As drugmakers push prices higher, some are attacking employers and payers that sponsor prescription drug coverage, writes John Jones, teacher of pharmacy law and ethics. "When it comes to how high they price their products, drug companies want the public to ignore what they spend on marketing and the tax breaks they get for direct to consumer advertising," Jones writes.
Pharmacy benefit managers make pharmacies compete for business, work out drug coverage with health insurance plans and process claims for subscribers, who pay only a copayment instead of the full price for drugs, says Pharmaceutical Care Management Association President and CEO Mark Merritt. "We want to make sure we're paying as little as we can and that's how the marketplace works," said Merritt.
Barbara Wallace of Savannah, Ga., former manager of MBA Diabetic Footwear Solutions, was sentenced to a 41-month prison term and three years of supervised release after admitting to a single count of health care fraud. Wallace, who was also ordered to pay restitution and forfeiture of $948,361, falsely billed Medicaid for unnecessary, unprescribed or unprovided medical equipment, authorities say.
Dr. John Couch, a pain specialist and co-owner of Physicians Pain Specialists of Alabama, was sentenced to 20 years in prison and ordered to pay restitution of $15 million for his involvement in a pill mill fraud scheme. Couch was convicted of improperly prescribing 548,711 kilograms of opioid medications such as fentanyl and oxycodone and fraudulently billing health insurance companies.
Mark Reiss, the former public safety director of Greenville, Mich., has entered a no contest plea to a health care fraud charge. Reiss was charged with failing to remove his ex-wife from his private health insurance plan and allowing her to use the policy after their divorce, causing $113,000 worth of losses to Blue Cross.
Christian Mathy, a former gastroenterologist at the University of California at San Francisco, entered a not-guilty plea Thursday to nine charges, including forgery, issuing a false prescription and fraudulently obtaining a controlled substance. Mathy is accused of fraudulently writing 86 prescriptions for Ritalin over three years using aliases to obtain thousands of doses of the drug for himself, according to officials.
Senate Republicans want to develop a plan to control federal Medicaid spending in their effort to replace the Affordable Care Act, but the exact strategy to do so remains a point of contention, with the proposal to cap payments to states a focal point in the debate. A fixed cap based on historical spending is one option, but it raises questions about fairness and coverage adequacy for individual states whose spending varies widely due to differences in policy choices, member health, program strength and market competitiveness, according to experts.
Indiana announced that it will request a federal waiver to add work requirements to its Medicaid eligibility standards, joining at least six other states that have already requested similar waivers or have indicated plans to do so. Wisconsin's Republican governor Scott Walker has requested a waiver that would require able-bodied, childless adults to submit to drug screening in order to enroll in Medicaid, along with work requirements and higher premiums for people who engage in unhealthy behaviors such as smoking.
Senate Majority Leader Mitch McConnell, R-Ky., said he's unsure how Senate Republicans, who hold a 52-48 majority, will gather enough votes to pass legislation to unravel the Affordable Care Act as they balance demands from conservatives and moderates, but he said he intends to work without Democrats. McConnell, who declined to reveal any target bill provisions or a timetable for release of draft legislation, said he is more optimistic about the prospect of tax reform.