Pharmacy benefit managers are simply the latest iteration of the whole malignant "managed care" nonsense that arose during the Reagan administration with "diagnostic related groups." (Yes. I am old enough to remember all that.) Managed care simply inserts another layer of paperwork (and thus costs) into the healthcare system and is set up to deny actual care. Time to surgically remove the profit incentive from U.S. healthcare and replace it with rewards for keeping people healthy by using alternatives whenever appropriate.
Unfortunately, the percentage of likelihood of that happening under a Republican administration is about zero. Profit before people. That's how they roll, and they are very proud of it.
do you really believe the dems are any better in that regard? they talk a good game, but when in position to actually do anything they don't, and they blame the republicans for their own failures. biden said if a bill like that came across his desk he'd veto it, and 'obamacare' was originally mitt romney's plan, and it was nothing more than a giveaway to/windfall for 'big insurance.' until we stop playing the red v blue game, nothing will change...
I suspect that United Healthcare may be over paying their vendors owned by Optum for medical services which increases Optum profit, although those expenses are tracked under the ACA MLR requirements.
Basically, I suspect they pay their vendors are higher rate, because the ACA MLR requirements limit profit, they can earn on fully insured medical plans. The higher cost they pay to their vendors increases Optum profit margins significantly, and thereby the profit for UnitedHealthgroup, who accepts the lower profit margins from Unitedhealthcare, knowing that the overall profit of the company has increased significantly.
There is no way to fix this problem than universal healthcare. All that money they send to foreign countries and wars. That money should stay here helping the Americans get free healthcare .
This company denied care to my wife when she had cancer. Then we fought them for 6 weeks and they finally sent approval for her surgery. Then two weeks later they sent another letter cancelling their approval, while my wife was recovering from surgery. The company, as a matter of policy, would regularly deny payments for care and kick providers out of network so they could pass more cost to the patients and providers. They even lobbied congress to pass legislation to be able to control the amount they pay out in OON claims. I knew nurses that worked for their claims dept and they were incentivized to find any possible way to deny payment for care. This company has made record profits the past several years, and are currently being investigated by HHS for overcharging the taxpayers for their Medicare Advantage program. These people are scum, including that CEO who got himself executedAnd lest we forget, he was currently being investigated for insider trading by the FTC.
PBM is indeed a cost problem, but I don't like the kind of piecemeal approach of fixing one aspect of a thoroughly corrupt health care insurance industry. What about UnitedHealth Group's price gouging on the Medicare Trust Fund for their Medicare Advantage policies compared to Traditional Medicare? We are talking about a gap of $140 Billion. What about the enormous denials of care for Medicare Advantage patients? What about the delays in being able to consult a specialist only to find your illness becomes either chronic or terminal? When so many hospital providers nationwide are pulling out of Medicare Advantage due to non-timely payments, we can easily diagnose that these are serious systemic problems that require a comprehensive approach to fixing the system. It is so easy to get sidelined and I seriously doubt President Elect or President Trump will actually do anything towards fixing the Pharmacy Benefit Manager problem, or any of the other serious complaints from customers/payers of these less than reputable insurance policy practices that have given our For-Profit Health Care System the bad ratings for quality care. When is Congress going to do something rather than bickering partisan differences? Healthcare reform should be a genuine priority, not just empty promises.
UHC/Optum are nothing more than price gouging garbage. I have their so called health care. We cannot afford meds thru this company due to their 170% price increases.
They line their pockets while Americans die unable to afford meds and care.
I cannot wait for RFKJ and Trump team to dismantle this entire system.
The coterie of mega-millionaires soon to be installed in our federal government, many of whom have made their wealth off of the backs of the working class (ie. low pages, few-to-no benefits, no paid leave, no participation in IRAs/retirement programs) are extremely unlikely to aid the average American, the "little people," or anyone in a myriad of categories (minorities women, LGBTQ, diasabled/other-abled, the elderly, the uneducated, etc.). Past behavior is predicate of future behavior -- the oligarchic white guys (Bezos, Musk, Zuckerburg, Kennedy, etc.) that will be standing next to Trump on his inaugural dais, have a long history of serving themselves. They aren't paragons of equitable and fair business practices, nor do they have personal histories of charitable sharing and caring -- quite the opposite.
And now, along with the in-their-pocket lobbyists and politicians helping them to further game the system, THEY WILL BE THE SYSTEM. Trump sold his voters a populace bill of goods, and now the 34x convicted felon/tax-dodger/multi-bankruptcy-implementer is about to embark on the creation of the biggest "Swamp" ever. He will dismantle the whole system, for sure -- but it is not in the way you hope and think it will be.
Look clearly at what/whom he is surrounding himself with -- not one single champion of the middle-class among them, and nearly all have garnered their wealth off the vain hopes, beliefs, aspirations, and taxes (SpaceX, anyone?) of We The
People. These vultures will be privatizing Medicaid, Medicare, Social Security, and welfare programs across the board, and we will end up with even fewer of the benefits originally funded by our tax dollars. After all, they have sixth-and-seventh McMansions, and fourth-and-fifth yachts to pay for -- your broken leg or cancer treatments be damned.
Ever hear of "trickle-down economics?" Forty years of that calculated concept has resulted in the lower and middle classes getting pissed on instead. Trump is about to launch the Oligarchy of the Few, paid for by the Many. The ONLY bill he actually passed in his first administration was tax cuts for the rich (everything else was an "executive order," which are reversible in subsequent administrations). Look at his actions not his words, as he uses his working-class supporters to implement policies that actually disenfranchise them even further. He is the rabble-rouser of the "common man" on social issues, but behind the scenes you will be picked clean by the sociopathic Project 2025 that his REAL beneficiaries will be instituting. And those beneficiaries ain't the average Joe and Jane, sorry to say.
Bingo. I wonder how many average citizens or activists have actually read the 900+ page Project 2025. Had they made that effort, they would not take uninformed refuge in the false hope that a new federal government would be willing to help them.
The incoming administration is far FAR more likely to immediately complete two tasks: one, bail out United Health as well as the entire PBM industry; two, grant huge tax cuts and incentives to both of those in addition to all related health insurance companies, chain pharmacies, and providers - and encourage private equity and hedge funds to take over the entire American health "care" system from top to bottom. The incoming administration is firmly and unalterably pro business, anti consumer. It will complete Project 2025 by getting rid of not only the Affordable Care Act -- but also Medicare and Medicaid via privatizing both, the latter with stringent work requirements added. Edited to correct typo.
"While the company chose not to break out exactly how much of Optum’s revenues of $298 billion came from Optum Rx, it appears that more than half of it was contributed by the PBM."
$298 billion was the revenue for UnitedHealthcare. You can see the Optum RX revenue on page 11 right here:
Profit mongering all , passing the hot potatoes back and forth. These corporate heads and CEOs will never yield because our way of doing things is based on profit for the few not the General Good.
I suspect that Pharmacy rebates are I suspect are where drug manufacturers rebate insurance carriers a portion of the cost of the retail cost of medication that they customers and individual who purchase a medication that’s is subject to pharmacy rebate. I believe this only applies to brand name medication, but may apply to more. If this is true, it would mean that a consumer covered by optumRX as part of their UnitedHealthcare health Insurance, would pay $1000 a month for a medication, and the manufacturer would then rebate $300 of that cost back to Unitedhealthcare.
If what I suspect is true, then The full cost of the drug would then be tracked as a medical expense under the ACA MLR requirement, while the pharmacy rebate would be retained by Unitedhealthcare as Profit.
I suspect that Pharmacy rebates can be as much as $200 per month (or more) for every member insured by a fully insured medical plan.
I suspect that United Healthcare may be over paying their vendors owned by Optum for medical services which increases Optum profit, although those expenses are tracked under the ACA MLR requirements.
Basically, I suspect they pay their vendors are higher rate, because the ACA MLR requirements limit profit, they can earn on fully insured medical plans. The higher cost they pay to their vendors increases Optum profit margins significantly, and thereby the profit for UnitedHealthgroup, who accepts the lower profit margins from Unitedhealthcare, knowing that the overall profit of the company has increased significantly.
Pharmacy benefit managers are simply the latest iteration of the whole malignant "managed care" nonsense that arose during the Reagan administration with "diagnostic related groups." (Yes. I am old enough to remember all that.) Managed care simply inserts another layer of paperwork (and thus costs) into the healthcare system and is set up to deny actual care. Time to surgically remove the profit incentive from U.S. healthcare and replace it with rewards for keeping people healthy by using alternatives whenever appropriate.
Unfortunately, the percentage of likelihood of that happening under a Republican administration is about zero. Profit before people. That's how they roll, and they are very proud of it.
do you really believe the dems are any better in that regard? they talk a good game, but when in position to actually do anything they don't, and they blame the republicans for their own failures. biden said if a bill like that came across his desk he'd veto it, and 'obamacare' was originally mitt romney's plan, and it was nothing more than a giveaway to/windfall for 'big insurance.' until we stop playing the red v blue game, nothing will change...
I suspect that United Healthcare may be over paying their vendors owned by Optum for medical services which increases Optum profit, although those expenses are tracked under the ACA MLR requirements.
Basically, I suspect they pay their vendors are higher rate, because the ACA MLR requirements limit profit, they can earn on fully insured medical plans. The higher cost they pay to their vendors increases Optum profit margins significantly, and thereby the profit for UnitedHealthgroup, who accepts the lower profit margins from Unitedhealthcare, knowing that the overall profit of the company has increased significantly.
There is no way to fix this problem than universal healthcare. All that money they send to foreign countries and wars. That money should stay here helping the Americans get free healthcare .
Universal Single Payer Healthcare for all. Full Stop! Free Luigee!
This company denied care to my wife when she had cancer. Then we fought them for 6 weeks and they finally sent approval for her surgery. Then two weeks later they sent another letter cancelling their approval, while my wife was recovering from surgery. The company, as a matter of policy, would regularly deny payments for care and kick providers out of network so they could pass more cost to the patients and providers. They even lobbied congress to pass legislation to be able to control the amount they pay out in OON claims. I knew nurses that worked for their claims dept and they were incentivized to find any possible way to deny payment for care. This company has made record profits the past several years, and are currently being investigated by HHS for overcharging the taxpayers for their Medicare Advantage program. These people are scum, including that CEO who got himself executedAnd lest we forget, he was currently being investigated for insider trading by the FTC.
PBM is indeed a cost problem, but I don't like the kind of piecemeal approach of fixing one aspect of a thoroughly corrupt health care insurance industry. What about UnitedHealth Group's price gouging on the Medicare Trust Fund for their Medicare Advantage policies compared to Traditional Medicare? We are talking about a gap of $140 Billion. What about the enormous denials of care for Medicare Advantage patients? What about the delays in being able to consult a specialist only to find your illness becomes either chronic or terminal? When so many hospital providers nationwide are pulling out of Medicare Advantage due to non-timely payments, we can easily diagnose that these are serious systemic problems that require a comprehensive approach to fixing the system. It is so easy to get sidelined and I seriously doubt President Elect or President Trump will actually do anything towards fixing the Pharmacy Benefit Manager problem, or any of the other serious complaints from customers/payers of these less than reputable insurance policy practices that have given our For-Profit Health Care System the bad ratings for quality care. When is Congress going to do something rather than bickering partisan differences? Healthcare reform should be a genuine priority, not just empty promises.
"Concepts of a plan." I'm not holding my breath.
UHC/Optum are nothing more than price gouging garbage. I have their so called health care. We cannot afford meds thru this company due to their 170% price increases.
They line their pockets while Americans die unable to afford meds and care.
I cannot wait for RFKJ and Trump team to dismantle this entire system.
Bring it on. Jan 20th cannot come soon enough.
Take down pharma and big health ins.
Um. The incoming administration is hardly going to dismantle anything that reeks of exorbitant profit.
The coterie of mega-millionaires soon to be installed in our federal government, many of whom have made their wealth off of the backs of the working class (ie. low pages, few-to-no benefits, no paid leave, no participation in IRAs/retirement programs) are extremely unlikely to aid the average American, the "little people," or anyone in a myriad of categories (minorities women, LGBTQ, diasabled/other-abled, the elderly, the uneducated, etc.). Past behavior is predicate of future behavior -- the oligarchic white guys (Bezos, Musk, Zuckerburg, Kennedy, etc.) that will be standing next to Trump on his inaugural dais, have a long history of serving themselves. They aren't paragons of equitable and fair business practices, nor do they have personal histories of charitable sharing and caring -- quite the opposite.
And now, along with the in-their-pocket lobbyists and politicians helping them to further game the system, THEY WILL BE THE SYSTEM. Trump sold his voters a populace bill of goods, and now the 34x convicted felon/tax-dodger/multi-bankruptcy-implementer is about to embark on the creation of the biggest "Swamp" ever. He will dismantle the whole system, for sure -- but it is not in the way you hope and think it will be.
Look clearly at what/whom he is surrounding himself with -- not one single champion of the middle-class among them, and nearly all have garnered their wealth off the vain hopes, beliefs, aspirations, and taxes (SpaceX, anyone?) of We The
People. These vultures will be privatizing Medicaid, Medicare, Social Security, and welfare programs across the board, and we will end up with even fewer of the benefits originally funded by our tax dollars. After all, they have sixth-and-seventh McMansions, and fourth-and-fifth yachts to pay for -- your broken leg or cancer treatments be damned.
Ever hear of "trickle-down economics?" Forty years of that calculated concept has resulted in the lower and middle classes getting pissed on instead. Trump is about to launch the Oligarchy of the Few, paid for by the Many. The ONLY bill he actually passed in his first administration was tax cuts for the rich (everything else was an "executive order," which are reversible in subsequent administrations). Look at his actions not his words, as he uses his working-class supporters to implement policies that actually disenfranchise them even further. He is the rabble-rouser of the "common man" on social issues, but behind the scenes you will be picked clean by the sociopathic Project 2025 that his REAL beneficiaries will be instituting. And those beneficiaries ain't the average Joe and Jane, sorry to say.
Bingo. I wonder how many average citizens or activists have actually read the 900+ page Project 2025. Had they made that effort, they would not take uninformed refuge in the false hope that a new federal government would be willing to help them.
I don’t think anything about healthcare will change with Trump.
The incoming administration is far FAR more likely to immediately complete two tasks: one, bail out United Health as well as the entire PBM industry; two, grant huge tax cuts and incentives to both of those in addition to all related health insurance companies, chain pharmacies, and providers - and encourage private equity and hedge funds to take over the entire American health "care" system from top to bottom. The incoming administration is firmly and unalterably pro business, anti consumer. It will complete Project 2025 by getting rid of not only the Affordable Care Act -- but also Medicare and Medicaid via privatizing both, the latter with stringent work requirements added. Edited to correct typo.
"While the company chose not to break out exactly how much of Optum’s revenues of $298 billion came from Optum Rx, it appears that more than half of it was contributed by the PBM."
$298 billion was the revenue for UnitedHealthcare. You can see the Optum RX revenue on page 11 right here:
https://www.unitedhealthgroup.com/content/dam/UHG/PDF/investors/2024/2025-16-01-uhg-reports-fourth-quarter-results.pdf
You literally linked this pdf in your post but chose not to read it apparently.
Wendell, this should explain how to fix the while problem without regulation or getting the government involved AT ALL
https://open.substack.com/pub/sentiahealth/p/commonwealth-fund-the-us-health-care?utm_source=share&utm_medium=android&r=473krc
Profit mongering all , passing the hot potatoes back and forth. These corporate heads and CEOs will never yield because our way of doing things is based on profit for the few not the General Good.
But how to disslodge them , that is the question?
Tom Payne
I suspect that Pharmacy rebates are I suspect are where drug manufacturers rebate insurance carriers a portion of the cost of the retail cost of medication that they customers and individual who purchase a medication that’s is subject to pharmacy rebate. I believe this only applies to brand name medication, but may apply to more. If this is true, it would mean that a consumer covered by optumRX as part of their UnitedHealthcare health Insurance, would pay $1000 a month for a medication, and the manufacturer would then rebate $300 of that cost back to Unitedhealthcare.
If what I suspect is true, then The full cost of the drug would then be tracked as a medical expense under the ACA MLR requirement, while the pharmacy rebate would be retained by Unitedhealthcare as Profit.
I suspect that Pharmacy rebates can be as much as $200 per month (or more) for every member insured by a fully insured medical plan.
I suspect that United Healthcare may be over paying their vendors owned by Optum for medical services which increases Optum profit, although those expenses are tracked under the ACA MLR requirements.
Basically, I suspect they pay their vendors are higher rate, because the ACA MLR requirements limit profit, they can earn on fully insured medical plans. The higher cost they pay to their vendors increases Optum profit margins significantly, and thereby the profit for UnitedHealthgroup, who accepts the lower profit margins from Unitedhealthcare, knowing that the overall profit of the company has increased significantly.