpg6.jpg">$7.85 for a diabetes treatment</a>, invokamet; <a href="http://ftpcontent.worldnow.com/wvue/documents/HOPCpg11.jpg">$12.39 for diazepam</a>, a drug that treats anxiety, muscle spasms and seizures.</p> <p><a href="http://www.newschannel10.com/story/31891070/zurik-copay-or-you-pay-prescription-drug-clawbacks-draw-fire">http://www.newschannel10.com/story/31891070/zurik-copay-or-you-pay-prescription-drug-clawbacks-draw-fire</a></p>

Be Aware of Prescription “Claw Backs” as Pharmacy Benefit Management Profit Centers Continue to Evolve

If you have watched the news of late, drug prices that we pay are a big item as the price of drugs keeps going up.  The pharmacy benefit ma...

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United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

<p>You can read the <a href="http://www.businesswire.com/news/home/20160419005655/en/UnitedHealth-Group-Reports-Quarter-Results">entire press release here</a> as the report is broken down in several entities, but I found the most striking of all to be the “revenue” section, in other words where the money’s coming from to be of importance.  What are we starting to see as the insurer states they are withdrawing from around 8 states with Affordable Care Policies beginning in 2017?   The company did not participate in a large way with many of the ACA insurance exchanges and yes a decent number of folks will have to change their plans next year.  But what’s the deal with OptumRX revenue?  Here’s a screenshot of the revenue numbers and you can look for yourself.   The first column is this year and the second column is 2015 for a comparison.  </p> <p> </p> <p><a href="https://lh3.googleusercontent.com/-LLcWBXpVNcA/Vxb9Qd155kI/AAAAAAABMuU/ATpnQkODLOg/s1600-h/image%25255B4%25255D.png"><img alt="image" border="0" height="217" src="https://lh3.googleusercontent.com/-49g0-b4sJ7k/Vxb9RP9b1kI/AAAAAAABMuY/V3yDPAAbRjk/image_thumb%25255B2%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="613"></a></p> <p>We know that United had a $10 billion dollar bond sale to buy the pharmacy benefit management company, Catamaran that in essence helped get Cigna sanctioned with not being able to sell anymore Medicare Part D policies and I think that restriction is still there today, as the company was denying too many drugs to those insured by Cigna.  I had some sources tell me that in some exit interviews, etc. that the Catamaran folks working with referrals and approvals had no idea why they were denying requests other than the fact that the “screen said no” and that ‘s a little scary in itself.  In addition, Cigna was supposed to be denied their bonus payments from CMS for a lot of this activity but they gave in and allowed Cigna to get their money from the government.  So now all who are insured by Cigna have a pharmacy benefit manager, OptumRX, which is owned by United Healthcare.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/01/cms-sanctions-cigna-no-more-selling-any.html">CMS Sanctions Cigna-No More Selling Any New Medicare Advantage Policies Until Algo Problems Denying Medical Coverage and Prescription Denials Are Fixed</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/07/united-healthcare-having-big-bond-sale.html">United Healthcare Having a Big Bond Sale to Finance Purchase of Catamaran Pharmacy Benefit Management Company, Huge 10.5 Billion</a></h5> <p>United, under the Optum name also bought a Workers Compensation pharmacy benefit management company, who’s largest account just happens to be the US Post Office along with other very large corporations like Southwest Airlines and move…more money. <h5><a href="http://ducknetweb.blogspot.com/2016/01/united-healthcare-buys-helios-workmans.html">United Healthcare Buys Helios Workman’s Comp PBM and Their Other Related Businesses</a></h5> <p>There’s so much money made here on the high prices we pay for drugs that Anthem is suing Express Scripts to get a touch of that money, while at the same time OptumRX is inching its way into Walgreens with a 90 prescription.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/03/walgreens-signs-agreement-with-pbm.html">Walgreens Signs Agreement With PBM OptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts</a></h5> <p>The pharmacy benefit management and making money model can be a little complex to understand indeed as the companies get what is called a kickback with sales of the drugs they distribute, and especially on generics, up to 80% can be handed back.  It can all add up to a lot of money.  So in essence, it may not always be the lowest price drug who gets the contract, it might be the pharma company that offers the biggest percentage kick back.  Being United owns OptumRX, this gets a bit tricky as they are there to negotiate drug prices; however, those kickbacks algo go to the United bottom line as profits so the very entity of an insurance company, United, they are there to work for and keep drug prices down, is also the same corporate umbrella that wants all the profit they can get from the pharmacy benefit management company as well.  I would think this really becomes a balancing act and this would be where they call in the company quants with math to figure it out for them. <p>Who knows, a United Healthcare/Optum subsidiary AxelaCare, (bought by the OptumRX subsidiary) may show at your home to administer infusion drug some day as OptumRX bought this company as well.  The link below also contains a ton load of cronyism connections that I just felt like adding when I wrote the post.  I dug up the CMS director’s relationship to the Elizabeth Warren family and a few money ventures and you can also read how Lorretta Lynch used to handle anti-trust suits for United Healthcare.  She’s busy with another job right now and won’t be doing any of that for a while anyway.  <h5><a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">OptumRX (United Healthcare) Buys Home Infusion Company AxelaCare-Using Algorithms To Determine Your Care With Being Financed By A “Too Big to Fail” US Health Insurance Company…</a></h5> <p>For the time being it appears Harken Health, another creation of United Healthcare will stay around for a while with the ACA state insurance policies going away as they put their quants to work to create yet another model of insurance to throw against the wall to see if anything sticks. <h5><a href="http://ducknetweb.blogspot.com/2016/03/united-healthcare-puts-their-quants-to.html">United Healthcare Puts Their Quants To Work Again-Designs a Subsidiary to Compete Against Them and Sell Insurance With a New Set of Algorithms Named Harken</a></h5> <p>The pharmacy software algorithms that help make money selling our data and creating these flawed medication <img align="right" src="http://lh3.googleusercontent.com/-KDDBEc3i-I4/VaiE5CvPnTI/AAAAAAABMco/U9a02nrysU8/image%25255B3%25255D.png?imgmax=800" style="float: right; display: inline">adherence scores goes way back to 2010 when CMS director Slavitt was President of Ingenix (now renamed Optum) and sold Express Scripts sofware and systems on how to start collecting and selling data on consumers.  You do wonder with all of this if we do have the fox minding the hen house today at CMS as it seems ironic that the exact same models, some of which are failing keep working their way from United Healthcare to CMS, i.e. population health which was created by United around 15 years ago with the Ingenix folks.  The pharmacy benefit management business has a very profitable side business of selling and scoring all consumers when we pick up our prescriptions and you get secretly scored and sold all the time.  If there’s not enough credit card records for them to drag through of yours to see if you filled a presciption, then you default to being an outlier, and if you pay cash, same result.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> <p>Here’s more detail on what’s going on with pharmacy data being sold and how you are secretly scored with proprietary metrics and algorithms that have never been proven for accuracy, but it makes for big money for pharmacy benefit management, sell that data and score those consumers, as pharma and insurance companies are the big buyers.  With OptumrX they can give all the scored data away to United as they own them and they’ll probably turn around and “score” you again with the data on some other correlated query.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p>The screenshot to the right shows how Express Scripts scores you and again this began in 2010 when Ingenix, now renamed Optum sold them the software needed to begin the scoring processes, when Andy Slavitt, who now runs CMS was the CEO of Ingenix.  Below is the back link on that story from 2010, so it revolves back again around one company and their algorithms and analytics, United or one of their subsidiaries.  <h5><a href="http://ducknetweb.blogspot.com/2010/10/express-scripts-new-program-to-contact.html">Express Scripts- New Program to Contact and Predict Patients Who May Not Be Taking Their Medicine Based On Ingenix Algorithms–We Want the Revenue Please Don’t Stop</a></h5> <p>So the pharmacy benefit managers are all doing it in one shape of an algorithm or another and the data and scored are flawed as now the have started bringing in social network garbage and give you a score that may not accurately represent<img align="right" height="199" src="http://lh3.googleusercontent.com/-WTU_WavuGLg/VYjYaFce1MI/AAAAAAABMZA/DCNNtafnZm8/image%25255B8%25255D.png?imgmax=800" style="float: right; display: inline" width="312"> you at all, but again it’s big money and maybe helps explain the big push by United into pharmacy benefit management.  The last quarter revenue tells the story does it not? <p>So it’s very interesting is it not to see this huge shift of revenue from OptumRX to even outshadow their insurance group revenues?  It beat all of them on it’s own.  Of course though if you want information on your doctor or hospital, the last bone thrown at you by United is to link you to the most flawed site on the internet, Healthgrades to find flawed data, survey reviews and other information about them.  <p>By the way, don’t bother with a Healthgrades survey as they tie it to your phone number or email address so they can profile you for more e-commerce behavior analytics and who knows if they are selling that back to United?  It seems to be the way it works as we all know Healthgrades is not much more than clickbait for the site to generate ad revenue.  You can read below on that topic. <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-hits-bottom-of-barrel.html">United Healthcare Hits the Bottom of the Barrel Linking Doctor Information to Healthgrades Flawed Data</a></h5> <p>So what is the future here?  Big push into pharmacy benefit management and getting drug kick backs from pharma in the name of lower priced drugs?  When do we ever get to see that part of it?  Looks like the lost revenue claimed over the ACA insurance policies that are being dropped has been more than replaced, you think?  Of course in this process we can all look foward to a lot less privacy, as today’s it is already out of hand.  BD   

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

You can read the entire press release here as the report is broken down in several entities, but I found the most striking of all to be the...

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United Healthcare Buys Helios Workman’s Comp PBM and Their Other Related Businesses

<p>Here’s another purchase, <a href="http://www.helioscomp.com/home">Helios,</a>  and the big focus here is the pharmacy benefit management.  It was just last year that United/OptumRX bought Catamaran.  What’s interesting about that purchase is that all the folks insured by Cigna now all have OptumRX as their pharmacy benefit manager.  Nothing like having a competitor for Cigna like United with their nose in a big part of your business, especially when Cigna just got sanctioned from CMS and can’t sell any more Medicare Advantage policies for a while.  <h5><a href="http://ducknetweb.blogspot.com/2016/01/cms-sanctions-cigna-no-more-selling-any.html">CMS Sanctions Cigna-No More Selling Any New Medicare Advantage Policies Until Algo Problems Denying Medical Coverage and Prescription Denials Are Fixed</a></h5> <p>Helios has some big contracts as well, such as the US Post Office and Southwest Airlines to name a couple.  As a claimant, you get set up<a href="http://www.helioscomp.com/resources/mail-order"><img align="right" alt="image[4]" border="0" height="93" src="https://lh3.googleusercontent.com/-MooegQBMbzU/Vqw-_mGLuFI/AAAAAAABMqc/4dif0z69gJE/image%25255B4%25255D%25255B3%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image[4]" width="242"></a> with a credit card to get your prescriptions so all of that can be tracked and of course sold.  All pharmacy benefit managers work that way.  <strong>They offer you a MasterCard, the biggest data selling credit card service in the US and you have to put the money in, so it’s not like you are given money to charge against any settlement</strong>, one more way to get more data from you for the case and to sell.  The Preferred provider for scripts is Walgreens and they will want you on mail order too.  They have the same old predictive analytics they write about like all the others…they will predict your case, how long, the severity of the injury and so on.  If you want to read about what goes on if you pay cash on any prescriptions, almost anywhere, read this link below as you are now “scored” as an Outlier if they can’t find enough data about you and by default you score to a level of noncompliance. <h5><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> <p><em>“Four years ago, we began our predictive analytics program by calculating an individual risk score to measure the potential of a claim becoming a high-cost pharmacy claim. Our clinical services team of pharmacists and nurses used these risk scores to prioritize claim intervention efforts following a needs-based triage approach that combined the numbers from the algorithms with the experience of the clinician.”</em> <p>With owning more and more clinics, I could guess in time you will be referred to Optum owned urgent care centers as well.  Some states are blanketed with them already with the purchase of MedExpress, who’s buying up more private practices all the time.  <h5><a href="http://ducknetweb.blogspot.com/2015/05/optum-clinics-holdings-new-subsidiary.html">Optum clinics Holdings, New Subsidiary Incorporated In 2015 Raises Over 36 Million (Exchange of Shares) From Investors Unknown-Form D Used to Maintain Secrecy Of Who They Are For Now…</a></h5> <p>In addition, if you need some infusion drugs, there’s probably another Optum subsidiary that will pay you a visit at home. <h5><a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">OptumRX (United Healthcare) Buys Home Infusion Company AxelaCare-Using Algorithms To Determine Your Care With Being Financed By A “Too Big to Fail” US Health Insurance Company…</a></h5> <p>Have you ever noticed the investments in low income housing from United? <h5><a href="http://ducknetweb.blogspot.com/2014/06/united-healthcare-expands-into-more-low.html">United Healthcare Expands Into More Low Income Housing Investments, This Time in Austin - They Want Your Rent Check Too-Subsidiary Watch</a></h5> <p>Notice this cozy arrangement with HHS and Optum Labs where HHS didn’t even use their own FDA agency Sentinel program that does the same thing.  Do read some of my links above and you might be surprised on what’s going on in plain sight around you.  United has just under 400 subsidiaries all involved in many types of business and is not just an insurance company.  BD  <hr> UnitedHealth Group Inc.'s acquisition of workers compensation pharmacy benefit manager Helios will help the health insurer grow by expanding its offerings in the pharmaceutical space, an analyst says. <p>OptumRx Inc., UnitedHealth's PBM unit, acquired Helios on Jan. 15, spokespeople for the companies confirmed Wednesday. <p>While terms of the deal were not disclosed, Bloomberg reported it could be worth up to $1.7 billion. <p>Helios was established effective August 2014 following the merger of two workers comp PBMs, Progressive Medical Inc. and PMSI Inc. <p><a href="http://www.businessinsurance.com/article/20160127/NEWS08/160129835/optumrx-acquires-workers-comp-specialist-pbm-helios">http://www.businessinsurance.com/article/20160127/NEWS08/160129835/optumrx-acquires-workers-comp-specialist-pbm-helios</a>

United Healthcare Buys Helios Workman’s Comp PBM and Their Other Related Businesses

Here’s another purchase, Helios,   and the big focus here is the pharmacy benefit management.  It was just last year that United/OptumRX bou...

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Rite Aid Pharmacies are the Latest to Begin Used Flawed Data Provided by the EQuIPP Platform Relative to “Scoring” Patients for Predictive Medication Adherence–The “Outlier” Patients…

<a href="https://www.blogger.com/blogger.g?blogID=3741684961227307530" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=3741684961227307530" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=3741684961227307530" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="http://2.bp.blogspot.com/-DN2en0D1OOs/VnGK0wq8qRI/AAAAAAABMnQ/OLPAoVydEp0/s1600/equippp.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=3741684961227307530" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=3741684961227307530" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=3741684961227307530" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><img border="0" height="88" src="http://2.bp.blogspot.com/-DN2en0D1OOs/VnGK0wq8qRI/AAAAAAABMnQ/OLPAoVydEp0/s320/equippp.png" width="320" />I have had some conversations with pharmacists who are on a pay for performance metric program based on this program and they don’t like it.  The big reason is the data that is provided to them is flawed.  The program finds information around the web about patients and combines it into a report that pharmacists must look up.  In addition they need to fix the flawed data that is reported.  You are probably not aware of this program as a patient but it exists and it is full of flawed data, being that you are reported as being non compliant if it does not located enough data about you.<br /> <br /> These scores are being sold to pharma and to insurance companies.  Yesterday I read an article that just about made me choke, with an executive being quoted as saying “don’t waste your time on this patient, spend more time on this one as they show they are taking their medications”…again here we go again with flawed data.  You can look at the link below to see an actual conversation I had with a pharmacist and how this works.  They hate it as the executives from the EQuiPP program are constantly breathing down their backs as the pay for performance numbers are not improving fast enough, when in fact the data is not correct.  Patients who pay cash are being classified in error as Outliers.<br /> <h5> <a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> Do you not think these flawed scores will be used to deny or allow access?  Better think on that one again.  <img align="right" src="http://lh3.googleusercontent.com/-WTU_WavuGLg/VYjYaFce1MI/AAAAAAABMZA/DCNNtafnZm8/image%25255B8%25255D.png?imgmax=800" style="display: inline; float: right;" /> We know CMS is having a hard time today with many of their models with flawed data and in turn not improving care to the patient.  Also, don’t confuse medication prediction scores with “actual” facts that PBMs use to see who’s filling their prescriptions.  Those are actual transactions that have taken place where most of the predictions scoring is pure bullshit.  <br /> <h5> <a href="http://ducknetweb.blogspot.com/2015/10/cms-medicare-part-d-program-with.html">CMS Medicare Part D Program With Medication Therapy Management–Here Comes the Flawed Medication Adherence Prediction Scores, Make Sure Jane Doe Gets the “Cheap Meds”..</a></h5> All pharmacy benefit managers today are using some kind of prediction scoring and just take a look at the screenshot right off the Express Scripts page to the right here.  Do you see open discrimination here?  You should as they use 300 “secret” metrics created by some algorithm to give you a “secret” score that you can’t have or see.  If the code were ever broken down so we could see the metrics here I’m sure you would see all kinds of queries related to race, etc. as you can already see one in the image for “income” and “age” if under 65 years old.  You are being scored on many things you can’t change which is not fair. <br /> <h5> <a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> All of this “scoring” costs  lot of money and in healthcare today, we are paying for tons of predictive queries and software platforms that offer little or no ROI and this is a big one.  We come right back to Excess Scoring of US Consumers and we get no benefit at all.  Here’s some additional links below if you want to catch up on what’s going on today with all of this.  Pretty much all of this goes back again to a division of Untied Healthcare, called Ingenix, which is now Optum Insights which created such “scoring” of patients as that’s what they do.  In addition, you can find some <a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">shocking “Cronyism” political ties</a> here that might help make more sense of what’s going on and who’s pocket all of this is feeding.  <br /> <h5> <a href="http://ducknetweb.blogspot.com/2014/06/fico-medication-adherence-scoring.html">FICO Medication Adherence Scoring Should Be Banned As It’s Quantitated Justifications for Profit That Hurts US Consumers Using Proprietary Algorithms That Cannot Be Replicated For Accuracy or Audited</a></h5> <h5> <a href="http://ducknetweb.blogspot.com/2010/10/express-scripts-new-program-to-contact.html">Express Scripts- New Program to Contact and Predict Patients Who May Not Be Taking Their Medicine Based On Ingenix Algorithms–We Want the Revenue Please Don’t Stop</a></h5> All in all, predictive medication scoring also helps pharma substantiate the high prices of their drugs as for years it’s been a media circus of “keep blaming the patient” for non perfect results.  I learned that tidbit from a former executive and code writer at the NISS many years ago.  Anyway, pay attention here is this is what your pharmacist does today for their performance metrics, dealing with the flawed data that comes down the line.  Former President Jimmy Carter made a speech not too long ago about the US not being a democracy any more and how now is becoming more of a dictatorship and here’s one big example of how this works with using algorithms and flawed data created by coders and developers to control individuals in the US.  BD  <br /> <br /> <hr /> CAMP HILL, Pa.--(<a href="http://www.enhancedonlinenews.com/">EON: Enhanced Online News</a>)--Rite Aid Corporation (NYSE: RAD) announced today that pharmacists across its nearly 4,600 locations chainwide are now utilizing Pharmacy Quality Solutions’ (PQS) EQuIPP, an information management platform that provides access to performance data across key patient care quality metrics, including those focused on medication adherence and appropriate medication use. Rite Aid is the largest drugstore chain to provide EQuIPP access to all pharmacists.<br /> “Value-based healthcare is here to stay and that’s why it’s important for Rite Aid to provide our pharmacists with the resources and tools they need to deliver improved health outcomes for their patients,” said Jocelyn Konrad, Rite Aid executive vice president of pharmacy. “Our pharmacists are committed to providing excellent care to their customers, and with EQuIPP, we’re empowering them to make an even greater difference in the health and wellbeing of their customers and succeed in today’s healthcare environment.”<br /> <a href="http://www.enhancedonlinenews.com/portal/site/eon/permalink/?ndmViewId=news_view&newsId=20151216005752&newsLang=en&permalinkExtra=Rite-Aid-Pharmacists-EQuIPP-Platform-Measure-Patient-Focused">http://www.enhancedonlinenews.com/portal/site/eon/permalink/?ndmViewId=news_view&newsId=20151216005752&newsLang=en&permalinkExtra=Rite-Aid-Pharmacists-EQuIPP-Platform-Measure-Patient-Focused</a>

Rite Aid Pharmacies are the Latest to Begin Used Flawed Data Provided by the EQuIPP Platform Relative to “Scoring” Patients for Predictive Medication Adherence–The “Outlier” Patients…

I have had some conversations with pharmacists who are on a pay for performance metric program based on this program and they don’t like it....

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