Payer behavior

“AARP (formerly the American Association of Retired Persons) has over 38 million dues-paying members, but nearly 40 percent of the organization’s revenue comes from royalties from one of the nation’s largest health care conglomerates, UnitedHealth Group. In fact, UnitedHealth provides AARP twice as much annually as the organization collects through dues from their members.

UnitedHealth is an insurance giant that sells Medicare Advantage and Medicare prescription drug plans through an endorsement deal with AARP.  Put simply, UnitedHealth gets to use AARP’s name and AARP gets over $627 million a year in cash in return, according to the organization’s most recently available tax returns. [..]

While it makes financial sense that major insurance companies like UnitedHealth would promote the use of step therapy, adverse tiering of personalized treatments can have a significant impact on seniors – particularly patients suffering chronic medical conditions.

The federal government is implementing these policies for many seniors on Medicare plans — forcing them to fight these arbitrary rules in order to access medications and treatments that their physicians have deemed most appropriate for their specific situations. Unfortunately, the AARP is virtually absent from this debate and is failing to advocate on behalf of some of their most fragile members.

The second issue concerns middlemen known as Pharmacy Benefit Managers or PBMs.  They’re supposed to serve as honest brokers between insurers and pharmaceutical companies – pooling purchasing power to secure better pricing and reduce the cost of medications. In theory, PBMs exist to negotiate rebates with drug companies in an effort to keep costs low. But keep costs low for whom? 

UnitedHealth’s ownership of PBM OptumRx offers a pretty good clue.  This might explain why AARP opposed a new mechanism to ensure that patients receive the benefit of rebates from drugmakers rather than have them gobbled up by PBMs like OptumRx and their parent company – UnitedHealth. [..]

Sadly, PBM rebates aren’t being used to reduce a patient’s share of the cost of prescriptions.  Worse, the system actually discourages the use of lower-cost generic medications. Health and Human Services (HHS) actually found that “a growing number of (Medicare) Part D plans have moved generic drugs to non-preferred tiers and have yet to realize the potential of biosimilars for high-cost biologics. Too often this is because insurers and Part D plan sponsors can extract higher rebates for brand name drugs and biologics.”

Remember, these rebates exist to help customers keep out-of-pocket costs low – and in the case of Medicare patients, we are talking about seniors who often struggle to make ends meet. Patients should benefit from savings realized from rebates – not PBMs and insurance companies.”

Opinion: Not What the Doctor Ordered | The Lund Report (2019.10.18)