30 Days of US Healthcare: DIR Fees

[@BeeWhere]

I always felt knowledgeable about how messed up our system is. But this series is enlightening just how deep it goes...

[@tayloranderson456]

Wait till you learn about the macro economics of it. Doing an even partially competent job at prevention=Great Depression.

[@dwarvenpepperoninipples]

Friendly reminder that 20% of the richest country in the world's GDP is spent on healthcare. Everywhere else it's in the single digits.

[@MyBiPolarBearMax]

I would unironically vote for dr glaucomflecken for congress or to rewrite health care laws.

[@absolutetuber]

More corrupt than anything.

[@SharynS.]

@@MyBiPolarBearMaxI would support that but I’m not sure I’d want to consign him to that Hell

[@prelvas88]

As a pharmacist who went from community pharmacy to hospital pharmacy, I really appreciate the light you shine on a lot of these topics. It’s easy to point the finger at just one broken gear of the machine, but it’s amazing to see that the entire machine is built on so many broken pieces. Sadly all of them revolving around the incentive of making more money.

[@seanheath4492]

It's only broken if you assume it's intended to provide healthcare to patients.

[@sonipitts]

I mean...realistically, the entire machine is actually built on robust and nearly indestructible pieces that are exquisitely designed, engineered, and maintained specifically to achieve these ends, and is working perfectly to spec. This is why we can't fix it by "repairing" those pieces. Any "repairs" made with the intent to shift that output just get routed around by shiny new arbitrage design and engineering adjustments to course correct back to payor profits. If we really want to fix it, we have to dismantle the whole thing and start over. Which, given that the Big 5 alone have more operating capital than many decent-sized nations to throw against said change, is going to require a literal revolution.

[@spam-el3ee]

@sonipitts Sounds like my communist buddies. tbh I think revolution may indeed be necessary but I'd prefer a nonviolent one... which probably doesn't exist.

[@evilsharkey8954]

These gears aren’t broken. They’re intended to make maximum profits for already rich people at the expense of everyone else.

[@XRaeVision]

​@sonipitts This is exactly why my answer is "You need to burn the whole system down and start from scratch" when any of my friends or family members ask me what I, as someone in the healthcare industry, thinks the solution is.

[@iremaday7163]

"If you don't pay us money we will destroy your establishment" is considered mafia if you do it by walking up to people and say it out loud but when you bend the rules and just don't say it out loud its totally legal

[@amandasigler9802]

The sales pitch for every type of insurance sounds a lot like a maphia enforcer demanding "protection" money. It was even more prevalent before they paid off the government to legally require everyone to purchase their services. Now your only choice is which scam artist do you think is going to financially ruin you the least.

[@i-love-comountains3850]

​@@amandasigler9802 I want to be mad and tell you you're wrong but I'm more mad that you're absolutely correct😅

[@theplaylab9336]

The awareness you're building is incredible, and should be used in Senate hearings. Lawmakers need to be watching these!

[@paulbaurichter7228]

I can imagine it now, lawmakers using the videos as "proof" the situation is just a lighthearted joke and nothing to be concerned about.

[@kimrespess6580]

We can share with our representatives. And keep sharing. Relentlessly.

[@richmahogany1]

The cynic in means believes that they are all acutely aware of this stuff. But it means big corpos make big money, which...well...we've seen this story before. The question is, why is the US government so interested in prioritizing corporate profit over all else. Yes they get lobbied and kickbacks, but I think there's more to it. Having most of the richest companies in the world in the US makes the country "more powerful" in a variety of ways. The US tries to be as hospitable to corporations as possible so that they will stay in america. I think it's a tough balancing act because one day if the government started enforcing policies which are more pro-citizen, there's not much stopping corporations from simply packing up and going to a country where they can make more profits.

[@estudiordl]

Oh they know... they know 😢

[@lchn12345678]

not with lobbying still intact

[@KnightMD]

The ophthalmologist took precious time out of his family time and time seeing patients and operating to single handedly script and act out 30 videos for the betterment of this entire country in the face of mega billion dollar abusive corporations. Respect and thank you.

[@carmenlewis8563]

I'm a pharmacist. PBMs are *almost* single handedly ruining our profession. If something doesn't stop this, I'm really not sure how pharmacies in general will be able to stay open.

[@TakenTook]

I suspect corporate chain pharmacies are already planning to replace human pharmacists with robots and AI. They will come for the pharmacy techs first, and probably expect one pharmacist to remotely supervise all the machinery doing the tech functions at 3 or 4 different physical locations, while still being on site to administer vaccinations at one of those 3-4 locations. All of you -- pharmacists, techs, cashiers, delivery drivers - need to stop them from getting rid of jobs for humans. Of course, they will try to cite patient safety as a way to threaten you out of striking and shutting down locations for a while, the way they threaten physicians. But if we keep letting corporations replace humans with machines, patients will have bad outcomes when the machines make mistakes, and our economy will continue to go down the drain as fewer people have gainful employment.

[@solario8628]

All according to keikaku. (note: keikaku means plan)

[@msmartiellen]

They aren’t staying open

[@falconerd343]

Oh it's not just pbms. Don't forget about the drug manufacturers increasing drug prices many times faster than inflation. Or about insurance companies in general (though they are basically the same as pbms now since they bought them all up). Or about pharmacy chains squeezing the life blood (sometimes literally) out of their staff while still posting record profits. Or about pharmacy schools increasing class sizes (and thus profit margins) long past the time when economic indicators showed job stagnation and thus a need for fewer pharmacists. Or about the rise of McPharmacy (drive thrus) leading to the expectation of free, instant access to prescriptions, despite no other aspect of health care being available instantly on demand (other than the ER, which charges astronomically for the privilege). It's not just PBMs, it's capitalism and profit in health care that has ruined our profession.

[@Christian-os3kk]

I feel like this is some sick high level game, where the insurance industry just wants more of a cut from the profits of big pharma

[@blublank]

My state, North Dakota, actually passed a law in 1963 that requires that all pharmacies be owned (at least 51%) by a registered pharmacist within the state. As such, there are only 20 pharmacies state-wide that are owned by corporations (existed before the law was passed), so nearly every pharmacy in the state is an independent pharmacy. Super helpful, especially for rural communities.

[@Idran]

Don't they still get slammed by DIR fees? Or does the state do something to help out on that too?

[@blublank]

@Idran I honestly don't know, but I do know that they are pretty much all still in business. I'm assuming, because they have a little more collective bargaining power because of that state law, they are able to negotiate better rates with the main insurance providers in the state.

[@blublank]

I should mention that North Dakota is a little different in a couple of other ways from every other state in the country. Only state in the country that does NOT require voter registration, the state also has a voter approved savings account (the Legacy Fund) which could cover all state expenses for 18+ months currently, and the state government OWNS AND OPERATES both a bank plus a grain mill and elevator (both of those last two were set up to help farmers get inexpensive loans and to stabilize crop prices). For such an otherwise extremely conservative state, we have some oddly socialist institutions and laws.

[@jintsuubest9331]

​@@blublank Huh, almost as if economic policies has nothing to do with your political ideologies.

[@blublank]

@jintsuubest9331 I mean, the "savings account" thing is because the state is fiscally conservative and that's why it was voted in. The bank and grain mill and elevator were established in 1919 and 1922 respectively, and the political views of the states citizens were MUCH different then. They were, at the time, fighting back against corporate banks and corporate grain mills which had a stranglehold on things. But again, those were established over 100 years ago, so a lot has changed in the political climate of the state since then.

[@Tactical_Turtwig]

Fun fact: Distilling the tears from those employed in the medical field is actually UHC's primary source for Saline. 😭

[@DrMrH-RPh]

As a pharmacist in an independent pharmacy... We are rarely reimbursed the cost of the drug up front and then 2-6 months later, DIR fees create larger losses. I think we had roughly $100,000 in DIR fees in the first half of 2023. Insurance companies can also audit us on a medication and if we don't do calculate the day supply correctly or don't have specific info (like affected area or max daily dose) in the instructions of the prescription, they can take all of the reimbursement for all of the prescriptions for that drug, even if the other prescriptions were processed correctly.

[@DrMrH-RPh]

I've seen them take $10,000 of prescription income away for rounding the wrong direction on a day supply. Calculation came out to 90.6 days and we ran for 91 days, they stated we should have run it for 90 days because 91 days was an "abnormal value"

[@souldancersbyjennifer]

​@@DrMrH-RPhI'm so sorry for what you guys are going through. I wish you all have permission to punch them right in their collective nuts and guts. Why such atrocities are allowed to happen, only God knows... But with this series, may it be brought to light and change. Our prayers with you all...

[@sopyleecrypt6899]

😮

[@lolzormachine]

Oh, so theft isn't an exaggeration

[@grmpEqweer]

So this is obviously designed to bankrupt independent pharmacies. That's the point of this. The insurance companies want patients to use pharmacies contracted to, or part of, the insurance company.

[@harnutvlad7662]

With each video I come to realize how fucked up everything in the US Healthcare really is

[@z-rossi3672]

Worst part is.... its worse than just that lol.

[@LexYeen]

​@@z-rossi3672there is always more, and it is always worse.

[@dianna3157]

It's enough to make a legitimate doctor with a thriving practice turn into an incredibly funny KZbin sensation. 😂😢

[@Nan-59]

@@dianna3157good one ☝🏻

[@MonkeyJedi99]

We the People need to pool our money and buy some Senators so we can have a chance against these corporations.

[@ItsAsparageese]

Reminder to everyone that as soon as the series finishes (or sooner if desired) if even just a few thousand of us participate, it'll be trivially easy for us to make sure the playlist link gets emailed, tweeted, etc. linked to every member of Congress and every major healthcare CEO every day for at least several weeks

[@danielb8954]

seconding this idea, perhaps it will change a few minds.

[@jonarecker]

I think you mean crucial, or paramount, not trivial.

[@cbpd89]

If we could get an organized campaign it could be extremely effective! Have you seen what John Green has been doing to lower the prices of TB medication? It's been very, very effective!

[@ItsAsparageese]

@@jonarecker I meant trivial as in easy for us to accomplish without any one person needing to put a lot of time or effort into it. But you're absolutely right, the _effect_ would be anything but trivial. I'll edit for clearer wording haha

[@ItsAsparageese]

@@cbpd89 YES that's precisely the kind of aggressively-wholesome energy I would love to see this community come with

[@ashreecar]

It's so sad that this is all true. PBMs are a big reason why independent pharmacies especially in rural areas get shut down which then decreases the number of accessible healthcare options people who live in more rural areas have. It's a lose-lose situation 😢

[@alexbrewer4570]

I read an article recently about rural hospitals signing up for a system that lets trained doctors help out by video call, because there aren't any doctors in the area. Part of the article describes how a doctor is coaching some nurses on how to intubate a patient, but can't do much else, since they're a thousand miles away. As the old Russian saying goes... "And then things got worse"

[@dormantlime215]

and the few pharmacies that are left, the chain locations and grocery store pharmacies, become swiftly overwhelmed trying to handle all of the clients that could have otherwise been spread out across more shops.

[@ashreecar]

@@dormantlime215 exactly

[@loftyguy11]

Ah yes. The dreaded "What do you want to learn today" question. 😂

[@DaTimmeh]

I let out an audible “Oh no” when I saw the video. How can content be this dreadful, yet absolutely entertaining…

[@beniowski5079]

These US healthcare video series made me appreciate UK's NHS a bit - something I never thought would happen.

[@ianwells7916]

The grass is always greener until you realize no one but the extremely wealthy can afford the abhorent costs associated with laying on the yard on that side of the fence.

[@matthewhall5571]

One of Doc Glauc's associates, Medlife Crisis, is a UK doc. He pointed out that the US system and the defunded UK system are the worst possible examples of private and public healthcare, respectively. And neither one should really be emulated by anybody else. The UK system is better if you are poor. The US system is better if you have a rare disease. But both of them will chew you up and spit you out unless you are VERY vigilant.

[@evilsharkey8954]

The grass is only greener in the US for cutting edge care and new drug development, which is where we excel. Everything else is a mess.

[@immoloiser6134]

The fact that the US can’t compete with even the worst of the worst public healthcare systems goes to show how screwed their system is

[@geebster.]

The best possible care in the world is here in the US, problem is no one actually accesses it except the ultra wealthy. Its meaningless for the general population that actually paid for those advancements with their tax dollars. When all outcome metrics are worse (5 year survival, screening rates, etc) it doesnt matter if your country had the capacity to do it the best. What actually happens for patients is what should matter and really doesnt here. As a canadian who is now a doc in the US I couldnt possibly have more negative things to say about the care here and where the incentives are.@@evilsharkey8954

[@kap4020]

Support your local independent pharmacy! They usually offer better customer service and mine delivers every day!

[@cindylutz7442]

My dad lives in a small farming community. The independent pharmacy is the coolest store in town, and probably is the only pharmacy. One hopes they hang in there. But it explains (more fully?) why they also are the boutique clothing shop, kitchen gadget shop, candle, soap, Hallmark, candy, kids' toys and game shop as well.

[@thegreatwal1224]

@@cindylutz7442 yep. Pharmacies can’t make money on prescriptions anymore. This is why you see so many pharmacies transitioning to promoting ‘wellness’ through supplements and things. They have to find a way to stay open.

[@souldancersbyjennifer]

​@@cindylutz7442may they survive through the darkness 🙏🏻

[@jonarecker]

I truly have come to despise big chain pharmacies

[@vidaudink3044]

I'm learning SO MUCH about the terrible intricacies of our healthcare system with this 30 Days of Healthcare series. I'd otherwise never know about any of this behind the scenes corruption!

[@rxanime535]

As someone in pharmacy I can confirm many of us did come on because of the colorful complex labels that print off. In all seriousness though this is why a lot of independents prefer cash price for Rxs. No DIR fees and we make just above cost which allows us to stay afloat.

[@popenieafantome9527]

So this can be avoided with a simple “cash only” sign or is there is a clause somewhere preventing doing that.

[@rxanime535]

@@popenieafantome9527 it’s more of most people don’t like to do cash when picking up prescriptions. A lot of generics aren’t very expensive. Brand names is where it gets pricey. The chains most of the time don’t have the ability to check for issues like independents do from my experience in both. And with the cost of some very important drugs it is easier and less expensive for patients to use insurance IF they are covered. Case by case like everything else. Pharmacy used to be only cash based or patients would call their insurance to be reimbursed for rxs

[@rxanime535]

@@popenieafantome9527 also the drug manufacturers are in Kahoots with the insurance so kind of hard to lower the drug cost. Insurance will rarely cover compounded prescriptions so it’s mainly cash. Compounds and shots/Covid tests the past several years kept sooooo many independents in business, but with the high cost of them right now we shall see.

[@KirisutonoNeko]

“Would you like to play with stickers…?” 😁

[@denimator05]

Reminds me of something I saw about modern business. The quote roughly goes "Today's entrepreneurship isn't about creating value, but finding new ways to capture value." Basically instead of creating something new people are working on how to make money from other people's labor as a middleman

[@maxfieldstanton4541]

I worked for an independent pharmacy at the tail end of 2020. The pharmacy itself has been around since like 1934 or something like that, but of course has seen multiple owners. The owner I worked under refused to use certain insurances because they literally did not reimburse the pharmacy, meaning he would lose money on the prescriptions. I, unfortunately, had to leave when they went solely compounding (I'm not a compounding tech). 99% of insurances don't cover compounded meds, but often they are more effective for patients. Especially pets.

[@vinifavier]

wow. This is just insane. Coming from a developing world country such as Brazil. I feel blessed our government has popular-based pharmacy policies to distribute essential medicine at a accessible value (or sometimes free) to the population. Our free universal healthcare system might not work a lot of the time because of underfunding and corruption, but in this aspect, we are in a much better position policy-wise.

[@hawktheelfowl]

Doctor: You need this medication every day Insurance: You are only allowed to source this through ExpressScripts mail order not the local box chain pharmacy ExpressScripts: We only use US Postal Service US Postal Service (also privatized): Your in the middle of town location is an overtime route and we’re just not paying somebody to deliver mail routinely despite the fact you are in walking distance to us. Me: Guess I’ll just go die in a ditch then.

[@tamzinbrown9384]

up, you nailed it.

[@tamarinmangold1414]

😱😭😡🤬 This is appalling! I'm shocked!

[@lh3540]

oh, we had a huge problem in our mountain towns where the USPS is contracted to do last leg delivery for amazon, and then they weren't delivering the regular mail. people were waiting in line for 2 hours at the post office.

[@waffles3629]

Doctor- you need this medication Insurance- you have to get it through express scripts Express Scripts- we legally can't mail that medication Me- hey, insurance, how am I supposed to fill this med? Insurance- through express scripts 🤬🤬🤬 I did eventually get it, and thankfully I didn't need it every day. So my doc just wrote me the max she could and the "week" supply at max dosage lasted me 10+ months. And I've since had surgery and no longer need it (getting them to pay for that was awful as well)

[@hawktheelfowl]

@@waffles3629 Aw man! That’s always irritating too. Having to keep way more medication than you’ll ever need or having the risk of getting addicted and having a ready supply just sitting there.

[@driftwolf]

wow. Just.... wow. Definitely need to make this series more known to Canadians, since we have certain parties here that keep claiming that "private healthcare is so much better!". No, no it bloody isn't! Not for the patients, citizens, doctors, and anyone other than the few rich people who own the thing.

[@jamesodell3064]

When I talk to fellow Americans who think our medical system is better the Canada's health care system I tell them that the lifespan for a Canadian is about 3 years longer then ours. Canada must be doing something right. I live in the Detroit area my two prescriptions are cheap, but if I needed an expensive one I have the option of driving to Windsor, Ontario where prescriptions are a lot cheaper.

[@WVURxMan]

Private funded healthcare is basically the exact same thing but with numerous useless middlemen in between that make things needlessly more expensive.

[@waffles3629]

​@@jamesodell3064 yep. I've had other Americans "explain" to me that "universal healthcare is so horrible you have to wait *weeks* to see a specialist". Like great, I waited 3 *months* for an "emergency priority appointment" that another doctor had to call and beg for earlier than 10 months for me. I had a brand new nonstop migraine and lost 20% of my weight waiting for that appointment because it caused chronic nausea and the meds barely kept me from puking, eating was out of the question nearly half of days. But sadly I generally get called a liar by people who believe universal healthcare is horrible. Because apparently if my "story" was true I'd have had an appointment the next day.

[@angeliamoore6973]

I have noticed the big take over of independant pharmacies but I didn't know how until this video. Wow unbelievable depths of layered wicked way for insurance companies to win. Not our finest hour

[@tinaperez7393]

I'm totally getting trauma from this series. This isn't just something that should be illegal its just plain sickening.

[@grmpEqweer]

It's rather literally "your money or your life," and for those who haven't got enough money... An estimated 68,000 people a year die from treatable causes because they can't afford treatment. (Yale and Florida State University study)

[@dormantlime215]

literal crimes against humanity

[@BlindBatG34]

This hits so hard. We had the BEST independent local pharmacy close up shop recently. My Doctors/Nurses always used to say they were the best pharmacy to deal with and I 100% agreed. My options now are drive a half hour to a CVS or use Express Scripts. :(

[@SarafinaSummers]

I haaaaaaate CVS. "We have spoken rx!" No, no you don't. The machine is never working for you to print the labels. Stop advertising it.

[@zyxavier]

I never knew this. This is absolutely horrible. This has kind of ruined my day. Thank you for making your videos; I love them so much and they are actually quite informative. Please keep making more.

[@dormantlime215]

the more you learn about the US healthcare system the more it just leaves a sour pit in the bottom of your soul lol its so nasty

[@christallemolina2224]

As a french viewer, we would always joke with my friends by saying "thanks that we are not in the US" (or any other country with such a health system). The more I watch the videos of the 30 days of US healthcare, the more I realize it is worse than what we joked about, and I can't imagine having to navigate in such a healthcare system.

[@seebluesea219]

Same here in Germany. The glorification of the USA is such an exaggeration.

[@readyforlol]

It's just worse than anything we could have imagined. It's the kind of stuff you could write fiction about and be called out for being unrealistic.

[@horizon319]

It’s also why, as an American, I dream about living abroad.

[@kylepessell1350]

It's pretty hellish to put it lightly and every year it seems to get worse.

[@rainbowstarfall]

Yeah maybe don't joke. It's really not funny.

[@Emilio1985]

When a problem is systemic or institutional, the effects of that problem can be seen everywhere. Some parts of the problem are more apparent than others, but most parts are incredibly subtle and out-of-sight for the vast majority of people who are forced to participate in that system. These skits are revealing about the myriad ways our healthcare system is an institutionalized attack on the health of the American citizens in service of greedy fuckers at the top of the corporate ladder. Think about it. 30 days of skits. That's 30 illustrations of separate parts of the problem of our health care system, at the institutional level, all converging on the same outcome: the already profanely rich people make more money while everyone else is left to quite literally suffer and die.

[@Sahdirah]

+

[@BKScience812]

This makes me think of A Modest Proposal

[@suemilkbone4868]

That's just it, people are not just inconvenienced or have to pay more than necessary, they are actually dying because of our corrupt health care system...and it's legal and condoned by the United States government.

[@redspec01]

This is the truth.

[@tejumolaolaoye9266]

That could not have been said better.

[@benjaminkuch2558]

Here in Germany our medical system is far from perfect, but damn you guys over there are so screwed...

[@1901180108]

Yeah, we really are. This country is dysfunctional.

[@matthewhall5571]

Germany and Switzerland have some of the better systems on average globally. Because they figured out how to have a working hybrid model of private and public market instead of trying to do it 100% one way or the other. Very well thought out system.

[@andydoucette1680]

"Fun" fact: DIR stands for Direct and Indirect Renumeration. It's the "Indirect" fees that really get ya.

[@yoopergirl9069]

Thank you for what you’re teaching us. I had a great little pharmacy down the block from where I worked that I went to for years…until ES refused to pay for my scripts there. 😡

[@aland7236]

Aww man, I just spent a month working with a vendor trying to get all of the little tiny details on our labels aligned so they print properly. They're in Kansas and I'm in Florida, it was fun 🙃

[@matthewhall5571]

Florida Pharmacist 😉

[@aland7236]

@@matthewhall5571 Not quite, Computer Systems Administrator. I do know some pharmacists though, I see them in the parking lot at Walmart every time I drive by.

[@thegreatwal1224]

Thanks so much for this. Most people don’t realize how difficult it is for pharmacies to stay open. Can’t tell you how many times I’ve had to tell a patient that a med isn’t available from our wholesaler just because if we dispensed it to them, we would lose to much money.

[@erinwoolfrey7650]

Hang on- so you have the medication right? But it would cost you so much money to give it to the pt that you are forced to lie and claim it isn't available? I really hope I have this wrong... I'm in Australia. I am an NP, working in the hospital- and so this concept , if I have it correct, seems downright criminal! And what does the pt then do in order to get their required medication? If it costs your pharmacy too much to dispense it, then surely it costs ALL pharmacies too much to dispense and so where does that leave the pt? Can they get an alternative? Is there a ' cheaper' option they can use? And finally, does this apply to life saving medication ( for example antihypertensive meds, diabetes medication, other first line cardiovascular meds...) or is it something that only happens with off brand prescriptions or off label prescriptions where a med is prescribed outside of regulations? Man, the horror of knowing you can't give someone their medication, not because they don't need it, not because there was a prescribing issue- but because it will send their pharmacist broke is beyond tragic. It really is criminal. US Big pharma needs immediate reform!

[@SN-cx8sz]

We can actually tell them that we would lose $ if we sold it to them? I’ve been told to just lie to the pt

[@SN-cx8sz]

@@erinwoolfrey7650I feel qualified to answer this! If the medication I will be processing results in a loss of profit I have no choice but to lie to the patient that we can’t order it or don’t have it in stock. Otherwise my pharmacy would lose money. $20-40 loss a month seems small, but multiply by 12 months and that’s an easy $240-$480 a year, then multiply that by how many people I let slide. That’s a huge loss for me. I would usually tell patient that they need to find a different pharmacy to fill it. Usually bigger chains like CVS do not show DIR fees or flag upon loss of profit, so I prefer to refer my patients to them since they really initially care about script count first. So ultimately, patient ‘can’ still get their medication. They just have to go through a few hoops and hurdles. It’s unfortunate and I feel shitty doing it. But my business needs to survive too…

[@erinwoolfrey7650]

@SN-cx8sz , terrifying. Tragic and just terrifying! But I did just see some comments that said, it can be avoided if the pt pays in cash? Is that right? Again, I literally have no concept of US prescribing regulations and or pharmacy/insurance costs. So from the outside, if paying cash means insurance misses out, it's almost win win.... but then I think, hang on.... of insurance misses out, exactly how much is the med going to cost? Are pts told they need to pay like a grand for basic meds? And in cash too, so insurance isn't included- just to get a medication they need???

[@thegreatwal1224]

@@erinwoolfrey7650 no your first statement is absolutely correct. Patients usually get stuck in this loop of getting passed around between different pharmacies because no one wants to fill it and lose money. It’s terrible. It can happen with any medication but to give you an idea - regularly dispensed, cheap, generic medications like statins or ACE inhibitors usually only incur a small loss - like a dollar or less per script. We’ll usually just fill those. Usually the big losers (where you’ll lose more than $10 by filling the script) are less commonly filled drugs. Brand names can be particularly bad. I’ve seen a bowel prep for a colonoscopy come through where we would have lost over $70 by filling it.

[@oldandstillhere]

Thank you for making this series even though I get depressed over it.

[@luke2v52]

I love these 30 days of healthcare videos. Funny and informative. Can’t solve a problem nobody knows exists, so these are great!

[@HappyCat3096]

I always try to use my local independent pharmacy.

[@Pingieking]

But if they are taking a loss on every prescription, wouldn't you using them make them go out of business... faster? American healthcare is so fucked.

[@chelseajewell9291]

I literally have no idea if there even is an independent pharmacy where I live

[@robertmorrow3511]

These videos are great they really show that the system is not broken. It's working exactly as intended

[@bardyn1]

And no independent retail pharmacies means the only choice is one of the big chains. Next up is probably increasing automation and decreasing staffing in the interest of greater corporate profit.

[@norniea]

So sad. No wonder our pharmacies are so stressed😫

[@retired5218]

Will is so good at keeping his characters distinct and unique. I'm sure I would get them all confused and ruin everything. And great acting by the way.

[@Spiritofeowyn]

Only independent pharmacies I know are compounding ones and since so few insurances make using them to pay for meds worth it it’s sometimes cheaper. Had the same grocer pharmacy for a decade and had to switch to Walgreens because insurance decided to become a controlling (insert bad word of choice). Walgreens is much slower and crappier around here and the insurance’help’ is often not enough to make it worth it to not just use a general discount and pay out of pocket.

[@hlalani1]

Thank you Dr. G for shedding light on these complicated and frustrating topics in healthcare with some satire! I'm a primary care physician and health policy researcher studying the issues with the prescription drug market.

[@rookiemoves]

This series sent me back down the rabbit hole giving An American Sickness another read…

[@someguyontheinternet4277]

My eyes have been opened and I am Dropping out of med school to pursue a career as an Admin

[@goodfortunetoyou]

Hold your horses. Most people aren't management, and even management can't fix this stuff. The rules of the game make the players.

[@curiouslycs]

what we really need is a political/activist movement to take down Citizen's United (the Supreme Court decision that allows money in politics) and get better laws in place to prevent this. The better laws probably won't happen 'till we break the power of the corporate lobby, though. I did go into politics instead of graduate school for climate science when I realized climate change was largely a political problem, so there's precedent.

[@ellec2935]

I'm in admin... don't do it. We get hit with layoffs every year.

[@JS-hu7pv]

I’m a physician, my father a retired pharmacist (both hospital and retail). I don’t see, nor does my father, how small independent pharmacies make it anymore. Wal-Mart makes money by making deals that are advantageous to them, such as signing a deal to only use one distributor and getting an exclusive volume discount. The problems come when that particular distributor doesn’t have that drug in stock or has difficulty getting it. Thankfully, that means as of late, we’ve seen our patients transfer their scripts to the independent pharmacies around us. If people really understood how the insurance companies have their tentacles in every aspect of the process, they’d go ballistic.

[@Cardboardruna]

It's been at least 30 years since I've seen any independent pharmacies in my county. Oddly enough, 30 years ago was right around the time they started conglomerating our healthcare providers...also around the time Walgreens started popping up.... Surely it's just a coincidence. /s

[@TakenTook]

The 1990s were also the heyday of the earliest HMOs. Corporations making a profit off of healthcare was an expansion of the greed of the 80s in general, only now it was being even more broadly applied to professional fields where we previously thought the nature of our work would make us immune to corporate raiders and the like. In the "learned" professions, we thought that we wouldn't need labor unions to protect us, because we foolishly thought our personal intellectual abilities would give us the upper hand. But we are still part of the pool of labor when you think about it, and there are plenty of smart people who work blue-collar jobs without getting a bunch of alphabet soup after their name. Needing to unionize isn't a matter of education or job classification. It's a matter of protecting the livelihood of humans, instead of the bottom line of corporations and the passive income of shareholders.

[@1492sonia]

Great job explaining this obscure practice… I encourage you to make one about what’s going to happen about these fees in Jan 1st, 2024. As an independent owner, i am very concerned even though we have been preparing financially and mentally. Thank you!

[@joshuawagner1149]

One of the few things the Ohio Senate did right was voting to allow the Ohio Department of Medicaid to demand all the care plans offering Medicaid insurance use a single pharmacy benefits manager. The nail in the coffin for these damned insurance companies was things like DIR fees and clawbacks, where the insurance company would pay the pharmacy 80$ to dispense meds, and then only charge the patient 40$. They would report to medicaid the 80$ they paid the pharmacy, get reimbursed 80$, and then go to the pharmacy and say "hey whoopsy-doodle our contract says we'd pay you 50$ for those meds not 80$; give us our 30$ back." Boom. Insurance has just made some extra cash by screwing over the pharmacy. With a single PBM, they can't do that so easily...

[@Cailus3542]

And US legislators cheerfully let it happen, even though they have the power, responsibility and resources to change things. Baffling.

[@Crymeariver227]

Because THEY are profiting as well. Otherwise don’t you think they would change?

[@cockatoo010]

Not baffling at all. Pharma lobbyists give them a slice of the misery pie

[@tinaperez7393]

Yup - not baffling - they're profiting as well, campaign financed and lobbied and strongarmed to the hilt - aka dependent/ beholden to the big corporations. And of course always the threat of all the jobs that would be lost if anything changes in the current insurance based and owned system.

[@dormantlime215]

its because theyre making money off of it. seriously, take a nice long look at who donates to legislators/their parties/the personal 'donations' made to legislators/personal business handling of legislators. you will immediately see why federal law doesnt line up with the national civilian consensus on a lot of things; because the people writing the laws are making a lot of money writing them in a way that pleases entities with very deep pockets.

[@tlpineapple1]

its not at all baffling when you realize there are more lobbyists in capital hill then politicians.

[@thewatchersofthewood3530]

Ooooooohhhhh!!!!!!!! Now I understand why the local independent specialty pharmacies charge extra for medications that Walgreens do not! When I needed to get special opioid liquid painkillers when my 8 year old had neck surgery they were the only ones that could make it. It was not very expensive and was super glad to have tit as she was in extreme pain for several days. That pharmacy also makes the special radiological meds for cancer treatments. I use them as much as I can ❤❤

[@KirisutonoNeko]

A favorite of mine was when Ozempic’s manufacturer retroactively decided not to pay/discount for lacking type 2 diabetes diagnosis codes and charged pharmacies over $1,000 _per prescription_ months later… (Like, that’s fine that you don’t want to pay, but don’t say you will and then change your mind when the product is already gone and used…) Or when Medicare decides they didn’t get enough documentation for a patient’s diabetes testing supplies, again charging the pharmacies $100s months afterwards for documentation not filled out properly by the prescribing doctor. And patients wonder why it takes so long to get their diabetes products.

[@nygiantpanda]

I sent my congress rep a link to these videos. I think every law maker needs to see them, Even if they already know some of them

[@Ryan-dj5ku]

Lol, I've contacted my representative in the past too.... They usually never respond and if they do it's an intern. Though I guess if a million people emailed the same representative... We may get some where.

[@sharvo6]

These should be shown in the schools. They should be shown before movies in theaters like they used to show news reels in the 40s. They should be on billboards. They should be on subway advertising. They should be on andwich boards in every neighborhood. They should be required PSA's on every broadcast platform. And the Glauc Doc should get a Nobel. ❤

[@Ikajo]

The only Nobel price he could get is the peace one... and there are many amazing people who deserve that one.

[@privacyvalued4134]

Brutal. Exactly what my Saturday needed. Thank you.

[@amandabevan6331]

I work for a medical group that runs several hospitals/clinics. In the last year or two my health plan has moved to require that we use the retail pharmacys out of the hospitals or their mail order option.

[@backtracker4256]

THANK YOU for talking about DIR fees from PBMs... it is 100% legalized theft... and worst of all, it increases costs for patients...

[@Loopooo45]

Every one of these videos hurts my soul a little more. Thanks for the insight Dr. Glaucypoo.

[@ericlorenzen4795]

Wow, sides of this mess I never would have known existed until now. Looks more and more like a mafia shake down.

[@cameronno6039]

That's what came to mind for me too. Pay up or a fire might happen.

[@kaboom4679]

If you think these pharma and insurance companies make the old Mafia look downright reasonable and principaled, wait until you meet the Dons that allow them to operate as long as they get their cut of the action . You know , the gang of armed thugs they insist would most assuredly take over in their absence ? Crime absolutely pays , as long as they pay their tribute .

[@MSte21]

That is precisely what Big Pharma and Big Insurance are. Corporate mafia.

[@dianagibbs3550]

*deep sigh* it's getting me angry now. Doc please tell us you'll end with some action items, something we can do to help fix this mess?

[@JimYeats]

Only one independent pharmacy left in the area I work. They just closed down one of their locations though. I’m sure the end is nearing. I give them all the business I can.

[@kamikaze_22]

Watching these videos makes me appreciate that I live in New Zealand! I have no idea what goes on behind closed doors at pharmacies, but I am happy to pay $5 every 3 months for the medication I have been taking for 20 years

[@lh3540]

my eye drops were $430 for 2 weeks

[@kamikaze_22]

@@lh3540 holy shit! Why? Just.... why?

[@lh3540]

​@@kamikaze_22that's the low end. It's not uncommon for a prescription to be over a thousand dollars.

[@kamikaze_22]

@@lh3540 🫣

[@waffles3629]

You want fun, try nausea meds that are $485/month. Which is literally more than triple my food cost. The only reason I can "afford" them is I'm so poor I'm on state insurance that actually covers them. I also have to get a prior authorization from a GP in order to see a psychiatrist. So I'm gonna be without a psychiatrist for at least a year because the GP I was randomly assigned is booking new patients more than 6 months out, and then I get to book with a new psych and wait for that as well. On this insurance you can also self refer to a urologist for erectile dysfunction. Priorities 🤬

[@grandmasgopnik9642]

Yeah my husband is a retail pharmacist and pretty much this is how most of our hometown pharmacies went out of business. The other side being our town wasn’t profitable enough to replace the independent owned ones with chain pharmacies so now the elderly have to drive two towns over for prescriptions so they just…don’t often times 😅.

[@Aniram789]

Proving once again that healthcare should never be put in the hand of corporations. 😨

[@florianschneider3982]

why do you think that? If this series proves one thing, it's that the government is corrupt.

[@jeanjaz]

That is the real choice, not private vs social; It is private vs CORPORATE.

[@RedCurlyQ1]

​@@jeanjazmore people absolutely need to understand this.

[@karmadave2000]

Help is on the way. In 2024 CMS will implement significant reforms to the DIR issue. They will address transparency, predictability, and reduce the financial burden on independent pharmacies. Hopefully, this will be more than a bandaid solution. Only Express Scripts of the top three PBMs by market share is a publicly traded independent company. The other two are CVS Caremark (#1) and Optum RX (#3). Those three claim about 80% of the market share. DIR fees have been a problem with all of them for a long time.

[@stapedium]

On the doctor side this is run by CMS itself and called MACRA. Come up with new criteria each year. Release them after data collection is supposed to start. Adjust the % compliance requirement post hoc until their budget is balanced.

[@elizabethmende4191]

I hope you have a food taster and a body guard. You are shining a light on some painful truths others would like to be kept secret. Thank you for you bravery to speak out.

[@christianj7076]

It’s really sad for the DIR fee issue. The fee is essentially us being contractually obligated to gamble our own reimbursements competitively against other pharmacies. The only way to avoid fees is to be in the top 5% of performing pharmacies. These metrics are not communicated well, and these metrics are also a monopoly- everything runs through a shady system called “Outcomes” which is owned by Cardinal Health. . . We lose money on over 75% of prescriptions, and anything that is Medicaid is almost guaranteed to be a loss. The same with Express Scripts- which among other plans, is what covers veterans.

[@bcd4562]

😮 Every US legislature needs to watch these videos. Unreal. 😡

[@sambackman6272]

Most of them know about this already unfortunately, and choose to do nothing. A minority know, and choose to do something, but because they’re in the minority it’s hard for them to really change anything. Republics don’t work if the people elect representatives who don’t actually work for them. In our system it seems that there is a broad consensus among politicians in both parties that they should favor the medical insurers over the patients and medical workers, so it’s hard to say we need to elect better representatives because we’re almost always choosing between two people who are only superficially different on healthcare issues.

[@nancylindsay4255]

At least one of the independent pharmacies in my area was an absolute rock star from the beginning of the pandemic. True heroes in how they made tests and vaccine available to people.

[@lukesmith5018]

The more I learn about the US, the more it sounds like a dystopian novel

[@ianwells7916]

There is a reason '1984', 'A Clockwork Orange', and 'The Giver' were all written here. Regarding introspective works; Russian literature tends to be about starvation, British literature tends to be about classism, and American literature tends to be about corruption in the guise of salvation. I mean, for fuck sake, if you think too hard about it '50 Shades of Gray' is about a woman being abused by a powerful businessman so much that she gets horny for it. If that isn't the perfect analogy for the American experience, I don't know what is.

[@lukesmith5018]

@@ianwells7916 1984 and A clockwork orange were both written by English authors in the UK, but I get your overall point

[@Ikajo]

​@@ianwells79161984 takes place in the UK...

[@grmpEqweer]

American writer wrote "the handmaid's tale." That one seems eerily prescient now.

[@chrisflynn372]

@@grmpEqweer Have to correct you there, was written by Margaret Atwood who is Canadian

[@olavkarlsson6430]

I'm working in healtcare in sweden as a psycholigist. We have private companies taking on goverment contracts to give care within the public system. They are supposed to provide care with a patient focus. But whenever the profit is at risk care comes in at best as a second priority. I'm so, so angry right now about how it works here. But after seing this I feel that at least there are places worse of than here.... I would be looking for a pithfork and a torch if I worked in your system.

[@ARedFeather]

Once again, im glad to live in the uk

[@tscimb]

This one makes me just want to cry. jfc, we *knew* this series was going to be hard to get through, but gddamn.

[@viciouschrisss]

I'd like to laugh, but DIR fees just cost me my job and closed a 71-year-old independent pharmacy. Now I get to work Big Corporate pharmacy because nobody else can afford to stay in business.

[@gibson17155]

A more accurate description of community pharmacy would have been “we get the medication orders, realize the doctor wrote for a quantity of 1 for a BID med written once daily with a note that says ‘dispense 90 day supply,’ we call the office to leave a voicemail because they closed 15 minutes ago, then we get yelled at by the patient because we are ‘withholding their medication’ by not breaking the law and we have a line of 15 other people wanting their meds and 7 vaccines, and the drive thru has been ringing and there are 6 people on hold on the phone…and I’m the only one here”

[@Valentina.Montano]

That sounds horrible 😢

[@santarosa6676]

You are describing our local CVS. The pharmacist looks like he wants to hang himself!

[@gibson17155]

CVS and Walgreens are notoriously bad for employee morale. In some places, following the COVID outbreak, CVS and Walgreens got so desperate for pharmacists that they’d offer $30,000+ sign on bonuses with the stipulation being that they had to stay for a year. Then, being a part of the US healthcare system, of course they would screw them over by firing them with a month left before the stipulation period ended, forcing them to pay back the entire $30,000+ bonus. People tend to focus on doctor and nurse burnout, but pharmacist burnout is just as severe. Pharmacists, especially in retail/community pharmacies, are forced to work long hours, get little respect from their patients, are forced to deal with impossible corporate metrics, and are contractually prohibited from sitting down for some reason. With the increase in the number of pharmacy schools over the last 15 years, the quantity of pharmacists went up, while the quality has dropped. Since quantity went up, the price for pharmacists went down and pharmacist salaries have stagnated. In the pharmacy world, the goal for many pharmacists is to find a job outside of retail (hospital, clinical, industry, government) with decent enough pay to justify spending $150,000-$200,000 and 6-10 years getting their degrees. The state of pharmacy is not good right now, but the COVID mass exodus of pharmacists to burnout has lowered the supply enough that I am hopeful change can happen.

[@plantnerd7565]

The only independent pharmacy in my rural hometown eventually had to close do to this and in my adult life the only independent pharmacy I've used is a compounding pharmacy.

[@tammymavery]

We only go our independent pharmacy. Our whole town goes because cvs is the worst

[@runner7409]

I wonder if the United people are watching this and laughing because it's so spot on.

[@johnreed4743]

What they say: "Universal, single payer healthcare would be too expensive for the state and too inefficient for patients!" What they mean: "It's fine if universal healthcare is expensive and inefficient, as long as it's universally private."

[@Sahdirah]

+ This.

[@raisins7777]

That's the best part, the US public pays too because it's still mostly tax money! Per capita in USD, for every $1 Canadians pay for healthcare, Americans pay $1.37 of taxpayer money and another $0.76 of private money. American healthcare taxes are the highest in the world, all for no better health outcomes and a fun dystopian insurance nightmare.

[@Birdsong-A]

🎯

[@KirisutonoNeko]

How would that solve this problem? Medicare and Medicaid send chargebacks and such too…

[@raisins7777]

@@KirisutonoNeko I am reading your question as "medicaid is government healthcare and has problems sometimes, so why should we want universal national insurance" and the answer already given above is because it would cost half as much. All the other developed democratic nations (European, Nordic, UK, Canada, Australia, Japan, all of them) with their dreaded "socialized medicine" pay drastically lower healthcare costs, and have lower healthcare taxes than the US.

[@scottread2979]

Flabbergasted. Never knew this happened.

[@Banc2008]

The awareness you bring is awesome. I had no idea about the pains pharmacists had to deal with as well. The whole industry needs reform

[@MaryJohanna]

You are a national treasure. I so appreciate your content!

[@rowennaclark6175]

Noooo I can’t lose my favorite little independent pharmacy 😭 they are truly the best, better than any other pharmacy I have used. I love them.

[@Traisas]

This one in particular is pretty wild. As many others have pointed out, this whole series is eye opening and kinda mind blowing.

[@jacob2359]

As a pharmacist, this is true. Shockingly accurate actually.

[@gallinesferiche]

Hug?

[@WVURxMan]

This is why I work for CVS. I really don't want to. I'd much rather have a truly patient-focused pharmacy that I run myself. But the PBMs have made it very difficult to make a profit. It's considerably more logical to just take the $150k a year guaranteed from the corporate giants.

[@alsmith20000]

DIR stands for Direct and Indirect Remuneration for those who are interested.

[@WWFanatic0]

I've been through the ringer in the medical system as a chronic health/pain patient. I won't lie, there's certain specialties of doctor that I hate more than cardiology and nephrology hate each other. The only thing more frustrating is the insurance/cost side of things. I still remember when my insurance wouldn't cover my pain medication because of the new prescribing guidelines. The guidelines advise to stay under 90MME if at all possible...I was stable at 15MME...and they used the "don't go over 90MME" guideline as justification to deny coverage. Ironically they were happy to cover certain interventions like ESI which cost them way more and did way less for me. It's like when they wanted to look for nerve compression and an MRI was ordered...but told to do an X-ray first...because that's how you see the nerves right? With an X-ray. Then after that was inconclusive they covered the MRI. Congrats insurance, you wasted your money, everyone's time, an X-ray for someone who could have used it (rural medicine understands) and let my condition get just a bit worse in the meantime only further increasing you costs. Then when they were playing games with covering treatments, enough time had passed that the doctor wanted a new MRI (which i got) to see if things had changed. Despite thinking I've seen it all, your videos remind me there's always a new low. Continually surprised and disappointed...

[@sneauxone]

The saddest part is that there are so many things going wrong and we feel helpless in making any significant changes in a reasonable time frame.

[@falconerd343]

Oh my god, that last line is so true. "How do Independent pharmacies stay open? We don't"

[@falconerd343]

Just in the last 3 months the regional grocery chain I work for bought the pharmacy files of several independent pharmacies that were closed by their private equity owners. Now the outlying towns' only options for medications are mail-order or driving into the city to come to the pharmacies that just don't have the staff or time to give them the care they're accustomed to. (not to mention the increased work load of all the patients we acquired)

[@wellivea1]

The fact that the biggest network of pharmacies in the US (CVS) was allowed to buy one of the largest insurance companies in the US while also being a PBM is insane! The quality of service at my local CVS locations has gone down dramatically since the Aetna merger. I don't know if the two are related but my insurance won't let me use Walgreens and almost none of the pharmacies are 24/7 anymore...

[@msmartiellen]

True, I wondered that myself when it occurred.

[@brainkill7034]

Doing the good work here, thank you for sharing. We could use someone like this in a position of authority. Sadly, bribery thinly veiled as “lobbying” will ensure that cannot take place.

[@jerrykinnin7941]

Yep. Happened about 20 or so years ago in my hometown a 2nd gen pharmacy shutdown and the pharmacist went to work for CVS out of NECESSITY.

[@dhandley8893]

Love my INDEPENDENT Pharmacist. I teach health and wellness classes and whatconsumers don't know about what's being done in their name is extensive. How did the world function without PBM's before they were invented? Actually, very well. Greed greed greed greed greed. Thank you Dr. Glaucomflecken for these videos.

[@Hi-TechHillbilly]

Preach! Press like if you've ever been through a CVS Caremark Audit.

[@Grumpy-old-dad]

This whole series is like the dark side of administration. I ❤️ what you're doing.

[@waffles3629]

Yep. On my last insurance I had to use Express scripts for every prescription beyond the first two fills or insurance wouldn't pay for it. Which is real fun when they can't ship one of your meds due to laws and regulations. It's real fun to call up insurance every [insert random number of months] to explain that you can't transfer a prescription to mail order because it is illegal for them to ship it therefore they flat out deny the script. Thankfully I didn't need much of it and my doc gave me a "weeks" supply so I was usually good for at least 10 months per fill.

[@Dualhammers]

My company switched to using CVS Caremark and my RX costs went up 300% using the pharmacy I've used for years.

[@powers1217]

Our insurance started using CVS Caremark last year. It’s been a cluster f**k ever since. Our insurance has always been good since we pay through the nose for it. Now prescriptions are getting bumped every time I turn around…prescriptions I’ve been taking for many years. 😡

[@JulieStones]

The PMB character sounds like a Mob Thug looking for protection money