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Merry Christmas!

Merry Christmas!

The team at DocSpot wishes you a joyful time with family and friends.

Pharmacy benefit managers (PBMs) got a start by promising their customers huge savings when ordering medications on behalf of their customers. It appears that a focus on percentage discounts (rather than absolute costs) drove drug manufacturers to raise their list prices, so that PBMs can tout greater savings. Pricing models became more complex and in many cases, patients end up paying more for medications. KFF Health News profiled someone whose job was to educate others on the pitfalls of PBMs and who ended up bringing a lawsuit against her employer -- a drug manufacturer.

Pharmacy benefit managers (PBMs) got a start by promising their customers huge savings when ordering medications on behalf of their customers. It appears that a focus on percentage discounts (rather than absolute costs) drove drug manufacturers to raise their list prices, so that PBMs can tout greater savings. Pricing models became more complex and in many cases, patients end up paying more for medications. KFF Health News profiled someone whose job was to educate others on the pitfalls of PBMs and who ended up bringing a lawsuit against her employer -- a drug manufacturer.

In terms of good news, there is a new type of PBM on the market, which simply adds a processing fee. As highlighted in the article, those entrants appear to be gaining some traction, as evidenced by several large companies and the state of Connecticut switching over to these newer PBMs. It might still be a decade or more before incumbent PBMs vastly change their business model.

Despite recent legislation to prevent surprise billing in the form of out-of-network providers, KFF Health News described another way that some physicians can surprise their patients with bills. Apparently, some physicians have started classifying certain "procedures" as surgery, despite those procedures being as removing a splinter. Classifying procedures as such allows physicians to bill more, and if a patient has not met the deductible, the patient may be the one paying. It seems that in many cases, when doctors are about to perform a procedure that will add an additional charge -- especially an unexpected one -- they should inform patients about the extra charge. For example, when a customer is having his car serviced in a repair shop, the mechanic generally recommends procedures, and the customer can decide which of the recommendations to pay for -- before the mechanic performs the procedures.

Despite recent legislation to prevent surprise billing in the form of out-of-network providers, KFF Health News described another way that some physicians can surprise their patients with bills. Apparently, some physicians have started classifying certain "procedures" as surgery, despite those procedures being as removing a splinter. Classifying procedures as such allows physicians to bill more, and if a patient has not met the deductible, the patient may be the one paying. It seems that in many cases, when doctors are about to perform a procedure that will add an additional charge -- especially an unexpected one -- they should inform patients about the extra charge. For example, when a customer is having his car serviced in a repair shop, the mechanic generally recommends procedures, and the customer can decide which of the recommendations to pay for -- before the mechanic performs the procedures.

The article discussed some of the motivation behind this new practice. For a few decades now, physician compensation has been largely influenced by a committee that helps determine the relative value of different procedures (such as an office visit versus a wart removal), and the article explains that "Since surgeons are overrepresented on the committee, the valuation of anything defined as an operation has only increased, giving billers the incentive to classify even the most mundane interventions as surgery." It is not surprising that providers want to be paid more, but this method of classifying simple treatments as surgeries would likely be a surprise to many inside and outside the medical community.

Sometimes, professional medical organizations will declare that anyone who has fulfilled the necessary steps to secure a medical degree (and perhaps obtained certification) is adequately competent to treat patients. Yet, providers can vary in their judgements and skills, sometimes leading to very different patient health outcomes. KFF Health News published a piece that opens with a patient who received very different treatments from different providers. One provider apparently said that the patient should not be expected to recover from a heart attack, while another successfully treated the same patient, giving him enough time for a heart transplant. More generally, the article is about the inadequacies of one health system (where the first provider worked), which could become complacent after it formed from a merger, because it became the sole health system in a large area.

Sometimes, professional medical organizations will declare that anyone who has fulfilled the necessary steps to secure a medical degree (and perhaps obtained certification) is adequately competent to treat patients. Yet, providers can vary in their judgements and skills, sometimes leading to very different patient health outcomes. KFF Health News published a piece that opens with a patient who received very different treatments from different providers. One provider apparently said that the patient should not be expected to recover from a heart attack, while another successfully treated the same patient, giving him enough time for a heart transplant. More generally, the article is about the inadequacies of one health system (where the first provider worked), which could become complacent after it formed from a merger, because it became the sole health system in a large area.

Part of the challenge is that while some people are privy to the internal benchmarks, quality reports are not made publicly available. The CEO of the health system has strong relationships with state and local officials, who support the health system and may be suppressing quality issues. Essentially, both the health system and some government officials ask for the trust of the public that the health system is performing adequately. Meanwhile, people who are familiar with healthcare quality have raised concerns, echoing concerns from local medical professionals. Cases like this illustrate why releasing quality reports to the general public can be helpful to individuals who, as described in the article, might actually move out of the area for better health care.

Happy Thanksgiving!

Happy Thanksgiving!