Top Tweets for #PHYChat

The HHS Sec is correct to state that the MMR vaccine is the most effective way to prevent measles. But he doesn’t say that it’s safe (it is) and he doesn’t urge unvaccinated people to get vaccinated (he should) and he has repeatedly downplayed the risks associated with a measles infection. Why won’t Sec Kennedy unequivocally urge unvaccinated people to vaccinate themselves and their children? The answer is that he doesn’t believe the vaccine is both safe and effective.

Sen. Bill Cassidy: "My voice cracked because…as a little boy, I would read history books and I would read about these great decisions on the Senate floor…The fact that I, Bill Cassidy, was able to do that, I am so privileged, and whenever I just for a second am hit by the gravity of that and the honor of that, I get emotional."

More revisionist history. I was never in govt and had nothing to do with “lockdowns.” Here’s what actually happened in 2020: the ICUs across America were being overwhelmed with very sick Covid patients and mortality increased as a result. The governors made the decision to issue stay at home orders, in order to give the ICU docs, nurses, respiratory therapists a fighting chance to save lives. I believe Gov DeSantis was among the early adopters of this. He really had no other choice, otherwise mortality before vaccines became available would have skyrocketed even more. That’s the reality…

The city of Denver makes it’s PBM contract available online. So I grabbed it and had Claude look at it and answer a simple question “Where are they getting ripped off” Here is it’s response: Denver is getting hit in six places, and the contract says so out loud. This is a self-funded City & County of Denver plan (4,051 employees / 8,554 participants, 1/1/2023–12/31/2025, $80M max) where the only stated pharmacy fee is… nothing. The medical admin fee is $45.13 PEPM. There is no PBM admin fee. That’s your first tell — the pharmacy program is priced entirely in the dark. 1. Spread pricing, written into the contract three separate times. Section A7 (Claims Processing): on mail, specialty and retail, United retains the difference between what it reimburses the network pharmacy and what Denver pays. It’s repeated in the General Conditions of the Pharmacy Financials exhibit and again in the Specialty Pharmacy Discount Guarantee conditions. So the AWP-discount guarantees describe what Denver pays — not what the pharmacy receives. The delta is Optum’s revenue, uncapped and unreported. For a public entity, that’s the whole ballgame. FTC found the Big 3 generated an estimated $1.4 billion of spread income on specialty generics alone. 2. Rebates: 100% retained, replaced with a fixed per-script number. Section A8: United keeps 100% of pharmacy rebates and pays Denver a fixed brand-script guarantee instead — $740.43 retail / $1,020.22 mail in 2023, rising to $885.02 / $1,105.10 by 2025. The contract then says explicitly that any rebates above the fixed amount are United’s to keep. Manufacturer rebate administration fees are folded into the guarantee, meaning they’re netted against what Denver was already owed rather than paid over. Denver has no idea what the actual rebate yield is, and no contractual right to find out. 3. The Rebate Credit clause is the biosimilar killer. If Denver moves to a biosimilar, an authorized alternative, or a lower-WAC brand, United gets credited toward its rebate guarantee for the manufacturer revenue it would have earned had Denver stayed on the high-rebate originator. Translation: United is financially indifferent to Denver buying the cheaper drug. Denver’s savings on ingredient cost get clawed back through the rebate math. 4. Your five clauses — all present, all in United’s favor. Specialty Drugs are defined as “Prescription Drugs available at United’s Specialty Pharmacy.” That’s a circular definition: whatever Optum stocks is specialty. Then: “United reserves the right to change the designation of a drug from specialty to non-specialty based on market conditions.” Then: specialty dispensed inside United’s specialty network is excluded from the retail and mail guarantees. Specialty dispensed outside it gets swept into the retail guarantee. Specialty rebates are “included in retail.” The specialty guarantee itself is 20.7% off AWP composite — and any specialty drug not on United’s list is guaranteed at only 14.0%. United controls the list. Every new high-cost launch defaults to the 14% bucket. And spread is retained on top of the discount either way. 5. Medical-benefit specialty has no guarantee at all. “Specialty drugs typically covered under the medical benefit (physician’s office, ambulatory, home infusion), and/or transitioned to the pharmacy benefit, are excluded from all guarantees.” That’s the buy-and-bill oncology and infusion book — the most expensive spend in the plan — with zero pricing accountability. On medical drug rebates Denver gets 80%, United keeps 20% plus float interest, and an unnamed subcontractor takes an undisclosed cut on top. 6. The lock-in clauses, which are the reason you can’t fix any of the above. Denver may not negotiate with any manufacturer for rebates or direct purchase — doing so forfeits earned-but-unpaid rebates. All pricing guarantees require United as exclusive mail provider. Terminating pharmacy services early means United keeps every pending and future rebate.

There are moments in medicine that stay with you. This is one of them. Alma is sharing her experience and her story with you to make a difference. Alma and I are the same age, and we both work in healthcare. In 2021, she knew something wasn’t right. Her abdomen hurt and kept swelling. Her symptoms were addressed, but she was reassured that she would feel better soon. She visited multiple doctors and emergency rooms before finally being diagnosed with metastatic ovarian cancer at age 44. She was also found to carry the BRCA1 mutation. She found a wonderful oncologist and began treatment, but when her cancer progressed on the strongest medicine available to her, her doctor suggested that she go to MDAnderson for an alternate treatment. Alma has medical insurance, but says that when she reached out to MDAnderson, she was told it would cost $16,000 upfront to have her records reviewed and see a doctor for a second opinion. And this is only part of her story. There is so much more she has endured — more than can fit in a single video — and it deserves to be heard. Regardless of where you stand on policy, insurance, or systems, we can all agree that this is not the way insured patients should experience cancer. Her words that keep echoing in my mind: “Listen to your patients. We know when something is wrong.” Something is wrong, America. Let’s agree on that. Thank you for trusting us with your story Alma. Your voice matters.