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 theirimage chunk of money.  United Healthcare created the PBM model back in 1976 under the name of Diversified Pharmaceuticals, which ended up ultimately being purchased by Express Scripts via SmithKline Beecham.  Express Scripts also purchased another PBM a few years back called Medco, so combine all the algorithms with both companies and you end up with a massive collection of algorithmic computer code, there to create profits. 

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.

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..

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. 

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…

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.

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

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.

“One Trick Algo World” Needs to be Licensed and Indexed–Spurious Correlations “For Profit” Are Out of Control

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. 

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 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?

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.

If You Are Insured by Cigna, Guess What You Have a New Pharmacy Benefit Manager Named United Healthcare

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

Actually Express Scripts uses a lot of OptumRX algorithms already and has since 2010 with their bogus black box scoring metrics, so yeah they’re already connected at the algorithms you could say. 

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

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.

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

Did you know FICO buys all this scoring data from PBMs and sells it too?  Sure they want to cash in and mix this 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. 

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

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.  They want you to think of it like you have cancer, diabetes, etc.  Beware of PBM marketing for profit. 

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.  PBMs  want no prescription filled without a PBM getting a DIR fee attached in the overall performance standards levied on the pharmacy.

Pharmacy Benefit Managers Invade Medical Records and Electronically Connect Cash Patients to RX Discount Cards-OptimizeRX-to SingleCare to OptumRX

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! 

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…

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.

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…

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..

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

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


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