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.
Most Connecticut hospitals will lose a portion of their Medicare reimbursement payments over the next year as penalties for having high rates of patients being readmitted, new data from the Centers for Medicare & Medicaid Services (CMS) show. Statewide, 27 of the 29 hospitals evaluated—or 93 percent—will be penalized in the 2019 fiscal year that began Oct. 1, according to a Kaiser Health News analysis of CMS data. The Medicare program has penalized hospitals since the 2013 fiscal year for having high rates of patients who are readmitted within a month of being discharged. Nationally, hospitals will lose $566 million in penalties, which were instituted as part of the Affordable Care Act to encourage better health care delivery.
Dialysis centers in Connecticut continue to improve their overall quality of care, with 12 facilities reaching Medicare’s highest patient-care rating and just one scoring on the low end of the scale, the latest data show. That’s an improvement from the 2014 data, when six dialysis centers in the state scored low in quality-of-care ratings. Dialysis helps those with kidney failure remove waste from the body, regulate chemicals and control blood pressure. Most often, patients have their blood removed and cleaned in a machine called a dialyzer before it’s returned to the body. Another form of dialysis uses a cleaning fluid and the stomach as a filter.
Four nurses, all of them affiliated with a Derby pain clinic, were responsible for nearly all of the state’s 2014 Medicare spending on the powerful opioid painkiller Subsys, which is at the center of a kickback probe. New Medicare data for 2014 show the four nurses, all who worked at the Comprehensive Pain and Headache Treatment Center of Derby, were responsible for 279 claims for Subsys, at a cost of $2.3 million. The highest prescriber was Heather Alfonso, an advanced practice registered nurse (APRN) formerly employed by the clinic who is awaiting sentencing on charges she took kickbacks from Arizona-based Insys Therapeutics for dispensing Subsys to patients. The new data is the first indication that the propensity to prescribe Subsys extended beyond Alfonso, to other clinic staff. None of the other three nurses has been implicated in an ongoing federal probe of Insys’ marketing of Subsys that resulted in the criminal charges against Alfonso.
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.
Six dialysis facilities in Connecticut received low quality-of-care scores under newly updated federal Medicare ratings, while 11 facilities received the highest rating possible. Connecticut has 45 dialysis facilities in the Medicare program, all but four of them for-profit. Of the 41 for-profit centers, the majority are owned by two chains – DaVita, which has 24, and Fresenius Medical Care, with 13. The federal Medicare program rates dialysis facilities on a scale of one to five stars, based on nine measures of quality of care. The measures include mortality and hospitalization rates of patients, as well as rates of hypercalcemia, catheterization of more than 90 days, and the percentage of dialysis patients who had enough wastes removed from their blood during dialysis.
A Stamford-based podiatrist faces hefty fines and prison time after she pleaded guilty this week to submitting fraudulent Medicare claims.
Amira Mantoura pleaded guilty Monday in Hartford federal court to one count of making a false statement to Medicare after she billed the government program for foot surgeries when she merely clipped patients’ toenails, according to Deirdre M. Daly, U.S. Attorney for the District of Connecticut. Mantoura, 53, lives in Greenwich and has a practice at 95 Morgan St., Stamford. In her guilty plea, she admitted that she submitted false claims to not only Medicare, but Medicaid and private insurance companies as well, Daly said. Reached by phone at her practice Tuesday, Mantoura declined to comment. According to court documents, between January 2009 and August 2013, Mantoura “knowingly submitted materially false claims” seeking payment for nail avulsions, which are surgical treatments for ingrown toenails.
Five dialysis facilities in Connecticut received low quality-of-care scores under a new Medicare rating system, including one center cited for a high death rate, while 11 facilities received the highest rating possible, federal data show. Connecticut has 45 dialysis facilities in the Medicare program, all but four of them for-profit. Of the 41 for-profit centers, the majority are owned by two chains – DaVita, which has 24, and Fresenius Medical Care, with 13. Medicare began rating dialysis facilities earlier this year on a scale of one to five stars, based on nine measures of quality of care. The measures include mortality and hospitalization rates of patients, as well as rates of hypercalcemia, catherization of more than 90 days, and the percentage of dialysis patients who had enough wastes removed from their blood during dialysis.
All but one of Connecticut’s acute-care hospitals will lose Medicare reimbursement in 2015-16 as a penalty for high readmissions of discharged patients, new federal data show. The penalties against 28 hospitals mean Connecticut has one of the highest percentages nationally – more than 90 percent — of hospitals facing Medicare reductions. Only the Hebrew Home and Hospital of West Hartford escaped penalties; the Connecticut Children’s Medical Center is exempted from the federal program. None of the state’s hospitals faces the maximum 3 percent reduction to Medicare reimbursement, but seven face reductions of more than 1 percent. They are: Milford Hospital (1.70 percent); Middlesex, in Middletown (1.38); Johnson Memorial, in Stafford Springs (1.27); Charlotte Hungerford, in Torrington (1.19); St.
Eight of the top 10 prescribers of a potent narcotic used for cancer pain were paid more than $870,000 in speaking fees by the drug maker in 2013 and 2014 — indicating that Derby nurse Heather Alfonso was not the only high prescriber compensated by the company. Alfonso, an advanced practice registered nurse (APRN) who worked at the Comprehensive Pain and Headache Treatment Center in Derby, pleaded guilty last month to accepting $83,000 in kickbacks from 2013 to March 2015 from the drug company Insys Therapeutics, which has heavily marketed a painkiller called Subsys, a sublingual fentanyl spray approved only for cancer patients. Alfonso was paid to speak about Subsys at more than 70 “dinner programs,” but most of those programs were attended only by her and a sales representative for Insys, or by Alfonso’s colleagues and friends who had no authority to prescribe the drug, according to the U.S. Attorney’s Office for Connecticut. Alfonso faces a maximum prison term of five years and a fine of up to $250,000 on the charge of receiving kickbacks in connection with a federal healthcare program. In pleading guilty, she admitted that the money she was paid influenced her prescribing of Subsys, often to non-cancer patients, federal investigators said.