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Why All Health Care Providers Should “Opt Out” of CVS Health’s (Care Mart) Opioid Abuse Prevention Plan
CVS Health Response to Troy Brennan Letter and Health Affairs Blog
This link is to an extensive review of CVS Health’s (CVS Care Mart) plan to use it Pharmacy Benefit Plan (PBM) as a tool to try to limit opioid abuse. Below are the nine sections to this material which includes a section on Preliminary Conclusions, SETMA’s Tools for addressing opioid abuse and the CDC’s “Primary Care Guidelines for Prescribing of Opioids.”
The section on “Conclusions” addresses my concern about CVS Health’s plans and my recommendation that all healthcare providers and health plans:
- Carefully examine the use of PBMs by large pharmacy monopolies.
- Recommendation that all healthcare providers and health plans “opt out” of CVS Care Mart’s plans. As indicated, CVS Health is using the “opt in” – automatically including all health plans, health providers and patients in CVS’s PBM plan -- method to manipulate plans who CVS Health believes will not take the initiative to affirmatively “opt out.”
Interestingly in other healthcare decision making where “opt in” or “opt out” is an option such as in Health Information Exchanges, it is considered ethical only to employ a decision where the patient must affirmatively “opt in” in order to benefit from the HIE. It would be easier for medical practices to use the “opt out” method but it is thought that that is not ethical.
Why then does CVS Health automatically include in their opioid plan all health plans who use their PBM? They state it very plainly. As will be seen by their own words, it is because they are confident that plans will not “opt out” and therefore, CVS Health’s methods will be applied to all.
In this review of CVS’ announced plans to further intrude into health care delivery, we will review:
The following is the “Conclusion Section” of this review:
Conclusions - Preliminary
My overall conclusion is that CVS’ effort to contribute to the abusive use of opioids is laudatory.
However, while it may be considered that CVS’ initiatives are healthy disruptive innovations in healthcare, there are serious questions about their violation of regulatory oversight involving their Pharmacy Benefits Management (PBM) Company and their pharmacists in overstepping their professional boundaries in patient care? Historically, the ideal of pharmacists/healthcare provider collaboration was a team dialogue. CVS appears to want to eliminate the team and have the pharmacy benefits manager, pharmacy, pharmacists and CVS retail stores, with captive employed Nurse Practitioners, take over healthcare. The deficiency of the care which is being provided by CVS retail stores is obvious to everyone except CVS.
CVS is using their commercial enterprises to compete in a potentially monopolistic way with the primary care healthcare providers upon whom their commercial enterprises are dependent. It is possible that an organized effort on the part of physicians can direct their pharmaceutical business to other pharmacies which are not involved in competition with primary care providers.
This reaction can extend to primary care physicians who are involved in managed care organizations who use CVS Care Mart to demand that another PBM company be used. The very nature of illegal monopolies is that the size, influence and power of the perpetrator of the monopoly is insensitive to market demands. CVS’ size and profitability has them in that position presently but their leverage. At the very least every healthcare provider who is participating in a management care organization which contracts with a Pharmacy Benefits Manager should demand to know what utilization management tools are in place with the PBM which allows the physicians prescriptions and/or orders to be ignored without notification of or consultation with the healthcare provider.
The image of a retail pharmacy chain, through their extensive commercial enterprise and their powerful PBM, “taking over” healthcare is alarming to me. As a healthcare provider who is involved in primary care, in patient-centered medical home, and in managed care which contracts with CVS’ Care Mart, I argued for years that the Affordable Care Act did not intrude between the provider and the patient. What I did not recognize was that an intrusion had taken place and is expanding and it is through the collaboration between HMOs and PBM and the retail, commercial stores which are owned by a PBM.
At the least the following should happen:
- Every healthcare provider and particularly every primary healthcare provider should demand to know the policy of PBMs for changing a physician’s orders or prescription.
- CVS Care Mart must disclose its relationship with CVS’ extensive primary care network, particularly as to whether CVS NPs will be employed in the counseling of patients who come to the pharmacy but which are referred to the NP for education, counseling or changing of the primary physicians orders.
- All health plans should “opt out” of CVS Care Mart’s utilization management program which allows them to change physician orders or prescriptions without consultation with the physician.
- The recommendations made in the 8th installment of SETMA’s 2017 series on opioid abuse should be implemented. These can be read at: The Opioid Epidemic: Part VIII - What is the Solution.
I hope that all healthcare providers and healthcare plans will consider this choice and will “opt out” of CVS Health’s (Care Mart) plan. The treatment of opioid addiction and abuse is uch more complicated than the manipulative plan proposed by CVS Health. A review of the section of this review entitled”: A brief review of Southeast Texas Medical Association, LLP’s (SETMA) Efforts to Decrease the use of Opioid Medications, can be reviewed at this link.
Significantly, SETMA’s tools, which we designed and deployed before the CDC published its Guidelines, address almost all of the CDC’s Checklist for Prescribing Opioids.
Sincerely yours
James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com
Adjunct Professor
Family & Community Medicine
University of Texas Health San Antonio
The Joe R. and Teresa Lozano Long School of Medicine
Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center
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