23 Comments
Mar 30, 2022Liked by Matt Stoller

Independent Pharmacy Owner - We received this insulting contract last week and immediately opt'd out of it. Most contracts the past few years have been insulting but this one took the cake. We will loose customers because of this decision but that means we will be here for those who see value in our pharmacy. Most pharmacy owners are short sighted and are afraid to draw a line in the sand. They end up filling more scripts for less and eventually burn themselves out or end up offering the same shitty service as the large chains. Any owner that takes this plan is a whore to the Pharmacy Benefits Manager and views themselves as only a dispensing machine. If we are seen as only a dispensing machine then we will be replaced by one at some point. These Pharmacy Benefit Managers need to be brought out into the light and exposed.

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Mar 30, 2022Liked by Matt Stoller

Your GoT example is very apt: The reason Robb Stark had to appease Walder Frey was because Frey controlled The Twins, the fortified crossing of the Green Fork of the Trident--and the only way across the river for hundreds of miles in either direction, thereby giving Frey a monopoly over the main route from Winterfell to Riverrun.

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I know that Biden is being sucked up by world events but he has a critical election coming up. I cannot understand why he is not sucking up every news cycle to talk about how he and his FTC are taking on these issues that resonate with all voters, and pointing out how the other party are fighting him on this. Sh*t, if you develop a winning strategy then hammer it home.

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This article should be required reading for every member of congress. I'd be willing to bet that 90+% have no idea how bad things really are for the general public, not to mention those independent pharmacies. The whole prescription drug business in this country is like a cancer and there doesn't seem to be any chemo in sight.

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Thank you for this writeup. Unfortunately, practices like this have been occurring for years in pharmacy and continue to get worse. It has led to a depressing atmosphere in the pharmacy profession with many pharmacists trying to gain employment outside typical pharmacy dispensing roles. CVS has many nicknames like the 'red devil' or 'CVStress' due to the vitriolic feelings toward the company. It is amazing how little the public knows about the monopolistic powers of their local pharmacy chain. One of the few areas to make a profit in pharmacy is through the 340B drug program, which, in a short way to describe it, is a massive government program that gives massive discounts to certain pharmacies (mainly hospitals) that serve a disportionate Medicaid population. These discounts can make a drug like Enbrel that is ~$5,500 cost a $0.01. That too is another distorted area of pharmacy that the PBMs have gotten their hands into.

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"PBMs are particularly bad for independent pharmacies, who are a critical lifeline in many underserved parts of America. 77% of independent pharmacies serve communities with fewer than 50,000 people. In these places, the independent pharmacist often is the health care infrastructure."

Indeed, it's worth pointing out that, during the initial vaccine rollout, in WV independent pharmacies did a better job of vaccinating seniors in that state than the major pharmacy chains did in other states. The health and survival of independent pharmacies, like rural critical care hospitals (subject to many a VC rollup), is life and death.

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CVS has been my supplier for years, making at least one mistake or delay or refund or copay error every 90 days.

They give different excuses in different stores.

The app has been atrociously inaccurate, stale data, etc.

They make you call pharmacy (since the app cannot do many changes) to manage prescription changes, which means 5 to 55 mins on hold, if they even answer at all. Even worse when they are supposed to have someone giving covid injections.

Short staffing because it's not a good place to work either. I have complained through my large employer, and minor fixes got done albeit many weeks later.

Thanks for the excellent article, donating.

Where can one pound one's fist?

How to formulate a proper jurisdiction and level of service standard?

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Astounding. Just another hidden monopoly that I was entirely unaware of and which nevertheless impacts me greatly. Thanks American Government for protecting us all these years!

Great article.

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A desire for Safari on Android puzzles me; My experience with it on iPhone is I get so many ads and popovers I cannot use the mobile web. It is relatively difficult to get a complete independent browser approved in the app store, so the only other useful option seems to be Brave which is what I'm using. (I use Vivaldi everywhere else, and thus unsure of the value of Safari on Windows either.)

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A little off-topic, but you brought it up. Intuit is the worst, with that POS Turbotax. Free IRS e-file, but they then soak you $25 to file with your state. They sucked me in for nearly 20 years with that crap, but I use HR Block now, and feel a little less violated.

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Do away with stock based compensation (and buy backs) or make it onerous.. that'll solve a lot of (but not all) corporate greed. America is no longer a capitalist society..it's now crony capitalism..which started in 1998 and exacerbated in 2008..

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I listened to this entire hearing https://www.youtube.com/watch?v=XqHI29HAtUQ (DeGette was my rep). Takeaways: 1. we don't need PBM's/they add no value 2. the traditional crop of legislators are not going to do anything. We need national, single payer healthcare and negotiated (by the gov't) price caps.

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Edge is Chromium; look at this weeks news about Google and Microsoft urging Chomium-based browser users to update asap, due to a zero-day bug.

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founding

Great piece. The consolidation of the PBMs with insurance carriers, pharmacies and mail order suppliers has been a disaster for everyone but the PBM executives. The independents are getting forced out, the pharmacists at CVS are being burned out and patients are dying. Thanks for your good work.

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Could the Medicare system set up their own PBM, using the UK "NHS Business Services" organisation as a model? Maybe even seeing if NHS BS would sell the service into the US to expand bargaining power?

(NHS BS is government owned agency which does PBM role for NHS scrips; although actual deliveries to pharmacies are handled commercially, in house for some chains, or via a few big wholesalers such as the "Alliance" division of Walgreen Boots Alliance). Unsure if there is a PBM equivalent in the UK for private scrips which are rare.

Of course NHS BS is not perfect, with varying supply month by month for generics, generics generally forced unless doctor specificly mandates a brand on behalf of patient, and another government agency, "Health and Clinical Excellence" (usually called "NICE") has strict rules covering clinical benefit of expensive drugs and won't approve some for general NHS use, which makes them private only and most private insurance won't cover drugs not on NICE list either.

Emerging monopoly problem in UK? Sale of primary care networks (which are commercial, usually practitioner partnerships, paid by capitation to offer NHS service) to big operators such as Centene. Roll up about to happen, probably making stretched local services even worse.

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PBMs have spiraled out of control for several years now. No thanks to their strong lobbying, our leaders have turned a blind eye, while simultaneously filling their coffers. Mark-ups, spread pricing and DIRs have reached a boiling point now and will be interesting to see how both Congress and the FDA address this (given the fact FDA and Big Pharma have had an incestuous relationship for so long). Time will tell.

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