Here is what you need to know in healthcare this week.

I read all this stuff so you don't have to.

The honchos at the American Hospital Association, the American Medical Association, and the Pharmaceutical Research and Manufacturers of America (PhRMA) are beginning to understand that, as Ben Franklin wrote, “He that lieth down with dogs shall rise up with fleas." 

All of those big groups have been quite willing to hop in bed with Big Insurance over the years to put the kibosh on ideas like a public option or, God forbid, Medicare for All. They’ve kicked in untold millions to finance fear-mongering propaganda campaigns to protect the role private insurers play in our healthcare system, having been persuaded by Big Insurance that nothing could be worse than having the government play a more meaningful role.

Instead of anticipating how miserable life would become for doctors, hospital administrators, and even pharma execs once for-profit insurers bulked up and merged with huge PBMs to become the insatiably greedy, menacing, and controlling Goliaths they now are, they have helped Big Insurance fund front groups like the Partnership for America’s Health Care Future. (To its credit, the AMA dropped out of the Partnership a couple of years ago.)  Two of those giants (CVS/Aetna and UnitedHealth) are now among the five biggest companies in America. Having worked for two of the other giants (Cigna and Humana), I can assure you it is only a matter of time before Big Insurance will top that list. 

To assure continued profitability–and growth– insurers have erected numerous barriers that make it more difficult for patients to get the care they need and can afford. Those barriers take the form of sky-high out-of-pocket requirements, “narrow” and ever-changing provider networks, and increasingly egregious and life-threatening “prior authorization” demands.  

Now those groups are crying “no fair!” and insisting that the government do something to curb Big Insurance’s power, which they helped facilitate. Here are a few of the headlines from this past week:

• Lack of Prior Authorization Reform Escalating Physician Burden

• AMA: Payers not following prior authorization reforms they agreed to in 2018

• AHA calls for task force to investigate payment denials

• Medicare Advantage: OIG Report Finds Improper Denials

Journalist Lola Butcher wrote a really good piece for UnDark that explains why we need to care about this and why our doctors are taking aim at prior authorization. 

My advice to AHA and PhRMA: Follow the AMA’s lead and get the hell out of that bogus “partnership.” And if you really care about what prior authorization is doing to your patients, you’ll stop funding that propaganda outfit right now. If I were you, I’d even ask for my millions back. With interest.

As I noted earlier (and have written a lot about), Big Insurance has gotten even bigger in recent years by hitching up with another huge and largely unnecessary U.S. health care middleman: Big PBMs. These unholy alliances go a long way toward explaining why we have to pay so much for our medications out of our own pockets despite having health insurance. 

Well, doctors, drug companies, and other health care providers are now behind an effort to get the government, which many of them have vilified for decades, to do something about PBMs, too. And the government is responding in various ways, as these headlines suggest:

• New Senate bill aims to empower FTC to crack down on PBMs

• Pharmacy benefit managers' profits targeted by new U.S. bill

• Washington once again targets prescription drug middlemen

• New York Establishes First Pharmacy Benefits Bureau in the Nation as Registration and Annual Reporting Deadlines for Pharmacy Benefit Managers Approach

• Gov. Scott signs law that targets prescription drug intermediaries

• PBMs are increasingly restricting patient access to medicines, report finds

• Pile-on over PBMs continues with FTC comments and a new bipartisan Senate bill

That last story noted that the Federal Trade Commission has received more than 500 comment letters from “stakeholders” about the growing power and influence of PBMs. Many of those stakeholders are patient and consumer advocacy groups, like the Lower Out-of-Pockets NOW Coalition and the Center for Health and Democracy, which I lead.

I hope you all have a wonderful holiday weekend. Please pause for a minute to express appreciation for the many men and women for which Memorial Day was established. Here (thanks to PBS) is an excerpt from James A. Garfield’s speech at the first commemoration at Arlington National Cemetery on May 30, 1868:

“We do not know one promise these men made, one pledge they gave, one word they spoke; but we do know they summed up and perfected, by one supreme act, the highest virtues of men and citizens. For love of country they accepted death, and thus resolved all doubts, and made immortal their patriotism and their virtue.”