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This week, a federal judge in Greeneville, Tennessee, sentenced seven individuals and seven related corporate entities for their roles in a multimillion-dollar health care fraud scheme...Peter Bolos and his co-conspirators, Michael Palso, Andrew Assad, Scott Roix, Larry Smith, Mihir Taneja, Arun Kapoor and Maikel Bolos...deceived pharmacy benefit managers, such as Express Scripts and CVS Caremark, regarding tens of thousands of prescriptions. The PBMs processed and approved claims for prescription drugs on behalf of insurance companies. Bolos and his co-conspirators defrauded the PBMs into authorizing millions of dollars’ worth of claims that private insurers such as Blue Cross Blue Shield of Tennessee, and public insurers such as Medicaid and TRICARE, paid to pharmacies controlled by the co-conspirators...READ MORE

The econowonks at the Centers for Medicare & Medicaid Services recently released the latest projections for U.S. spending on healthcare. These data provide our first official look at post-pandemic U.S. healthcare spending...As you will see below, outpatient prescription drugs dispensed by retail and mail pharmacies are projected to remain a small share (8.4%) of total U.S. healthcare spending. What’s more, taxpayers—via Medicare and Medicaid—will continue to crowd out the private insurance market. One bright spot: consumers will account for an ever-smaller share of drug spending...READ MORE

One reason why Medicaid isn't so good is that many doctors won't actually accept Medicaid patients...If you rely upon the health insurance system for the poor, you'll likely not be able to get medical treatment in many places. Seeing as medical coverage is designed to provide access to treatment when needed, the system doesn't seem to work all that well. This is not a good thing. After all, a bit of bad luck, and one of us could be relying on Medicaid...READ MORE

The lawsuits, filed...in different federal courts, seek to get rid of an advisory opinion filed by the Department of Health and Human Services’ general counsel that says drug companies must offer 340B drugs to contract pharmacies, which are third-party entities that dispense drugs on behalf of hospitals participating in the program...The drug companies argue that the advisory opinion contracts (contradics) the statute for the 340B program, which requires manufacturers to offer discounted products to safety net hospitals and other providers in exchange for participation in Medicare and Medicaid...“The statute, on its face, does not require manufacturers to recognize any contract pharmacies, much less unlimited contract pharmacies,” the legal filing from AstraZeneca said...READ MORE

List prices of branded drugs in the U.S. rose by an average of nearly 5% last year, according to a report released...by Iqvia, a consultancy and research services provider. After accounting for the rebates and discounts pharmaceutical companies often pay insurers, however, the average increase was 1%, the fifth year in a row that net price growth has tracked below general inflation...Rebates and discounts on drugs don't necessarily translate to lower out-of-pocket costs for patients, and some, such as people covered by Medicare Part D or on high-deductible insurance plans, are more vulnerable to rising list prices, often referred to as a drug's wholesale acquisition cost...READ MORE

Several major payer groups and Medicaid advocates are pressing Congress for a 90-day heads up when the COVID-19 public health emergency ends, arguing they need as much time as possible to make Medicaid enrollees aware they could lose coverage...A collection of payer and Medicaid state advocacy groups wrote to congressional leadership on Thursday asking for the greater lead time. The letter comes as providers and other stakeholders are preparing for an end to key flexibilities granted back in January 2020...States and payers are facing the daunting task of redetermining the eligibility of Medicaid enrollees. The PHE prevented states from dropping any enrollees off Medicaid rolls for the duration of the emergency. States will have a year after the PHE ends to fully redetermine eligibility...READ MORE

In 2020, Indivior resolved the federal government's long-running probe into its aggressive marketing of the opioid addiction therapy Suboxone, reaching a $600 million plea deal. Now, it's paying up...Indivior will shell out $300 million to all 50 states, the District of Columbia and Puerto Rico to resolve claims that it “falsely and aggressively” marketed its opioid addiction drug Suboxone, leading to misuse of state Medicaid funds, California Attorney General Rob Bonta...READ MORE

The petition, going to Senator Catherine Cortez Masto and Jacky Rosen, pleads Congress to take action...Both Senators have cosponsored legislation to cap out-of-pocket insulin costs at $35...Senators Cortez Masto and Rosen also support giving Medicare more power to negotiate drug prices, and they are pushing for penalties that would keep drug companies from increasing prices faster than the rate of inflation..."I've seen it in my own family with my grandmother who had to make the decision whether she could put food on the table or pay for her drugs," said Senator Cortez Masto. "She was living off of Social Security after she retired. No senior, nobody should have to go through that."...READ MORE

The National Community Pharmacists Association is using social media, digital advertising, and a grassroots effort to push congressional budget makers to include a provision eliminating pharmacy benefit manager spread pricing under the Medicaid program and reimburse pharmacies in a fairer and more transparent manner...“PBM spread pricing costs federal and state taxpayers hundreds of millions of dollars every year. It does nothing to reduce the cost of drugs for Medicaid patients, and it drives local pharmacies out of business,” said NCPA CEO B. Douglas Hoey...Spread pricing is what happens when pharmacy benefit managers, known as PBMs, charge insurance plans like Medicaid one price for prescription medications, reimburse pharmacies that dispense them a much lower price, and then keep a big chunk of the difference for themselves...READ MORE

A Las Vegas man has pleaded guilty to bilking North Carolina Medicaid out of $13 million, prompting the forfeiture of an airplane, a sports car, a pickup, land and luxury jewelry...Timothy Harron, 52, has pleaded guilty to conspiracy to commit health care fraud, wire fraud, money laundering, and aggravated identity theft. Authorities said the guilty plea requires him to forfeit cash and luxury items...READ MORE