Antonio Ciaccia
@A_Ciaccia
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Advocate for drug price transparency, competitive healthcare markets, & patient-centered care @46brooklyndata @3AxisAdvisors . Dad to Franco, Marco, Vera, Enzo.
Grandview Heights, OH
Joined March 2013
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In my years in the drug pricing and pharmacy world, this is one of the best explainers I’ve ever seen highlighting the inherent dysfunctional rot at the core of the U.S. pharmaceutical ecosystem.
THREAD: There is a massive, totally legal bribery scheme driving up drug prices in America.
And pharmacy benefit managers—shady middlemen you’ve probably never heard of—are right at the center.
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At last month's House Oversight Committee hearing on PBMs, arguably no congressman stood out more than
@RepAuchincloss
, who clearly has an exceptional grasp on how drug pricing actually works and how PBMs exacerbate affordability problems for plan sponsors and patients. A+
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There is no broad shortage of pharmacists. There is a shortage of pharmacists willing to work in under-staffed and under-resourced pharmacies whose incentives drive their companies to fill more and fill faster, regardless of the erosion of care to the patient.
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Cigna/ESI vows to better defend & explain their value in the drug channel.
I’m interested in an explanation of how they have 44 different prices for the same drug across their Medicare plans, where their lowest one is still 92x higher than
@costplusdrugs
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Holy cow.
@SenWarren
goes for the throat. 🔥🔥🔥
Finally a real proposal on PBMs! Senator Elizabeth Warren's amendment would ban pharmacies from owning PBMs. Would be a break-up of CVS, Cigna, UnitedHealthGroup, and would end rancid conflicts of interest in the industry. 🔥🔥🔥
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Amazing things are possible in medicine when the prices paid by plan sponsors and patients are based on the actual costs of the drugs and not the over-inflated sticker prices borne out the twisted incentives of our broken pharmacy “benefits” system
@mcuban
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Perfect teammates? Mark Cuban’s
@costplusdrugs
lands a big partnership with
@PBGHealth
’s Emsana Rx in an effort to move around legacy prescription drug market distortions and drive savings to patients and plan sponsors.
@mcuban
@alexosh
@lizzymitch2
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Welcome to the world, Enzo Raymond Ciaccia.
We’re all already obsessed with the little man who just turned us into a party of six. Super Woman’s got nothing on my wife. Thanks
@OhioHealth
for first class care. It just doesn’t get any better than this.
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PBMs: “We don’t steer patients to fill prescriptions at pharmacies we own.”
Also PBMs:
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“The U.S. pharmacy benefits market has been built to obfuscate price information and blind decision-makers to how drug costs are set, calculated, and passed down to health plans and employees.”
@SmithRx_PBM
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I had people asking if I saw the
@costplusdrugs
reference on
@SHO_Billions
last week.
Yeah, but more importantly, I saw
@mcuban
name-drop Terry Funk. 🫡
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We saw big PBMs charge as much as $16,000 for an 180-supply of generic Tecfidera at the end of last year.
Mark Cuban Cost Plus Drugs charges $162 for the same prescription.
@martyschladen
@OhioCapJournal
@mcuban
@costplusdrugs
@alexosh
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PBMs say they don't set drug prices, but their own data disagrees.
For example, Medicare data for CVS Health plans show them setting 597 different prices for imatinib that are as low as $2,658 and as high as $8,199.
@mcuban
sells the same drug for $40.
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This is an excellent, sober look at why PBMs have emerged as a centerpiece of the national drug pricing debate. Lots of blame to go around at all levels but impossible avoid the harsh realities of how PBMs have distorted the market
@newshourfred
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Big PBMs say “Drugmakers alone have the power to set prices.”
Then how is that the same PBM set five different prices for the same drug, at the same pharmacy, on the same day, where the delta between the bookends had an over 10x difference?
Our latest:
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There is a reckoning occurring on over-inflated generic drug prices.
@david_wainer
highlights how
@mcuban
@costplusdrugs
and innovative independent pharmacies are shining a light on a dysfunctional marketplace and bulldozing a path out of the darkness.
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Employers are paying more for medicines, but small pharmacies are receiving less.
As the disconnect grows, and as more money is directed toward pharmacy benefit managers and their vertically-integrated affiliates, transparency is increasingly essential.
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PBMs said that if Kentucky messed with their secretive methods of impacting drug prices, costs would skyrocket.
Instead, after firing the old guard PBMs, increasing transparency, and standardizing pricing, Kentucky actually saved $283 million.
@d_yetter
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For context, with
@costplusdrugs
now offering Invokana for around $244 per month, despite years of deflation, this new price offering from
@mcuban
is actually a lower price than the original launch price set by
@JNJNews
back in 2013.
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When PBMs can manipulate the prices of medicines at both ends of the pharmacy transaction, the hidden markups inflate the costs for purchasers.
These spread pricing practices cost Ohioans more than $244 million in 2018, and as
@RepLaTurner
shows, Ohio wasn’t alone.
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I hurt my neck from nodding my head too much at today’s
@WhiteHouse
roundtable on the lack of transparency and warped incentives in the middle of the drug supply chain.
Really great stuff from
@mcuban
@alexosh
@BlueShieldCA
@linakhanFTC
@Commpharmacy
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Bad things happen when big PBMs and health insurers subjectively mark up and invent the prices of medicines that are primarily dispensed at the pharmacies they own.
We used
@mcuban
@costplusdrugs
data w/
@joewalkerWSJ
to show how conflicts harm patients.
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The list price for the brand drug was $8275/Rx.
Pharmacies could acquire the generic version for $184/Rx.
@RepHarshbarger
calls out how more than half of seniors in Medicare were forced by their PBM & health plan to buy the brand instead.
@GOPoversight
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Insurance is supposed to insulate us from high drug prices.
But what if insurance creates high drug prices?
Bravo
@TODAYshow
for a clear demonstration of how drug prices can be slashed when twisted market distortions are eliminated.
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Just so you’re all paying attention...
PBMs charged Ohio more than $244 million in just spread pricing over the course of a single year of Medicaid.
After firing the PBMs and moving to a transparent model based on real costs, all-in, Ohio will save $200+ million annually.
Wow.
BREAKING: As part of revamp, Ohio Medicaid hires watchdog for its state-run pharmacy benefits manager...Indiana firm's bid comes in 25% under estimate via
@DispatchAlerts
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This is my dad and his pharmacy team.
Despite a lack of provider status from
@CMSGov
, they will end up immunizing thousands of people and saving lives along the way.
Wear masks, wash hands, and use caution so these great people can see their families sooner rather than later.
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Invokana may be the first, but it won’t be the last.
@mcuban
is working to bust the bubble on over-inflated brand drug prices and restore order to a system that has gone off the rails.
@MaiaLura
’s got the details on what’s cooking at
@costplusdrugs
:
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“They keep stretching us thinner and thinner … I regularly work 10-hour days and don’t have time to pee or eat lunch. When you are expected to work like that, there are going to be mistakes.”
@davidhudnall
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In a system that continuously feasts on high drug prices and high patient out-of-pocket costs as subsidies to provide value to others, the race to drug affordability will be a perpetual loser.
How Money from Sick People works:
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Life comes at you fast.
During congressional testimony this week, CVS Caremark president David Joyner told lawmakers that they pass 99% of drugmaker rebates and fees to plan sponsors.
Hours later, it was announced that they coughed up $45 million to settle allegations in
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We were told that the FTC preliminary report on PBMs had no smoking gun, lacked evidence, was no big deal, blah blah blah.
Sounds like it’s a big enough deal for someone to want to erase it completely.
Noted.
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Big story from
@martyschladen
details significant alleged safety and quality issues at CVS pharmacies in Ohio, which have outsized market presence due to years of limiting patient choice, as well as underpaying – and then buying and closing – competitors.
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West Virginia becomes the first state in the country to require PBMs and insurers to share the rebate savings they receive from drug manufacturers directly with patients!
#GrossToNetBubbleGetsPopped
Today I signed several bills into law.
▪️SB 634: Requiring training of certain officers for autism spectrum disorders
▪️HB 2263: Update the regulation of pharmacy benefit managers
▪️SB 714: Relating to physician assistant practice act
Read more ⬇️
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CVS allegedly tells pharmacist that they must transfer cancer patient’s medication to their CVS mail-order pharmacy by law.
What they didn’t plan on was that that pharmacist knew that no such law exists. Why?
Because this pharmacist was on the Ohio Board of Pharmacy.
#oops
Pharmacist says CVS strong-arms cancer-drug business
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This is solid from
@RepAuchincloss
, who demonstrates superb understanding of our drug pricing conundrum in the United States and how you engage it at a varsity level.
To lower drug prices for patients, Congress must comprehensively reform the middlemen of drug pricing – PBMs.
Piecemeal legislation, even if strong, will just squeeze the balloon, instead of popping the gross-to-net bubble.
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Our commercial pharmacy benefits study showed big differences in PBM pricing between pharmacies
That is, when generic drugs were dispensed through local pharmacies, markups charged to employers were as low as $11/Rx
PBM mail/specialty pharmacies: $47/Rx
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CVS Caremark forces patients to use the pharmacies they own, and they literally call it their Maintenance CHOICE program, which is some all-pro satire game.
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There it is. PBMs head under the microscope of the FTC. Keep the coffee hot.
1. FTC has voted to order the six largest pharmacy benefit managers (PBMs) to produce documents and data as part of an inquiry into PBMs and their impact on patients, pharmacies, payers, and doctors.
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Let the demolition and rebuilding process commence.
PBMs tremble when they hear
@A_Ciaccia
’s name. Welcome to the world home of pharmacy Antonio! Let’s do this #...
@pharmacists
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APhA just went there. 👀
APhA CEO
@ScottKnoer
urges
@FTC
to break up massive
#PBM
conglomerates to protect patients,
#pharmacies
, & communities:
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“Express Scripts' software was allegedly set to refill 90-day prescriptions on day 60, meaning that each Tricare beneficiary received 73% more pills than prescribed over the course of a year.”
Note to plan sponsors: ‘auto-refilling’ also means ‘auto-billing’
Express Scripts' "refill pill mill" bilked the federal government and vendors out of billions of dollars, a whistleblower alleges in a False Claims Act lawsuit:
via
@modrnhealthcr
#PBM
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With all this said, you might imagine the amount of shock and awe built into today's announcement from
@mcuban
@costplusdrugs
that they have partnered with
@JanssenUS
to offer Invokana at a price of around $244 per month
🎉Cost Plus Drugs is excited to offer branded medications, manufactured by
@JanssenUS
.
Invokana® (Canagliflozin)
Invokamet® (Canagliflozin-Metformin HCl)
Invokamet® XR (Canagliflozin-Metformin HCl)
Sign up and ask your provider to send your Rx to Mark Cuban Cost Plus Drug Co.
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If you bought a dishwasher that had a rebate, but someone else pocketed the rebate, you'd say it was theft.
If you bought a medicine that had a rebate, but someone else pocketed the rebate, the US government would say, "more rebates please"
@EleanorLaise
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Honored to help
@ScottKnoer
& the excellent team at
@pharmacists
to repair a fundamentally flawed prescription drug supply chain and build better incentives in the pharmacy marketplace that lower costs for payers and raise the standard of care for patients
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“So far, the PBMs have not fully complied with our orders to turn over documents and data.
FTC orders are not suggestions and we will not hesitate to use the full extent of our legal authorities to mandate compliance.” -
@linakhanFTC
@martyschladen
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Why is the FTC is suing over inflated insulin prices?
Because drugmaker discounts on insulin have gone to other interests besides the sick patients who have overpaid in order to generate those discounts in the first place.
That’s money from sick people.
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Wow!
@RonDeSantisFL
put PBMs on blast today for marking up the costs for prescription drugs, calls for major audit of PBM activities in the Florida Medicaid program, and pledges to enact regulations to prevent “deceptive” spread pricing/clawbacks
@WFLASam
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Good news for patients who are sick of overpaying for Yaz and Climara.
Instead of using your hard-earned money to generate rebates for your PBM and health plan, you can now get big savings from
@costplusdrugs
.
@slupkin
@mcuban
@alexosh
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PBMs are running big PR campaigns to push back on the idea that they are price setters in the prescription drug supply chain.
Our latest report shows that not only are they setting drug prices; they are creating two very different drug pricing realities.
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“Cuban makes drug prices public, whereas CVS will not.”
And that’s all the people need to know.
@TaraBannow
@pharmalot
@mcuban
@costplusdrugs
@alexosh
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"PBMs were originally intended to reduce the financial burden on Americans for prescription drugs, the reality today is starkly different."
Good to see
@DaveYostOH
continuing to lead on drug pricing reform. Congress could learn a thing or two from Ohio.
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Or you could also not rely on just two pharmacy companies...
"CVS has made more progress as I sit here than Walgreens and we need Walgreens to get to the same level of penetration that CVS has," says
@GovMurphy
on vaccine rollout in long term care facilities.
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After months of mounting national scrutiny on PBM pricing schemes, things have gotten increasingly sour.
Check out
@EleanorLaise
’s rundown of the broader heat wave and the culmination of one of the PBM industry’s worst weeks ever.
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Wait, I thought GoodRx was just here to save everyone money.
U.S. online prescription drug price marketplace
@GoodRx
has confidentially submitted paperwork with U.S. regulators for a potential
#IPO
, according to people familiar with the matter
Sunday scoop with
@ASenjourno
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But I was told that PBMs don’t set drug prices…
Speaking of independent pharmacies dissappearing, checkout payment disparities in Ga. state plan.
@mcuban
@3AxisAdvisors
@costplusdrugs
@_APCI
@GeorgiaPharmacy
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Very interesting partnership here. Expect more of this in the near future from disruptor PBMs that seek to pop the balloon of artificially inflated generic drug prices.
@costplusdrugs
@alexosh
@ryanlkline
@mcuban
Rightway’s members now have direct access to all medications available through
@costplusdrugs
, which offers some of the lowest prices in the market. The more we maximize access to low-cost options, the faster we can drive down U.S. drug spending.
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The largest PBMs are avoiding covering the lowest-priced version of the best selling drug of all time.
We have a drug problem in the United States, but it’s not the one you may think it is.
If you are a self-insured company, THE FASTEST WAY TO CREATE CASH is to get all employees and covered persons to switch from Humira to Yusimry. The first costs you 80k per year. Yusimry from
Cost 7,200 per year. That's $72,800 PER EMPLOYEE PER YEAR.
You
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From this day forth, the FTC interim report on PBMs will be referred to as “The FTC Report that Express Scripts Would Like Deleted from the History Books”
Cigna and Express Scripts must be capturing enough of those prescription drug "savings" if they feel they can wage a costly legal fight vs. the FTC over a book report. Read more from
@pharmalot
.
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Look out
@GoodRx
and PBMs.
Mark Cuban
@costplusdrugs
has launched their own network where patients can now receive their medicines – and transparent, cost-plus prices – at their local community pharmacy.
Check out the first pharmacies here:
@mcuban
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It was an honor to speak with congressional leaders today about the complex role that PBMs in our prescription drug supply chain. Thanks to
@RepJamesComer
for the invitation and willingness to dig below the surface of our nation’s dysfunctional drug pricing system.
🚨 Americans spend more on prescription drugs than any other country.
Congress must review Pharmacy Benefit Managers’ role in rising prescription drug prices and today’s forum was a step in the right direction.
We need to solidify practices that actually benefit patients.
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“The reason that PBMs favor higher-priced biopharmaceuticals and exclude generics is simple: They are managing their formularies to maximize profits rather than to promote the most cost-effective medications.”
Spot on from
@PopovianPharmD
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The hits against CVS Caremark keep coming: Minnesota Department of Commerce fines CVS $500,000 for allegedly violating state laws against pushing patients to use pharmacies owned by their parent company
@keithellison
@AGEllison
@MNCommerce
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The budget is a done deal, and the state of Ohio just blew up the PBM status quo in Medicaid. The state has created unprecedented levels of drug pricing transparency and reinvested in local pharmacist care. Overall, big win for Ohio. Bravo
@GovMikeDeWine
.
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AMA: “The healthcare professionals best equipped to deal with dangerous drug interactions aren’t equipped to deal with dangerous drug interactions.”
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Read this, and read it again:
"By completely cutting out the insurance/PBM industry and charging cash, Hux and others say they’re able to offer generics at a steep discount — often even at a fraction of an insured customer’s copayment."
🤦♂️
@martyschladen
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Straight up, this will not happen.
Trump: "Drug prices will be coming down 80-90 percent." there's no evidence nor policy that will make that happen.
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CVS sometimes forces people to use its pharmacies. Now the Supreme Court will weigh in.
@martyschladen
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Years after
@martyschladen
@CCandisky
@darreldrowland
@SullivanLuke2
@DaveYostOH
and a couple Ohio drug pricing nerds exposed $245 million in hidden PBM spread pricing drug markups the US Senate Finance Committee has the costly scheme on the chopping block
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A big kudos to
@mcuban
@alexosh
@costplusdrugs
for this first big foray into disrupting bogus, inflated brand drug pricing and working to provide a true, transparent low price without the normal disparate pricing schemes that enable arbitrage, waste, and inequity.
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“When there’s a family facing a health crisis, it’s not CVS or PBM companies that are out delivering medications or opening the shop after hours to lend a hand.” -
@JamesSkoufis
@CloeyCallahan
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More upheaval in the big PBM marketplace: Tyson Foods drops CVS for upstart pharmacy benefit manager, as industry upheaval over cost concerns spreads
@berthacoombs
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CVS Caremark appears to be just begging for more enemies in the state of Oklahoma.
@denwalt
@glen_mulready
@gmccortney
@marcus_mcentire
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Breaking: The bell tolls for Ohio’s broken pharmacy benefit manager system that fleeced hundreds of millions from providers and taxpayers ...
@OhioMedicaid
releases formal request for proposals for the procurement of a single state-controlled PBM
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This is wild
The state of Utah replaced its complex UnitedHealth Group operated Medicaid reimbursement system with a four question Google form. And it works.
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When there are multiple prices for a drug, there is no such thing as 𝑡ℎ𝑒 price for a drug.
@martyschladen
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Hmmm... where have I seen this type of behavior before?
The owner of
@ChiPizzaBoss
shared this nightmarish Grubhub invoice that will haunt me for days.
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Five years after
@DispatchAlerts
and
@DaveYostOH
blew the lid off the $245 million PBM spread pricing scheme in the Medicaid program, the US House of Representatives is following Ohio’s lead and moving to outlaw the costly practice nationwide
@rachelcohrs
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BREAKING: Former PBM executive blows the whistle on the latest deceptive tactic created to rip off employers, providers and taxpayers!
Mark my words: Effective rate overcharges are the next big multi-billion dollar prescription drug scam.
@darreldrowland
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PBMs defend spread pricing as a benefit for plan sponsors to mitigate risks on drug pricing variability.
But often, PBM spreads are so high that they eclipse the cost of both the drug and the pharmacist.
That’s not mitigating risk. That’s creating it.
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It's one hell of a business model when you can subjectively set the rates that are paid to subsidiary companies you own.
It's even better when you can subjectively set the rates that are paid to competitors of subsidiary companies you own.
We're entering a new era of antitrust
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I often get asked, “How does GoodRx make money?”
Here is an outstanding explainer on just one of the ways.
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"I’ve always told people I’ll probably die at the counter, but I don’t know if I’ll have a counter to die at."
So sad to hear of the passing of my dear friend Mark Kratzer this week.
Mark was a pillar of his community in Wilmington, Ohio and was the first to blow the whistle on
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If you say you care about lowering drug prices, but you choose to ignore one of the primary mechanisms responsible for inflating those drug prices in the first place, then you may not actually care about lowering drug prices
@martyschladen
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Pay close attention.
@AmerAcadPeds
is upset about *pharmacies* giving life-saving vaccines. Their focus on the facility rather than the practitioner is the tell on what really motivates their opposition. It’s all about the business, and that’s all the people need to know.
Today's action by
@HHSGov
allowing pharmacies to provide vaccines to children ages 3-18 is incredibly misguided. Our full statement:
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The Federal Trade Commission is following the lead of
@DaveYostOH
and is officially on the hunt for rebate alligators 🐊
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Looking forward to discussing how perverse incentives, policy failures, conflicts of interest, and a lack of transparency in the legacy PBM model exacerbates American drug pricing dysfunction at next week's
@TheHillEvents
PBM reform forum
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The more that the feds tap pharmacists to be the front door for accessing more healthcare products and services, it begs the question for when they will finally update the antiquated laws/rules that disenfranchise pharmacists as recognized healthcare providers. Long overdue.
New: CMS says it has figured out a way to cover free rapid OTC covid tests for Medicare enrollees through direct payments to pharmacies, beginning in the spring.
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In all my time in the pharmacy benefits world, I have never seen an audit of a PBM where the PBM itself was granted the ability to author the results of the audit. Outstanding reporting from
@Celia_LJ
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Ohio sues Express Scripts for ‘egregiously’ overcharging for medicines
@Yost4Ohio
@edsilverman
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Big day tomorrow as
@OhioMedicaid
buries its long-plagued PBM-controlled prescription drug program for good and begins anew with a revolutionary model that is intended to maximize transparency, access, affordability, and value.
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CVS nailed with $250k fine from Ohio Board of Pharmacy after being found to be more than a full *month* behind filling prescriptions.
With this location placed under indefinite probation, more hearings are on deck for other CVS locations
@laurahancock
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Rebates are just money from sick people.
The first step is to make CEOs realize the rebates they are getting, are paid for by their employees. It’s as if they think it’s free money. It’s not.
If you are the CEO of a company that is getting rebates from your PBM, you have to understand that your employees are
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🚨 🚨 The latest multi-million dollar drug rebate scheme uncovered in Illinois
“This is only the latest instance in which one of the big PBMs and its GPO were cited for failing to pass along rebates.”
@pharmalot
@KwameRaoul
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“As an example of the apparent arbitrariness of the PBMs’ pricing, a recent analysis of Medicare data showed that plans owned by CVS paid 501 different prices for the same drug.”
The owner of one of the 3 largest pharmacy drug middlemen on Tuesday filed suit to quash an attempt by the FTC to investigate industry practices after it issued a scathing report saying PBMs inflate drug prices and thus make patients sicker.
@martyschladen
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Massive $215 million settlement over alleged PBM prescription drug overcharges in California in a case that all began in Ohio thanks to aggressive lawmakers, tenacious reporters at
@DispatchAlerts
, and relentless pursuit of accountability from
@DaveYostOH
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“It’s hard to understand why a PBM would offer one price in one Medicare plan and a price that is a hundred times higher in another.”
@brianreid
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