Steve Marvin

Pharmacist. Lucky Husband. Proud Dad. BBN

[Steve Marvin @SteveMarvin9]

@ThomasSowell And Stalin and Mao

[Ginny Crisp, PharmD @ginny_crisp]

The rebate check gets bigger every year. So does your net cost. Both lines can rise forever, because one of them was never the point.

[Steve Marvin @SteveMarvin9]

@DefiantLs Too modest also

[Steve Marvin @SteveMarvin9]

@ginny_crisp Wonder what they billed the plan? They love that spread pricing.

[Ginny Crisp, PharmD @ginny_crisp]

The FTC found the big-3 PBMs reimbursed their own pharmacies as much as 100% more than independents for the identical generic. Same pill. Same day. The difference was who owned the counter.

[Mark Cuban @mcuban]

Then I asked for a simplified version of the above :

Here it is in plain English. Denver hired UnitedHealthcare to run its employee health plan. Denver pays the actual medical and drug bills itself — United just processes them. That’s what “self-funded” means. The problem is that Denver can’t see what it’s actually paying for drugs.

1. United buys the drug for one price and charges Denver a different price. It keeps the difference. Say the pharmacy gets paid $40 for a prescription. United bills Denver $100. United keeps $60. Denver never sees the $40. The contract says this out loud in three different places — it’s not hidden, it’s just written in language nobody reads. There’s no cap on how big that gap can be.

2. Drug companies pay rebates. United keeps all of them and hands Denver a flat number instead. United collects rebate checks from drug manufacturers. Instead of passing those through, it promises Denver a fixed amount per brand prescription (about $740 in 2023). If the actual rebate was $1,500, United keeps the extra $760. The contract literally says any rebates above the fixed amount belong to United. Denver has no right to know what the real number was.

3. United decides which drugs are “specialty” — and specialty drugs are where the money is. The contract defines a specialty drug as, essentially, “whatever United’s own specialty pharmacy sells.” United also reserves the right to reclassify drugs whenever it wants. Once a drug is labeled specialty and filled at United’s own pharmacy, it drops out of the normal price guarantees entirely. So the most expensive drugs are the least protected.

4. The most expensive drugs of all — the ones given in a doctor’s office or infusion center — have no price guarantee at all. The contract flatly excludes them. Cancer drugs, infusions, injections administered by a provider. Zero pricing protection.

5. Denver can’t shop around, and it can’t leave without a penalty. Denver isn’t allowed to negotiate directly with any drug manufacturer. It must use United’s mail-order pharmacy exclusively. And if Denver hires an outside vendor that steers employees to cheaper drugs or cheaper pharmacies, United can cancel all the pricing guarantees. If Denver ends the drug program early, United keeps every rebate it owes.

6. Denver can’t audit its way out of this. Denver is allowed one audit a year, capped at 300 prescriptions, using a random sample United has to approve. No auditors paid on commission. No computer-based searches for errors. You cannot find a pricing problem across hundreds of thousands of claims by randomly checking 300 of them. The audit rules exist to make sure nothing gets found.

Is any of it illegal? Almost none of it. It’s a legal contract that Denver signed. The one thing that might cross a line: federal law since 2021 bans “gag clauses” — contract terms that stop an employer from seeing its own cost and claims data. This contract says United may let Denver see its pricing information, at United’s discretion. Federal regulators have said that “only if the vendor allows it” language is exactly what the gag-clause ban prohibits. And Denver has to certify to the government every year that it has no gag clauses in its contracts.

The one thing Denver could actually do about it: Colorado banned this drug markup practice, effective January 2025, and self-funded employers like Denver can opt in. It’s an election, not a lawsuit. Somebody should check whether Denver ever filed it.

The bottom line for an HR person: the drug program looks free. There’s no fee for it anywhere in the contract. That’s the tell. United isn’t working for free — it’s getting paid out of the drug prices, and the contract is built so Denver can’t measure how much.

[KP, Pharm.D. @kpharmd12]

No pharmacy in America should be subsidizing the cost of prescriptions for their patients out of the pharmacy’s bank account.

Change my mind.

[Dale Laine, Jr. @dalelaine]

Yep. At the same time, those middlemen #PBMs are killing off small, independent and family owned pharmacies. @TXpharmAssn @whoop97 @SeniorCareRx @60PlusAssoc @TxRuralReport @JohnCornyn @SenTedCruz @RepRonnyJackson @RepArrington @RepPfluger @RepNateMoran

[The Rojas Report @TheRojasReport]

“Nonprofit hospital” is one of the most successful phrases in American business.
It makes you picture a soup kitchen.

The Form 990 shows an $8.5 billion conglomerate that cleared $860 million and paid no income tax.

Nonprofit describes the tax treatment.
It does not describe the behavior.

[Dave Falk @falk_dave]

An independent Pharmacy Owner forced by a multi billion dollar corporation (pbm) out of NETWORK (under cost reimbursements) to not be able to serve United States service men and women and retirees. Let that sink in. It happened to over 13,000 independent pharmacies.

[Practical Patriot 🇺🇸 @InternetCPA]

Cut independent lab payments hard enough and the small labs disappear. Hospitals absorb the volume, the $45 blood test becomes a $700 hospital bill, and your doctor has nowhere cheaper to send you.

That's how a reimbursement cut becomes a healthcare monopoly.

[Steve Marvin @SteveMarvin9]

@ginny_crisp It’s 25% of the drug spend in my pharmacies.

[Steve Marvin @SteveMarvin9]

@bigbluehistory @KySportsRadio Lawrence County?

[Ginny Crisp, PharmD @ginny_crisp]

There's a public benchmark for what pharmacies actually pay for a generic: NADAC. Your PBM bills your plan off its own private MAC list instead. When MAC sits above NADAC, the gap is margin. Ask to see both numbers on the same claim.

[Steve Marvin @SteveMarvin9]

@redlgb1969 @rxman95 @axios Has anyone stopped stocking glp1’s. Huge part of my drug spend to MAYBE break even.

[Steve Marvin @SteveMarvin9]

@ginny_crisp @sterlingkoonce @wesmoss1018 That term makes my bp go to stroke level.

[REDBEARD1969 @redlgb1969]

another one. that makes 3 within the past 2 months and 5 for the year.

[Mr PitBull Stories @MrPitbull07]

This footage came from a home security camera inside a house in Knoxville, Tennessee.

The elderly man in the pajamas is Harold.

He’s 79 years old and lives with a progressive memory condition that sometimes causes severe nighttime confusion something doctors often call “sundowning.”

Late at night, Harold occasionally wakes up believing he still has somewhere important to be.

Work.
An appointment.
A meeting from decades ago.

He’ll quietly get dressed and head toward the front door.

Before last year, it happened several times a week.

Twice, he actually made it outside before his wife Carol could stop him.

Once, a neighbor found him wandering down the street at 11 PM wearing slippers.

The family tried alarms.

Harold learned how to disable them.

Then everything changed because of a dog named Samson.

Samson was a two-year-old Golden Retriever their daughter brought over temporarily after a housing issue.

Nobody expected him to become Harold’s nighttime guardian.

A few weeks after Samson arrived, Carol checked the security footage from the previous night after realizing she hadn’t heard Harold get up.

At 1:17 AM, the camera showed Harold walking slowly toward the front door.

But Samson was already waiting there.

Harold tried to move around him.

Samson stepped sideways and blocked the path.

Harold tried again.

Samson calmly repositioned himself a second time.

Then the dog gently took Harold’s pajama sleeve in his mouth and slowly guided him back down the hallway toward the bedroom.

And Harold followed him.

The family later showed the footage to Harold’s neurologist.

The doctor reportedly watched it twice before explaining:

“This is recognized redirection behavior used for memory-related wandering. The dog is doing it correctly — instinctively — without training.”

Now Samson sleeps at the foot of Harold’s bed every night.

When Harold was told what Samson had been doing for him, he looked at the dog for a long moment and simply said:

“Well… somebody has to look after things around here.”

Sometimes the right soul arrives at exactly the right moment.

And sometimes it walks in on four legs.

[Texas Pharmacy Assn @TXpharmAssn]

"Independent #pharmacies are closing at a rate of at least one per week—not because patients need fewer medications, not because competitors can provide care less expensively, but because vertically integrated PBMs have discovered they can systematically underpay independent pharmacies while overregulation limits our ability to adapt and expand services," said TPA Independent Pharmacy Academy Chair Crystal McEntire. "The path that we are on is unsustainable."

McEntire was invited to testify today before the Texas Senate Health & Human Services Committee and Chair @LoisKolkhorst as it examined the role of PBMs in health care costs and monitored the implementation of SB 1236, passed last year. #PBMReform #txlege

[Texas Pharmacy Assn @TXpharmAssn]

In her opening comments at today's Senate HHS Committee interim hearing concerning health care costs, Chair @LoisKolkhorst highlighted issues with #pharmacy benefit managers (PBMs). "It affects you hugely. They get rebates that we don't even know what it is because we can't look in the black box and know if we're getting a good deal or a bad deal. And all the while, we're putting independent #pharmacies out of business," she said. "If you can't tell, I'm fired up about this!" #PBMReform #txlege