Pharmacy benefit managers – the middlemen who negotiate drug purchases for insurers and large buyers – are coming under growing scrutiny and criticism both in Connecticut and nationwide for their role in the sharp rise of prescription drugs. The third-party companies, called PBMs for short, originally processed claims for pharmacies, but now are hired by Medicare, Medicaid and commercial health plans to manage pharmaceutical benefits. Their reach is broad: they choose what drugs are covered by insurance; negotiate purchasing deals with drug makers; determine co-pays for consumers; decide which pharmacies will be included in prescription plans; and decide how much pharmacies will be reimbursed for the drugs they sell. The growing legions of PBM critics, who include state Comptroller Kevin Lembo, pharmacists and their trade and service organizations, say that the industry is helping drive the unrelenting rise in prescription drug prices and insurance premiums.
PBMs, Lembo’s office and state pharmacists say, use a variety of tactics to capture cash from consumers, payers and pharmacies. One is spread pricing, where they pay the pharmacy less for a prescription than a payer gives them, sometimes even forcing the pharmacist to take a loss.
Betty Williams says giving up crack cocaine was easier than her ongoing struggle to quit cigarettes. “A cigarette is a friend,” said Williams, who lives with schizophrenia and chronic obstructive pulmonary disease. People with mental illness account for 44% of the cigarette purchases in the United States, and they are less likely to quit than other smokers. High smoking rates among people with mental illness contribute to poorer physical health and shorter lifespans, generally 13 to 30 years shorter than the population as a whole. About 37% of men and 30% of women with mental illness smoke.
When immigrant families bring their children to the Yale Children’s Hispanic Clinic, it’s just not about check-ups and vaccinations. Clinicians help them deal with everything from teething to nutrition to finding a place to live. But these days when front-line clinicians encourage families to use the many services offered through federal public programs, parents have questions—and misgivings. “They are hesitant because they are afraid,” said Patricia Nogelo, a clinical social worker at the Yale Children’s Hispanic Clinic. A proposed change in immigration law is making immigrants in Connecticut and nationally wary of utilizing federal programs that cover health, food and housing assistance.
Federally Qualified Community Health Centers (FQHCs) in Connecticut have expanded services, upped their staffing and renovated their facilities mostly due to increased revenue streams from the Affordable Care Act (ACA). Connecticut and the 30 other states that opted for the ACA Medicaid expansion program have benefitted from billions of dollars in additional core grant funding, with Connecticut receiving $150.7 million from 2011 to 2016, according to a January report by the Congressional Research Service. Health centers in Connecticut used some of that funding to hire professionals to enroll thousands of residents in health insurance—residents who were previously uninsured and used the centers for their health care. Now the centers are serving about 70,000 more insured patients, mostly covered by Husky Health plans. The cost of treating uninsured patients has declined by about $10 million since 2012, according to Deb Polun, director of government affairs and media relations at the Community Health Center Association of Connecticut.
Since 2011, Connecticut has issued more than 39,000 new Medicaid cards to prisoners returning to communities, connecting them to health care services with the goal of keeping them healthy and out of prison. This initiative, which gives ex-offenders the opportunity to see a primary care physician on a regular basis and access critical mental health and drug-abuse treatment programs, exists because of the Affordable Care Act (ACA), and Medicaid pays most of the costs. Recidivism data show that the initiative is working, state officials say. Yearly, the Court Support Services Division (CSSD) refers approximately 20,000 adults on probation to various behavioral health programs and tracks them for 12 months. In 2016, CSSD reported that 23.1 percent of adults who completed their referral program were rearrested, a five-year low since CSSD started tracking in 2012.
Low-income women in Connecticut who have just given birth and know they don’t want to get pregnant again anytime soon are now offered a long-acting birth control option postpartum. Medical providers say the policy by the U.S. Department of Health and Human Services will reduce the number of unplanned pregnancies, as well as lead to better maternal health outcomes by ensuring pregnancies are spaced a healthy length of time apart. Connecticut’s HUSKY program is one of 26 state Medicaid programs nationwide that reimburses hospitals for administering long-acting reversible contraception (LARC)—namely, intrauterine devices (IUDs) and subdermal implants—to Medicaid patients. HUSKY started reimbursing for the devices last year. “It’s a great thing,” said Dr. Elizabeth Purcell, an obstetrician and gynecologist practicing in Hartford.
Now is the time to repeal a 40-year-old law that perpetuates inequality among women. The Hyde Amendment, which bans the use of federal funds to pay for abortions except in certain circumstances, is unfair. The amendment targets women who rely on Medicaid for their health care coverage. According to the federal Centers for Medicare and Medicaid Services, roughly two out of three adult women enrolled in Medicaid are between the ages of 19 and 44—the reproductive years. Abortions can run upward of $1,000, which places the (legal) procedure out of reach for most women living in poverty.
Connecticut has a high prevalence of Medicare beneficiaries living with Alzheimer’s disease or other dementias, often placing an enormous financial strain on caregivers who are spending thousands of dollars a year on care, reports show. “Alzheimer’s is the most expensive disease in America,” said Jennifer Walker, vice president of communications and advocacy for the Connecticut chapter of the Alzheimer’s Association. “The cost of care is very high.”
Medicare covers most fees for doctor visits, and some hospitalization, if needed; but other costs associated with care—including home health services, transportation, diapers for incontinence—are not covered. People with Alzheimer’s often suffer from other chronic illnesses such as diabetes, heart and hypertension, which add to the out-of-pocket costs for care. The financial burden is forcing families who rely on Medicare to tap into retirement savings, cutback on food and medical care for themselves, reduce work hours or quit work altogether to be caregivers, according to the Alzheimer’s Association report Alzheimer’s Disease Facts and Figures.
Medicaid will reimburse some health centers in the state for providing patients with access to medical specialist through electronic consultations, which some providers believe will increase low-income patients’ access to care. “The impact is potentially huge,” said Dr. Daren Anderson, director of the Weitzman Institute, which is the research and quality improvement arm of Community Health Center Inc. (CHC). CHC is a Middletown-based network of 13 health centers that includes facilities in New Britain, Stamford, Norwalk, Clinton, and Old Saybrook. An e-consult enables a primary care doctor to contact a specialist—for a second look at patient’s echocardiogram, for instance—and securely send part or all of a patient’s medical records electronically. The specialist then replies to the primary care doctor within a few days (but more typically within just a few hours), reducing the need for a patient visit to the specialist.
Health insurance coverage might be more accessible and affordable in Connecticut if the state applied for certain Affordable Care Act and Medicaid waivers, according to advocates who say the options should be explored. Two waivers in particular—Affordable Care Act (ACA) Section 1332 and Medicaid Section 1115—would let the state disregard certain federal requirements, possibly lowering health care costs for some individuals, according to a policy brief commissioned by the Universal Health Care Foundation of Connecticut and the Connecticut Health Foundation. “What we need to do in Connecticut is really think about … how could we creatively, imaginatively, innovatively use waivers to expand coverage to quality care and really help improve health,” said Frances Padilla, president of Meriden-based Universal Health Care Foundation of Connecticut. “We haven’t had that conversation yet in Connecticut.”
The ACA waiver isn’t available until 2017 but the Medicaid waiver is already being used by dozens of other states to lower costs, she said. “It allows a state to get past some of the requirements of Medicaid and do some things that are innovative,” she said of the Medicaid waiver.