Express Scripts Settles

Another day, another settlement (of charges that a big health care organization deceived patients and physicians)... Here is the story summarized in the Wall Street Journal:

Pharmacy-benefits manager Express Scripts Inc. agreed to pay $9.5 million to settle allegations that it asked doctors to switch drugs primarily so it could get bigger rebates from pharmaceutical companies.

The move all but closes the books on a four-year investigation of practices at pharmacy-benefit managers, or PBMs.

'Today's settlement completes our effort to clean up the PBM industry,' Vermont Attorney General William Sorrell wrote in a release. Vermont, which gets a $372,000 cut, was one of the lead negotiators with the company.

Fellow pharmacy-benefit managers Medco Health Solutions Inc. and CVS Caremark Corp. have already reached agreements with the states over similar issues.

The agreement states that Express Scripts 'engaged in deceptive business practices by encouraging doctors to switch patients to different brand name prescription drugs and representing that the patients and/or health plans would save money,' according to the Vermont attorney general's office.

The Hartford Courant's coverage added some more detail about the nature of the deceptive business practices:

Express Scripts told doctors that switching their patients to different cholesterol-lowering drugs would save money for patients and insurers, but they often saved little or incurred higher medical costs, [Connecticut Attorney General] Blumenthal said. Patients, for instance, might have had additional blood tests and doctor visits as a result of the drug-switching.

This is first a reminder of the amazing complexity of the US health care system. Not only are there the major organizational players, but numerous middleman organizations that work in the interstices of the system. Pharmacy benefit managers (PBMs), for example, work in the interstices between patients and physicians, pharmacies, pharmaceutical companies, and managed care organizations and insurers.

And it seems like each kind of organization may cultivate its own brand of deceptive practices. Note that Express Scripts is apparently the third PBM to agree to stop the kind of deceptive practice noted above.

The more complex the system, the more organizations shuffling money and paper around, the less transparency there is, and the more opportunities it seems there are to make money via deception.

Yet on a health care policy level, does anyone talk about developing systematic approaches to combat deception and unethical business practices, much less making the overall system more transparent? Not hardly....