Podcasts about PBM

On this episode of This Week in Pharmacy, we bring together three powerful voices shaping the future of pharmacy, independent practice, functional medicine, and healthcare transformation.   First, we welcome Kris Rhea, MBA, Contributing Editor with Dispense Times, a digital publication dedicated to supporting independent community pharmacy owners across the United States. Kris brings a business-focused perspective on pharmacy operations, growth strategy, workflow efficiency, data-driven decision-making, and market positioning. His work with Dispense Times helps independent pharmacists navigate today's rapidly changing healthcare landscape, including PBM pressures, evolving patient expectations, regulatory challenges, and the need for sustainable business models that keep local pharmacies strong.   We also speak with James Maskell, founder of Evolution of Medicine, an organization built to inspire, equip, and unite functional and integrative medicine practitioners. Evolution of Medicine provides education, practice-building resources, and community for clinicians who are working to build thriving practices rooted in whole-person care. James brings a national perspective on the movement toward functional medicine, community-based care, prevention, and new models that empower practitioners to better serve patients beyond the limitations of conventional healthcare.   Our third guest is Marina Buksov, PharmD, a pharmacist, herbalist, educator, podcast host, and holistic health consultant. After earning her PharmD from St. John's University and graduating Summa Cum Laude in 2013, Marina entered pharmacy eager to serve patients, but quickly recognized that traditional allopathic pharmacy did not fully align with her deeper calling to help people thrive through prevention, root-cause care, plant medicine, and sustainable wellness strategies. Her experience behind the pharmacy counter and as a patient herself inspired her to pursue health coaching, nutrition, functional medicine, and clinical herbalism. Today, Marina helps pharmacists and healthcare professionals explore natural-minded career paths and build meaningful work that bridges pharmacology, herbal therapeutics, and holistic care.   Together, this episode explores where pharmacy is headed: independent pharmacy survival, business model innovation, functional medicine, patient-centered care, pharmacist reinvention, and the growing demand for healthcare professionals who can connect science, prevention, and real-world practice.   Listen to This Week in Pharmacy on the Pharmacy Podcast Network. Pharmacy's future is being built by those willing to challenge the current model, support independent practice, and expand the role of pharmacists as trusted healthcare providers.

In this episode, Sheila Arquette, President & CEO of NASP, speaks with Jonathan L. Swichar, Duane Morris Pharmacy Litigation Group Chair, and Bradley A. Wasser, Duane Morris Pharmacy Litigation Group Partner. They discuss the 2026 Consolidated Appropriations Act and its landmark PBM reform provisions that impact pharmacy network access and transparency. These expert litigators go into detail about what specialty pharmacies should expect as federal agencies enforce the new law and what opportunities and challenges lie ahead for specialty pharmacies.

Let's talk PBM's.  What even is a P-B-M? Pharmacy benefit managers have been around since the 1960's, although back then, they were basically claims processors. Things changed in the 80's and 90's following the first iteration of ERISA when employers saw PBMs as potential cost containment strategies. The industry continued to explode until 2007 when CVS acquired Caremark, and now the market is really consolidated into just three major players. Why does this matter? Well, PBMs control just about everything drug-related in the US these days, and that includes the cost. Given that we have not seen the promised drop in drug prices, Americans and employers are still bearing the burden of this bloated and broken system.  To unpack how this works and what folks are doing about it, we invited back Shawn Gremminger, the President and CEO of the National Alliance of Healthcare Purchaser Coalitions. His organization works with regional coalitions of employers to help them advance health policy, leverage their collective power, and drive market change.

"Within five years of calling us charlatans, that hospital system was sued for multiple millions of dollars by their participants... You can go from charlatan to change agent fast."Is history about to repeat itself in the health benefits world?My guest this week is Jay Gepfert, Managing Partner of Culpepper RFP. Jay spent his corporate career on the retirement and 401(k) side of the industry, where he witnessed a massive fiduciary paradigm shift 15 years ago. Driven by regulatory changes and a wave of aggressive class-action lawsuits, traditional retirement "brokers" were forced to stop taking undisclosed kickbacks, disclose 100% of their compensation, and legally sign on as fiduciaries for their clients.Now, Jay warns that a “tsunami” is hitting the health insurance space. With major lawsuits filed at the end of 2025 targeting plan sponsors and major brokers over voluntary benefits and PBM conflicts, employers can no longer hide behind the "we've always done it this way" excuse.In this episode, we break down exactly what it means for a benefits consultant to legally act as a fiduciary, how hidden compensation and broker overrides create toxic conflicts of interest, and how Jay's firm helps employers run rigorous, process-driven RFPs to audit their vendors and protect themselves from massive legal liabilities.If you are a CFO, HR leader, or benefits consultant trying to navigate the new era of ERISA compliance and Consolidated Appropriations Act (CAA) enforcement, this episode is a stark wake-up call.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Episode Chapters(00:00:00) Intro(00:01:40) Meet Jay Gepfert and Culpepper RFP (00:03:30) Origin Story: Transitioning from 401(k)s to Health Benefits RFPs (00:06:54) The 401(k) Paradigm Shift: How Retirement Got Cleaned Up (00:08:50) The 2025 Wave of Health Benefits Fiduciary Litigation (00:13:49) Voluntary Benefits and the Commission Tsunami (00:17:19) What it Actually Means to be a Fiduciary for a Plan Sponsor (00:19:05) Mandating Your Broker Becomes a Fiduciary Consultant (00:21:05) Flat Fees, Eliminating Hidden Comp, and Disentangling Commissions (00:27:24) Exposing Toxic PBM Conflicts of Interest (00:30:19) The Customer Experience: Running a Modern Fiduciary RFP (00:35:08) Why Process and Documentation Matter More Than Perfection (00:38:13) The Consolidated Appropriations Act (CAA) & Gag Clauses (00:41:18) The Catalyst: When Will the Market Finally Shift? (00:44:14) The Multi-Million Dollar Lawsuit: From Charlatan to Change Agent (00:48:56) The 5 Questions That Eliminate Status Quo Brokers (00:56:18) The Ideal Plan Sponsor: Proactive vs. Reactive (00:58:54) Shifting the CFO Mindset & Unlocking the Bottom Line (01:04:01) Big Picture: The Breaking Point of Employer-Sponsored Care (01:06:40) Closing ThoughtsKey Links for Social:@SelfFunded on YouTube - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

"Within five years of calling us charlatans, that hospital system was sued for multiple millions of dollars by their participants... You can go from charlatan to change agent fast."Is history about to repeat itself in the health benefits world?My guest this week is Jay Gepfert, Managing Partner of Culpepper RFP. Jay spent his corporate career on the retirement and 401(k) side of the industry, where he witnessed a massive fiduciary paradigm shift 15 years ago. Driven by regulatory changes and a wave of aggressive class-action lawsuits, traditional retirement "brokers" were forced to stop taking undisclosed kickbacks, disclose 100% of their compensation, and legally sign on as fiduciaries for their clients.Now, Jay warns that a “tsunami” is hitting the health insurance space. With major lawsuits filed at the end of 2025 targeting plan sponsors and major brokers over voluntary benefits and PBM conflicts, employers can no longer hide behind the "we've always done it this way" excuse.In this episode, we break down exactly what it means for a benefits consultant to legally act as a fiduciary, how hidden compensation and broker overrides create toxic conflicts of interest, and how Jay's firm helps employers run rigorous, process-driven RFPs to audit their vendors and protect themselves from massive legal liabilities.If you are a CFO, HR leader, or benefits consultant trying to navigate the new era of ERISA compliance and Consolidated Appropriations Act (CAA) enforcement, this episode is a stark wake-up call.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Episode Chapters(00:00:00) Intro(00:01:40) Meet Jay Gepfert and Culpepper RFP (00:03:30) Origin Story: Transitioning from 401(k)s to Health Benefits RFPs (00:06:54) The 401(k) Paradigm Shift: How Retirement Got Cleaned Up (00:08:50) The 2025 Wave of Health Benefits Fiduciary Litigation (00:13:49) Voluntary Benefits and the Commission Tsunami (00:17:19) What it Actually Means to be a Fiduciary for a Plan Sponsor (00:19:05) Mandating Your Broker Becomes a Fiduciary Consultant (00:21:05) Flat Fees, Eliminating Hidden Comp, and Disentangling Commissions (00:27:24) Exposing Toxic PBM Conflicts of Interest (00:30:19) The Customer Experience: Running a Modern Fiduciary RFP (00:35:08) Why Process and Documentation Matter More Than Perfection (00:38:13) The Consolidated Appropriations Act (CAA) & Gag Clauses (00:41:18) The Catalyst: When Will the Market Finally Shift? (00:44:14) The Multi-Million Dollar Lawsuit: From Charlatan to Change Agent (00:48:56) The 5 Questions That Eliminate Status Quo Brokers (00:56:18) The Ideal Plan Sponsor: Proactive vs. Reactive (00:58:54) Shifting the CFO Mindset & Unlocking the Bottom Line (01:04:01) Big Picture: The Breaking Point of Employer-Sponsored Care (01:06:40) Closing ThoughtsKey Links for Social:@SelfFunded on YouTube - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

In this episode of the PBM Reform Podcast, host Greg Reybold, Vice President and General Counsel at APCI, welcomes Josh Golden, Senior Vice President of Strategy at Judi Health and a nationally recognized voice in Pharmacy Benefit Manager reform. With more than 20 years of healthcare consulting experience, Golden brings deep expertise in vendor procurement, contract negotiation, plan design, and benefit strategy for large employers, government entities, and unions. Together, Reybold and Golden examine the financial models behind today's PBM industry and why true transparency remains so difficult for employers, plan sponsors, patients, and pharmacies. The conversation explores how current PBM arrangements often benefit the PBMs more than the employers paying for coverage or the patients relying on their prescription benefits. Golden explains why auditing PBM contracts, rebate structures, spread pricing, administrative fees, pharmacy networks, and formulary decisions is essential to understanding the real economics of prescription drug benefits. This episode also addresses a growing concern in healthcare: PBM steering behavior. Are patients being quietly pushed toward specific formularies, specific pharmacies, and restricted networks that operate like closed networks without being clearly disclosed? Reybold and Golden discuss how this behavior can limit patient choice, disadvantage independent pharmacies, and distort the stated goal of lowering drug costs. The discussion also tackles the role of federal reform efforts, including whether the Appropriations Act represents meaningful PBM accountability or whether it risks becoming another layer in the broader shell game surrounding PBM reform. Finally, the episode asks one of the most important questions in pharmacy policy today: should PBMs own pharmacies? If vertical integration is promoted as a way to lower drug costs, where is the proof — and who actually benefits? Transparency, Auditing, and the PBM Shell Game | PBM Reform

Unlock the secrets of photobiomodulation and discover how red and near-infrared light therapy can supercharge your brain health, enhance athletic performance, and protect against cognitive decline! In this groundbreaking episode of the NASM “Master Instructor Roundtable,” Dr. Lew Lim—founder and CEO of Vielight and a pioneer in the field—joins hosts Wendy Batts, and Marty Miller, to break down the science, protocols, and real-world results athletes and active people are using now.

In this episode of the PBM Reform Podcast, host Greg Reybold, Vice President and General Counsel at APCI, welcomes Josh Golden, Senior Vice President of Strategy at Judi Health and a nationally recognized voice in Pharmacy Benefit Manager reform. With more than 20 years of healthcare consulting experience, Golden brings deep expertise in vendor procurement, contract negotiation, plan design, and benefit strategy for large employers, government entities, and unions. Together, Reybold and Golden examine the financial models behind today's PBM industry and why true transparency remains so difficult for employers, plan sponsors, patients, and pharmacies. The conversation explores how current PBM arrangements often benefit the PBMs more than the employers paying for coverage or the patients relying on their prescription benefits. Golden explains why auditing PBM contracts, rebate structures, spread pricing, administrative fees, pharmacy networks, and formulary decisions is essential to understanding the real economics of prescription drug benefits. This episode also addresses a growing concern in healthcare: PBM steering behavior. Are patients being quietly pushed toward specific formularies, specific pharmacies, and restricted networks that operate like closed networks without being clearly disclosed? Reybold and Golden discuss how this behavior can limit patient choice, disadvantage independent pharmacies, and distort the stated goal of lowering drug costs. The discussion also tackles the role of federal reform efforts, including whether the Appropriations Act represents meaningful PBM accountability or whether it risks becoming another layer in the broader shell game surrounding PBM reform. Finally, the episode asks one of the most important questions in pharmacy policy today: should PBMs own pharmacies? If vertical integration is promoted as a way to lower drug costs, where is the proof — and who actually benefits? Transparency, Auditing, and the PBM Shell Game | PBM Reform Josh Golden is the Senior Vice President of Strategy at Judi Health (a prominent healthcare technology and benefit management firm closely associated with Capital Rx) and a nationally recognized thought leader in Pharmacy Benefit Manager (PBM) reform. With over 20 years of healthcare consulting experience, Golden specializes in vendor procurement, contract negotiation, and plan design consultation for large employers, government entities, and unions.

On this episode of the Counter Talk™ Podcast, host Jason Callori sits down with Bryan Lowe, Director of Government Relations at Cardinal Health, for a deep dive into the political landscape of 2026. As state legislators begin a new legislative session, Jason and Bryan dive into state-level priorities, anticipated challenges and the key issues already dominating the agenda, including PBM reform, state budgets, and evolving scope of practice discussions.   Tune in for essential insights into the legislative year ahead!

On this episode of the Counter Talk™ Podcast, host Jason Callori sits down with Bryan Lowe, Director of Government Relations at Cardinal Health, for a deep dive into the political landscape of 2026. As state legislators begin a new legislative session, Jason and Bryan dive into state-level priorities, anticipated challenges and the key issues already dominating the agenda, including PBM reform, state budgets, and evolving scope of practice discussions.   Tune in for essential insights into the legislative year ahead!

On this episode of This Week in Pharmacy, we examine two major forces reshaping the profession: the unfinished business of pharmacist provider status and the legal landscape around direct-to-consumer pharmaceutical distribution. In part one, Erik Abel, PharmD, MBA, discusses his May 2026 analysis, “So Pharmacists Want to Be a Provider: Where the Profession Lost Its Way and Perhaps a Path to Get Back.” Abel argues that pharmacy's provider-status challenge is not a lack of clinical evidence, but a lack of operational infrastructure: credentialing, payer contracting, revenue cycle management, interoperability, and scalable business models. In part two, Darshan Kulkarni, PharmD, Esq., joins the show to discuss direct-to-consumer pharmaceutical distribution, legal risk, regulatory scrutiny, telehealth-linked prescribing, manufacturer strategy, and what pharmacists need to understand as drug distribution moves closer to the patient. This week in pharmacy news, Pittsburgh-area pharmacies continue to face uneven access to Adderall and other ADHD medications, years after the FDA first identified shortages in 2022. Patients are still calling multiple pharmacies, switching medications, rationing doses, or going without treatment as availability varies by dosage, formulation, manufacturer, and wholesaler. Pharmacists are also using medication therapy management to protect older adults from preventable medication-related harm. MTM reviews can identify risky prescriptions and OTC products, including diphenhydramine, duplicate therapies, drug interactions, and long-term proton pump inhibitor use that may need reassessment. In 340B news, CVS Health is facing federal lawsuits from major health systems alleging CVS Specialty and WellPartner improperly retained approximately $250 million in savings that should have gone back to covered entities. The litigation adds pressure to debates over PBM integration, contract pharmacy arrangements, and 340B transparency. On Capitol Hill, lawmakers are pressing the Department of Defense to commit to annual audits of the TRICARE pharmacy contract as concerns continue around PBM conflicts of interest, reimbursement practices, network adequacy, and access for independent and community pharmacies.

I wanted to talk to a lawyer 'cause, yeah, lawyers are the ones that see stuff that falls the whole way down to the level of legal action. But I wanted to find out what are the main categories of things that wind up in legal land when it comes to broker or EBC (employee benefit consultant) payment agreements. Like, what are the top ways that compensation agreements go horribly awry? For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Doug Aldeen, my guest today, rose to the challenge. And let me just state for the record that, while there are a whole lot of brokers and EBCs who would or do engage in some of these practices, there are also many who do not; and/or it might not be the broker/EBC themselves but the company that they work for who is up to some of the things that we're gonna be talking about in the episode today. But I really, for sure, want to support the gang of honest actors, great fee-based, integrity-based brokers and EBCs; and I wanna support them all day long, many of whom listen to the show and are part of the Relentless Health Value Tribe. But let's talk about how the rent-seeking ones roll so that you can spot them. See what they did there. So, yeah … the first kind of ground zero that Doug and I talk about today is just up-front direct compensation agreements, which may be just ridiculously complicated and/or ridiculously expensive compared to what others are charging for a similar group. Where there's mystery, there is margin. That is so relevant in so many situations, and this is just another one of them. So then, after that, Doug and I move on; and we get into three categories of stuff that sits in that undisclosed or maybe even disclosed zone, where just the whole model of payments is problematic on its face. First up (and this is a biggie), brokers/EBCs recommending rent-seeking solutions to their clients. Like, a broker or EBC suggests a solution to their client where the solution itself makes money on a perverse incentive, and then the broker or EBC gets a piece of that action, which might be called shared savings. So, yeah … even if the dollars to the broker or EBC are disclosed, a naive plan administrator might not see that overcharge for what it really is—and Doug gives a bunch of examples in the show that follows. Chris Deacon (post) and Justin Leader (post) also wrote posts about this. Donovan Pyle wrote a whole book about it. Okay … the next big category of typical payment model methodologies that Doug Aldeen (again, a lawyer) has seen plans get themselves into trouble with their EBCs and brokers—the ones who are sharks, I mean, circling the plan like it's a gold mine—this big category is undisclosed payments from vendors who the plan doesn't realize have a business relationship with the EBC or broker. This can also be a whole basket of solutions that the EBC/broker wants to install, which is basically this problematic payment model at scale. And, right, this matters because then the plan doesn't know if this particular point solution, PBM, stop-loss carrier … Right? They think their broker EBC is recommending it because it's the best option for that particular plan, not understanding that it's the right option for the broker or EBC. And these dollars can be undisclosed because, to a certain extent, the Consolidated Appropriations Act, it's a little bit unclear on certain points. There's some loopholes if you go looking for them because you are so inclined. We get into more detail on this later on. After this, Doug offers a really great roadmap with six steps in it for any plan to really think about as they consider. First, the maybe integrity of their broker or EBC and what is being recommended to the plan. And that's important because, look—and we say this in the conversation that follows, but I'm gonna say it again here loudly—if a plan realizes that their broker or EBC is not really serving the best interest of the plan, there are great options out there. There are great EBCs and brokers who are honest, upstanding that really care about their clients, their plans, their members, and doing the right thing. But telling the difference between the not-so-good ones and the good ones takes some diligence, takes some validation on the part of the plan sponsor. It just does. But the amount of dollars that can be saved is millions, and this is actually, saving those millions is actually better for the plan because it's not like those dollars were going in somebody's pocket. It's not like they were being put toward better, safer, lower premiums. These are dollars that can be cut, and the plan is actually better. My guest today, as I have mentioned at least several times already, is Doug Aldeen, who is a well-known attorney who has spent many years in the self-insured space. This podcast is sponsored by Aventria Health Group, and I do want to give a shout-out and a thanks to our 2026 series underwriter Payerset. Thank you so much for your financial support. That helps keep this podcast on the air. And with that, here is my conversation with Doug Aldeen. Also mentioned in this episode are Chris Deacon, Justin Leader, Donovan Pyle, Mark Cuban, Cost Plus Drugs, Aventria Health Group, Payerset, Cynthia Fisher, Lee Lewis, AJ Loiacono, Dave Chase, Nautilus Health, 32BJ, Andreas Mang, Jon Camire, and Tom Nash. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.   You can learn more on Doug's Web site and by following Doug on LinkedIn.   Doug Aldeen is an Austin, Texas–based Employee Retirement Income Security Act (ERISA) healthcare attorney. From 1997 to 2006, he served both as associate general counsel and general counsel for provider-sponsored HMOs in Champaign-Urbana, Illinois, and San Antonio, Texas. During his tenure at Health Alliance Medical Plans in Urbana, Illinois, he had a front-row seat to the US Supreme Court ERISA case in Pegram v. Herdrich. Since 2007, Doug has owned and operated his own law firm that serves the US self-funded market. In 2016, he served as ERISA counsel for the Berkley Research Group, who served as an advisor to the private equity firm Hellman and Friedman that purchased a majority stake in MultiPlan for $7.5 billion. From 2019 to 2024, Doug served on the government relations committee for the Self-Insurance Institute of America during the period when the Consolidated Appropriations Act was being implemented. In 2022, Doug was featured by KXAN television in Austin in an investigative piece that examined the collection practices of a local hospital. KXAN's investigative work resulted in an Edward Murrow award for public service. For the past 10 years, he has published "The Sunday Morning Bathroom Read" on LinkedIn, which features a weekly tongue-in-cheek review of recent events and the implications to the self-funded market in the US healthcare industry. 00:00 Introduction to this episode. 00:59 A caveat for the record on this episode. 02:11 The first problematic payment model discussed in this week's episode. 03:27 The second problematic payment model discussed in this week's episode. 06:16 The conversation with Doug Aldeen. 06:27 Why is reviewing broker/EBC compensation so important? 08:05 The Ohio Potato Company anecdote. 10:28 The first way brokers/EBCs might get paid. 11:45 What "cost of savings" means. 12:31 EP457 with Cynthia Fisher. 14:07 A rent-seeking solution that requires a cost-benefit analysis. 19:16 Why the broker/EBC is sometimes in the dark about vendor kickbacks. 21:46 Where the CAA is unclear. 22:23 EP508 with Lee Lewis. 22:58 EP379 with AJ Loiacono. 24:04 Actionable advice for plan sponsors. 24:57 The second piece of actionable advice for plan sponsors. 25:22 The third piece of actionable advice for plan sponsors. 26:08 Demystifying the commission structure. 27:35 Using a broker RFP from an open source. 27:54 EP484 with Dave Chase. 28:31 Why you should be auditing data and claims. 29:29 EP478 (Part 1) and EP479 (Part 2) with Andreas Mang and Jon Camire. 31:29 The importance of having an "out." 33:11 Why the broker community may be at substantial risk. 35:30 EP419 with Andreas Mang. Recent past interviews: Click a guest's name for their latest RHV episode! Dr Siva and Dr Monica Lypson, Betsy Seals, Patrick Nelli, Lee Lewis, Stacey Richter with 15 experts (EP507), Jerry DiMaso, Dr Ahilan Sivaganesan, Ryan Jacobs  

Thank you for listening to Bawk Tawk, Welcome to Chickenlandia's 100% Friendly Backyard Chickens Show! In this episode, we talk about feather picking, rooster damage, and much more. Hope you love it! Become a more confident chicken keeper with my new online course: Backyard Chickens 101 - A Chicken Course for Everyone. Click here for more.Order my book Let's All Keep Chickens! here.Join my mailing list and become part of Chickenlandia NationCheck out My Favorite Chicken for my favorite supplement DAILY HEN HEALTH plus all your other chicken needs! Use the coupon code “chickenlandia10” for 10% off your first order!Check out Small Pet Select and use the promo code SPSFLOCK15 for 15% off!Do you love my glasses? Check out CAVIAR EYEWEAR here and find your local dealer here

In this episode, we interview Stephen Ubl, President and CEO of PhRMA, to discuss what is happening across the industry at a time of significant change. We talk about biopharma’s continued commitment to innovation, what member companies are doing to help patients access medicines more directly, and how new tools from the organization are supporting patient affordability. We also cover the impact of policies like the IRA and MFN, along with the growing focus on PBM reform and other structural challenges in the system. It is a wide-ranging conversation about where the industry is headed and what it will take to ensure the country continues to lead the world in bringing new treatments to patients in need. Steve Ubl, CEO of PhRMA PhRMA PhRMA Leadership Transition PhRMA 3 Announcements Medicine Assistance Tool (MAT) America’s Medicines Jim Collins, Building Companies to Last FTC Settlement with Express Scripts IQVIA Data: Prior Authorization and Associated Delays and Denials of Branded Medication Dispensation Most Favored Nation Drug Pricing 340B Drug Pricing Program New York Times: How a Hospital Chain Used a Poor Neighborhood to Turn Huge Profits Hatch-Waxman Act Questions or comments?Email us at comments@prescriptionforbetteraccess.com.Find us on social media! Follow us on X, LinkedIn, YouTube and Threads.

NCPA President Kristen Riddle joins host Sam Manas at the halfway point of her presidency to reflect on a whirlwind year. She shares highlights from Capitol Hill meetings and visits to member pharmacies across the country, celebrates the landmark PBM reform signed into law this year, and offers a glimpse into how she balances it all with running her own pharmacy in Arkansas. Plus, a preview of what's to come in the rest of her term.

We bring compliance specialist Carol Taylor back to unpack why employers keep getting blindsided by benefit plan obligations like RXDC reporting, PBM disclosures, and fiduciary duties under ERISA. We map the real-world risks, the paperwork traps that cause rejected filings, and the simple audit habits that keep penalties from stacking up. • RXDC reporting basics and why it exists • why employers still miss RXDC years later • where legal responsibility lands even when vendors file • practical steps for HIOS access and employer uploads • CAA 2026 expansion of PBM disclosure and rebate rules • what PBM transparency can reveal about pricing and compensation • ERISA fiduciary exposure for employers and individual decision-makers • how advisors draw boundaries to avoid functional fiduciary status • renewed ACA employer mandate enforcement around 1094 and 1095 filings • why a mental health parity enforcement pause does not remove MAPEA duties • ongoing No Surprises Act IDR problems and cost impacts • using a compliance audit checklist and reviewing E&O coverage limits 

In this episode of IM: Unfiltered, Lindy Tentinger (President, VGM & Associates) and Ike Isaacson (SVP of Government & Regulatory Relations, VGM Group) sit down with Joel Gallion, CEO of Bellevue Healthcare in Washington, for a candid conversation about the urgency of advocacy in the home health and DME industry.They unpack the real risks behind new payer and TPA models reshaping care delivery — from sole sourcing and network restrictions to the erosion of quality and competition — drawing a stark parallel to what the PBM model did to independent pharmacies.Joel shares how Bellevue Healthcare went from advocacy bystanders to active champions of change through their state association PAMES, and why he believes the time to act is now, not tomorrow. Whether you're a large supplier or a small independent provider, this episode is a call to step up, get involved, and own your role in shaping the future of the industry.Watch on YouTube: https://youtu.be/6TTJ4e7ch5g

**In this episode, I explain why rapid growth in a PBM-heavy pharmacy actually triggers serious cash flow problems, how the timing gap between paying your wholesaler and getting reimbursed by PBMs creates a financial squeeze, and what you can do to offset it.** **Show Notes:** 1. **Introduction** [0:00] 2. **Cash Flow Challenges in Pharmacies** [0:10] 3. **Impact of Rapid Growth on Cash Flow** [2:45] 4. **Strategies to Mitigate Cash Flow Issues** [3:54] 5. **Financial Consequences of Pharmacy Growth** [6:19] 6. **Controlling Your Pharmacy Cash Flow** [7:17] **Links mentioned in this episode:** Join our DiversifyRx Facebook Group for FREE: https://www.facebook.com/groups/diversifyrx/   ----- #### **Becoming a Badass Pharmacy Owner Podcast is a Proud to be Apart of the Pharmacy Podcast Network**

I came up with at least one way to tell the difference between making a fair profit and profiteering. If someone makes more money when the patients or members they serve are worse off, yeah, call that profiteering. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. For more on what is fair profit versus what is profiteering, I would recommend you go back and listen to the episodes on mission and margin with Ben Schwartz, MD, MBA (EP481) and then with Mick Connors, MD (EP495). But it's probably not an accident that I have started an episode about Medicare Advantage in this fashion. To this end, I am very much looking forward to hearing what's up with Medicare Advantage from the one and only Betsy Seals, who is back for her third appearance on Relentless Health Value. And her advice in a nutshell is this: Don't profiteer. There are ample ways to make a fair profit. Just go back to basics and do it the right way. I wanna kind of tick through the list of things that I think about when I think about Medicare Advantage and just how it is relevant to absolutely everybody. The first thing I think about when I think about Medicare Advantage—and this is very obvious—is what Medicare Advantage plans do or don't do are our tax dollars at work or not at work, as the case may be. Along these same lines, the second thing: How does this impact our elders, our family, our friends, our grandparents? These are our senior citizens, getting the care or not getting the care that they may need. Those two are obvious. Now let's talk about a few less obvious things. Here's the third point that I think about as I listen to conversations about Medicare Advantage: cost shifting. Right? It is a well-known fact how big, vertically integrated carriers—and when I say big, vertically integrated carriers, I mean ones that have a Medicare Advantage line of business—when negotiating with big, consolidated health systems, the release valve of those negotiations is commercial rates. These are the rates that the self-insured employers are paying. So, the carrier says, "Look, gimme the best Medicare Advantage rates. I want the best Medicare Advantage rates because I, the carrier, am paying for those." Savings from those lower rates accrues to the Medicare Advantage plan and its shareholders or investors or executives, right? So, the carrier with the Medicare Advantage plan is like, "Look, go as low as we can go on the Medicare Advantage rates, but it's okay, health system, if you make up the difference with the ASO commercial book of business." Because right … ASO means administrative services only. It's not the carrier who's paying those commercial rates at the end of the day. So, the carrier uses its full book of business to negotiate lower rates for itself while, at the same time, cost shifting to commercial members. In fact, there was some research that was cited. It was episode 436 with Elizabeth Mitchell, and I quoted Luke Prettol. But there was research that puts this markup at 4.7% above what employers would otherwise pay if they had an ASO that did not have a Medicare Advantage Plan. So, yeah … number three big thing that I think about when listening to MA insights like the ones that Betsy drops today, I think about will this accelerate or ameliorate or really have anything to do with what is going on around those negotiating tables with ASOs and health systems? Because let's not forget, health systems account for about 50% of most self-insured employers' total health spend. The fourth thing that I think about: Will MA carriers underpay independent practices, especially primary care practices? Will it pay indies less? And then if it pays 'em a lot less, would ultimately manage to put them out of business, ultimately raising the total cost of care for everybody. But if we're thinking about this strictly from Medicare Advantage financial perspective, a really great move here, these are big, vertically integrated companies, don't forget. Many of them own provider organizations. This is why the FTC tends to frown on vertical integration. So, will these Medicare Advantage organizations who own provider organizations pay the provider organizations they own more? By the way, it's the same thing that's going on on the pharmacy side of the house when a PBM pays pharmacies that they own more. Here's a LinkedIn post by Stanley Warren about this topic. And there are a lot of obvious, maybe less obvious reasons for why paying providers the carrier itself owns more is a great short-term move. One of them is intracompany eliminations. Listen to the episode with Preston Alexander (EP482). But here's another reason: Rate increases paid by the government for Medicare Advantage plans are based on fee-for-service benchmarks. So, if fee-for-service rates go up, then the Medicare Advantage plans can negotiate more money for themselves. If the MA plans own the providers that are charging said FFS rates, then this is, I don't know, a great strategy, especially given the lobbying budget that some of these entities have. So, look … on today's show, I get the distinct opportunity to speak with Betsy Seals, my guest today, as I mentioned earlier; and we go through her advice for MA plans and what they need to get busy with and ensure, make a fair profit, go back to basics, and do it the right way. That's her bottom-line advice. Don't be putting your hands in the cookie jar. Sooner or later, you're gonna get caught. Focus on the members that you're really good at serving. And lastly, when it comes to STARS or other quality measures, lift them the right way—like, actually through better member health and actually better member experience, not some engineered mechanism by which one can check a box that honestly doesn't deserve to get checked. Because now we're back to the beginning and you're gonna get caught with your hand in the cookie jar, and it's profiteering. Let's just get real about that. If somebody's checking boxes that they don't deserve to check, member health is not improving. Betsy Seals, my guest today, as I have said at least three times, co-founded Rebellis Group, which is a Medicare Advantage consultancy. She became CEO of its parent company, Alerion Advisors. Now she is a board member, and also she works with start-ups in our industry. This podcast is sponsored by Aventria Health Group with an assist today from Payerset to help us with the financial support that we need to stay on the air. And with that, here is my conversation with Betsy Seals. Also mentioned in this episode are Alerion Advisors; Rebellis Group; Benjamin Schwartz, MD, MBA; Mick Connors, MD; Elizabeth Mitchell; Luke Prettol; Luke Trocchio; LoVasco; Stanley Warren; Preston Alexander; Aventria Health Group; Payerset; Eric Bricker, MD; Scott Conard, MD; Bob Herman; and Vivian Ho, PhD. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.   You can learn more by visiting the Rebellis Group blog and by connecting with Betsy on LinkedIn. You can also email her at bseals@rebellisgroup.com.     Betsy Seals is the co-founder of Rebellis Group, former CEO of Rebellis Group and Alerion Advisors, and a current board member of the Alerion Advisors family of companies. With over 25 years of experience across Medicare and Medicaid programs, Betsy is a nationally recognized leader known for her regulatory expertise, strategic vision, and ability to deliver measurable results. Betsy's work spans mergers and acquisitions, compliance, enterprise strategy, sales and marketing, supplemental benefits, and innovative benefit design that optimizes health plan performance and improves health outcomes. Betsy brings a strong blend of executive leadership, business acumen, and deep regulatory knowledge, with a focus on driving operational excellence and meaningful member impact.   00:00 Introduction to this episode. 00:43 Past episodes on profiteering: EP481 with Benjamin Schwartz, MD, MBA, and EP495 with Mick Connors, MD. 01:25 How Medicare Advantage is relevant to everyone. 06:15 A preview of today's conversation. 07:49 The "state of the state" of Medicare Advantage plans. 08:49 Video by Eric Bricker, MD, on the financial performance of the U.S. healthcare system. 09:32 Does Medicare Advantage's losses matter to the patients? 10:29 A recap of Betsy's insights so far. 11:19 The underlying strategic through line that needs to be considered. 13:04 The impact of Goodhart's Law. 14:12 What the players that are succeeding right now are doing. 14:22 The first pillar of a back-to-basics strategy: Don't get caught with your hand in the cookie jar. 16:07 EP463 with Betsy Seals. 16:50 Why short-term strategies don't work. 18:26 Stats report on prior authorizations serving the beneficiary. 19:32 EP482 with Preston Alexander. 19:38 Why prior authorization needs change. 21:28 The better strategy to use. 21:43 EP462 with Scott Conard, MD. 23:17 The second pillar of a back-to-basics strategy: Focus on the beneficiaries you actually serve well. 24:37 What it looks like to implement this focus on the beneficiaries you serve well. 25:29 How special needs plans play into this. 27:43 The third pillar of a back-to-basics strategy: Think about how STARS in clinical programs improve health. 30:04 The ethical component to implementing a Medicare Advantage program. 31:04 Betsy's advice for independent practices dealing with prior authorizations. 33:37 STAT article by Bob Herman about the effectiveness of Medicare Advantage lobbying on policy. 34:08 Betsy's final notes for all players impacted by what's currently happening.   @betsyseals discusses the impact of #medicareadvantage news on our #healthcarepodcast. #healthcare #podcast #financialhealth #commercialpayermarketplace #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Patrick Nelli; Lee Lewis; Stacey Richter with 15 experts (EP507); Jerry DiMaso; Dr Ahilan Sivaganesan; Ryan Jacobs; Stacey Richter (INBW46); Ryan Wells, Dr Leo Spector, and Adam Stavisky  

Near-Infrared Light Therapy After Stroke: Does the Science Hold Up? A viewer reached out recently with a question I have been getting more frequently: Does near infrared light therapy actually help the brain recover after stroke? It is a fair question — the claims circulating online range from cautiously promising to outright extraordinary. In this post, I am going to cut through the noise and look at what the peer-reviewed research actually shows. What is Near-Infrared Light Therapy? Near infrared (NIR) light therapy — also called photobiomodulation (PBM) or transcranial photobiomodulation (tPBM) when applied to the head — uses specific wavelengths of light (typically 630-1100 nm) to penetrate tissue and interact with cells at a biological level. This is not a tanning lamp or a heat lamp. The mechanism is specific: NIR light at the right wavelengths is absorbed by cytochrome c oxidase, a key enzyme in mitochondrial energy production. When stimulated, cytochrome c oxidase increases ATP synthesis — essentially giving cells more energy to carry out repair and function. For neurons recovering from ischaemic or haemorrhagic stroke, the theory is compelling: damaged brain cells that are energy-starved might benefit from an additional energy stimulus. The Mechanism: What the Biology Says The cytochrome c oxidase pathway is well-established in photobiology. What is less settled is whether light at therapeutic intensities can penetrate the skull deeply enough to reach relevant brain structures. Skull and scalp tissue absorb and scatter light substantially. Transcranial delivery requires sufficient power density (irradiance) at the source and long enough exposure to accumulate meaningful fluence (energy dose) at depth. Studies using ex vivo human skull specimens suggest that only 1-3% of surface irradiance reaches cortical tissue at clinically relevant depths — and deeper subcortical structures receive even less. This does not make tPBM ineffective — it means dosing is everything. And most consumer devices do not disclose their irradiance or fluence specifications, which makes comparing them to clinical trials nearly impossible. What the Research Shows Animal Studies: Encouraging Signals Several well-designed rodent studies have demonstrated that tPBM applied within hours to days of stroke onset reduces infarct volume, improves functional recovery, and modulates neuroinflammation. A 2019 study by Thunshelle et al. found tPBM reduced lesion size in ischaemic stroke models and improved neurobehavioural scores. Animal models are useful for mechanistic insights. However, rodent skulls are thinner and brain structures are more superficial than in humans — so translational accuracy is limited. Human Clinical Trials: More Complicated The human evidence is where the story becomes nuanced. The NeuroThera Effectiveness and Safety Trial (NEST-1 and NEST-2) were the most prominent early RCTs. NEST-1 (2007) reported positive outcomes for acute ischaemic stroke patients treated within 24 hours. However, NEST-2 (2009), a larger double-blind RCT with 660 patients, failed to replicate those results on its primary outcome measure. NEST-3 was halted early in 2013 after an interim analysis showed it was unlikely to meet its primary endpoint. What went wrong? Researchers identified several issues: heterogeneous stroke populations, inconsistent dosing protocols, and the fundamental challenge of transcranial light delivery in adults with varying skull thickness and tissue composition. More recent work has shifted focus. A 2023 review by Zomorrodi et al. examined pulsed tPBM and found preliminary evidence for cognitive and neurological benefits in traumatic brain injury and neurodegeneration — but noted the absence of large, well-powered RCTs in stroke specifically. The Consumer Device Problem Here is where I have to be direct with anyone considering purchasing a NIR device for home use. Clinical studies use medical-grade devices with precisely calibrated irradiance, typically 10-700 mW/cm2 at the source, with controlled exposure times to achieve specific fluence targets (often 0.9-36 J/cm2). Consumer devices vary enormously — and most do not publish their specifications at all. Buying a NIR cap or helmet marketed for brain wellness is not equivalent to receiving the protocol used in clinical research. This does not mean it is harmful. It means we do not know whether you are getting a therapeutic dose, a sub-therapeutic dose, or anything in between. The Stakes If you are in recovery from a stroke or brain injury and you are exploring every option — which I completely understand — the risk here is not primarily financial. The risk is investing hope, time, and energy into something that may or may not be delivering what clinical trials suggest is therapeutic. The opportunity, on the other hand, is real: the underlying biology is sound, and the research pipeline is active. This is an area worth watching closely. Three Actionable Steps Talk to your neurologist or rehab physician before purchasing any device. Ask specifically whether tPBM has been considered in your care plan and what the current clinical guidance is. If you want to explore the evidence yourself, search PubMed (pubmed.ncbi.nlm.nih.gov) for transcranial photobiomodulation stroke — filter for systematic reviews and RCTs published after 2018 for the most current picture. Check ClinicalTrials.gov (clinicaltrials.gov) for active trials recruiting stroke survivors for tPBM studies. Participation in a trial gives you access to a properly calibrated protocol and contributes to the evidence base. What Recovery Can Look Like When the brain is given the right conditions — adequate sleep, nutrition, rehabilitation, reduced inflammation, and potentially adjunct therapies that the evidence supports — healing happens in ways that can surprise both patients and clinicians. I have spoken with hundreds of stroke survivors on this channel who found approaches that contributed meaningfully to their recovery. Not a single one found a shortcut. But many found tools — used thoughtfully, in partnership with their medical team — that made a genuine difference. That is what this channel is about: doing the work so you can make informed decisions. References Lampl Y et al. Infrared laser therapy for ischemic stroke: a new treatment strategy. Stroke. 2007;38(6):1843-9. PMID: 17463313. pubmed.ncbi.nlm.nih.gov/17463313 Zivin JA et al. Effectiveness and Safety of Transcranial Laser Therapy for Acute Ischemic Stroke (NEST-2). Stroke. 2009;40(4):1359-64. PMID: 19233936. pubmed.ncbi.nlm.nih.gov/19233936 Thunshelle C, Hamblin MR. Transcranial Low-Level Laser (Light) Therapy for Brain Injury. Photomed Laser Surg. 2016;34(12):587-598. PMID: 27854434. pubmed.ncbi.nlm.nih.gov/27854434 Zomorrodi R et al. Pulsed Near Infrared Transcranial and Intranasal Photobiomodulation Significantly Modulates Neural Oscillations. Sci Rep. 2019;9(1):6309. PMID: 31004089. pubmed.ncbi.nlm.nih.gov/31004089 Bill Gasiamis is a stroke survivor and the host of the Recovery After Stroke podcast. He is not a medical professional. Nothing in this post constitutes medical advice. Always consult your treating physician before starting any new therapy. The post Near-Infrared Light Therapy After Stroke: Does the Science Hold Up? appeared first on Recovery After Stroke.

Julie Selesnick, Executive Director of Legal and Compliance at Judi Group, joins the Astonishing Healthcare podcast for an in-depth discussion on the Department of Labor's proposed rules aimed at enhancing PBM transparency. Julie shares the highlights of Judi Group's submitted comments and explains how the Department could help reshape the healthcare landscape, improve fiduciary practices, and drive systemic change in the pharmacy benefits ecosystem - but it shouldn't stop there.Julie dives into the arguments for and against the proposed rules, highlighting the importance of transparency in PBM compensation and the need for plan sponsors to understand the true costs associated with their health plans. She also discusses the potential impact of these regulations on reporting, which should get easier over time, and the medical side of drug spending, which is projected to outpace PBM-side drug spending in the near future. Julie's expertise and passion for improving fiduciary management make this episode a must-listen for anyone navigating the evolving worlds of healthcare policy and benefits.HighlightsJulie explains why the DOL's proposed rules are a critical step toward improving PBM transparency and enabling plan sponsors to make informed decisions.She emphasizes the need for clear disclosures on rebates, clawbacks, and indirect compensation to help plans verify reasonable compensation and minimize litigation risks.The discussion explores the growing importance of addressing medical-side drug spending, which could surpass PBM-side spending within the next five years.Julie shares insights on how machine-readable file disclosures could simplify compliance and create pricing benchmarks, enabling plan sponsors to evaluate whether costs are reasonable.State laws, the CAA 2026, these DOL proposed rules, and the recent FTC settlements all reinforce one another.Related Content & ResourcesFact Sheet: Proposed Pharmacy Benefit Manager Fee Disclosure RuleJudi Health Partner Summit Highlights: Progress is Impossible to IgnoreAH102 - PBM Reform Update: Health Policy Changes Slowly, Until it Doesn't, with Lloyd FioriniClick HERE for more information on Judi Group.Get in touch with Julie on LinkedIn.For more information about this episode, please visit Judi Health - Insights.

Tennessee lawmakers have passed a major pharmacy reform bill aimed at pharmacy benefit managers, or PBMs, by barring companies from owning both a PBM and a pharmacy. The legislation is widely seen as targeting CVS Health, which owns Caremark and operates pharmacies across the state. Supporters say the bill is designed to curb vertical integration, restore fair competition, and protect independent pharmacies from reimbursement practices they view as harmful to patient access and community pharmacy survival. CVS has pushed back hard, warning that the new law could force it to shut down its 134 Tennessee pharmacy locations and trigger a legal challenge. The company argues the measure would reduce access for patients and does not directly address broader PBM issues like pricing or formularies. This Tennessee fight reflects a larger national battle over PBM reform, pharmacy ownership, market power, and the future of prescription drug access.  

Joseph Kleiman, President of Buzz Health, is working to improve price transparency and affordability of prescription drugs. He states that providing price transparency as early as possible in the prescription process is critical for prescribers, patients, and health plans to make better, more cost-effective decisions. To achieve true transparency, all parties in the ecosystem must cooperate and share data, moving beyond pricing visibility to fully integrate systems and use real-time information to improve patient adherence and lower costs. Joseph explains, "Buzz Health really focuses on improving the process behind the scenes, developing technologies that sit within the prescription ecosystem, creating opportunities to improve price transparency, early adoption, and integrated benefits for members."  "We work with everybody from pharmacies to PBMs to payers to employer groups. Anybody we believe has an opportunity that, with technology and early adoption of price transparency and adherence, could benefit them and the members they serve." "What's interesting is that, like most things, the earlier you have information, the easier it is to make actionable change, things with long-term impact. So if you have price transparency and you have it early on, a prescriber can make more informed decisions. A patient, rather than showing up at a pharmacy counter, can make decisions earlier on. So again, it's kind of like the earlier you have anything in making a decision, the easier it is for you to make a really actionable change all the way up through a PBM or health plan. If they see gaps in coverage and they have that information, they can make changes early on as well." #BuzzHealth #PrescriptionDrugs #Pharmacies #HealthcareIT #PriceTransparency #PrescriptionAffordability #PharmacyTech #MedicationAccess #HealthcareTransparency #PrescriptionPricing #PatientCare #HealthTech #PharmacyBenefits #HealthcareInnovation #PatientOutcomes #MedicalTechnology buzzhealth.com Listen to the podcast here  

Joseph Kleiman, President of Buzz Health, is working to improve price transparency and affordability of prescription drugs. He states that providing price transparency as early as possible in the prescription process is critical for prescribers, patients, and health plans to make better, more cost-effective decisions. To achieve true transparency, all parties in the ecosystem must cooperate and share data, moving beyond pricing visibility to fully integrate systems and use real-time information to improve patient adherence and lower costs. Joseph explains, "Buzz Health really focuses on improving the process behind the scenes, developing technologies that sit within the prescription ecosystem, creating opportunities to improve price transparency, early adoption, and integrated benefits for members."  "We work with everybody from pharmacies to PBMs to payers to employer groups. Anybody we believe has an opportunity that, with technology and early adoption of price transparency and adherence, could benefit them and the members they serve." "What's interesting is that, like most things, the earlier you have information, the easier it is to make actionable change, things with long-term impact. So if you have price transparency and you have it early on, a prescriber can make more informed decisions. A patient, rather than showing up at a pharmacy counter, can make decisions earlier on. So again, it's kind of like the earlier you have anything in making a decision, the easier it is for you to make a really actionable change all the way up through a PBM or health plan. If they see gaps in coverage and they have that information, they can make changes early on as well." #BuzzHealth #PrescriptionDrugs #Pharmacies #HealthcareIT #PriceTransparency #PrescriptionAffordability #PharmacyTech #MedicationAccess #HealthcareTransparency #PrescriptionPricing #PatientCare #HealthTech #PharmacyBenefits #HealthcareInnovation #PatientOutcomes #MedicalTechnology buzzhealth.com Download the transcript here  

Episode Summary In this episode of the MedCity Pivot Podcast, host Arundhati Parmar sits down with Javier Gonzalez (Abarca Health) and Tanvi Patel (Amazon Pharmacy) to unpack one of healthcare's most frustrating processes: prior authorization. The conversation explores how outdated systems, lack of transparency, and fragmented communication are eroding patient trust and delaying care. From policy complexity and data gaps to operational risks, the guests break down why prior authorization remains such a challenge—and what it will take to modernize it at scale. They also highlight the critical role of transparency, interoperability, and consumer expectations in shaping the future of healthcare. With insights from both payer and pharmacy perspectives, this episode paints a clear vision of a more patient-centered system where access to medication is faster, clearer, and more trustworthy Links & Resources Connect with Arundhati Parmar aparmar@medcitynews.com  https://twitter.com/aparmarbb?lang=en https://medcitynews.com/ Keywords prior authorization healthcare transparency patient trust interoperability digital pharmacy healthcare innovation medication adherence health tech ePA patient experience healthcare systems PBM reform Amazon Pharmacy Abarca Health Episode Highlights 00:00–00:25 – Introduction to prior authorization challenges and patient frustration 00:01–00:49 – Overview of modernization efforts in healthcare systems 00:01:27–00:03:31 – The three core challenges: policy complexity, data quality, operational risk 00:04:11–00:04:29 – Real-life impact: delays in critical care (cancer case) 00:04:36–00:05:22 – How prior authorization erodes patient trust 00:05:59–00:07:00 – Medication adherence begins before the first dose 00:07:00–00:07:18 – 20–30% drop-off due to prior authorization failures 00:07:18–00:07:39 – Transparency as the key to patient engagement 00:08:20–00:09:45 – Benefits of electronic workflows (60–70% efficiency gains) 00:11:18–00:12:24 – What should be eliminated in a redesigned system 00:12:47–00:13:55 – Employers' role in improving benefit transparency 00:15:23–00:16:21 – Rise of modular PBM models and industry shifts 00:20:46–00:22:11 – Misaligned incentives across healthcare stakeholders 00:23:51–00:24:45 – Consumer expectations reshaping healthcare timelines 00:25:14–00:26:11 – The future: invisible, frictionless prior authorization

In this episode, we review a 2026 systematic review and meta-analysis examining the effects of photobiomodulation (PBM) on depressive symptoms. We break down the mechanisms, results, and practical clinical applications of this emerging, non-invasive therapy.Ji-Woo Seok, Kahye Kim, Jaeuk U. Kim, Jung-Dae Kim, "Effect of photobiomodulation intervention for depressive symptoms: A systematic review and meta-analysis," Journal of Affective Disorders,Volume 393, Part B, 2026, 120413, ISSN 0165-0327, https://doi.org/10.1016/j.jad.2025.120413YouTube ChannelView the many other episodes and videos available here Laser Therapy InstituteFurther Resources:Success with Laser Therapy Flowchart & Checklist InfographicCheck out these FREE Provider ResourcesRead about laser research on the LTI BlogLearn more about what we offer on the LTI websiteFind out how you can Customize your LTI experience

In this episode, Suzanne Spradley and Chase Cannon discuss two recent circuit court decisions and their impact on employer-sponsored group health plans. Suzanne first discusses a Sixth Circuit decision involving a state law that attempts to regulate PBMs. Suzanne and Chase walk through Supreme Court precedent that appears to be driving states to enact PBM laws, and they explain how ERISA preemption is at the heart of it all. Suzanne concludes the podcast by outlining another federal decision relating to a fiduciary breach claim of an employer group health plan.

On this Wellness Tech Series episode, Nurse Doza breaks down why red light therapy has become his go-to biohacking tool for mitochondrial health. He reviews the handheld LightpathLED panel he travels with — a dual-mode device combining red and blue light to regenerate cells, support skin health, and combat the effects of low solar exposure. Easy to use, easy to charge, and powerful enough to deliver results in just 10 minutes a day. Featured Partner: LightpathLED LightpathLED builds professional-grade red light therapy panels engineered for at-home and travel use — including compact handheld combo devices that deliver red (670 nm) and blue (450 nm) wavelengths in a single unit. That dual-mode technology directly addresses the two benefits Nurse Doza highlights in this episode: mitochondrial regeneration through red light and skin clarity through blue light. With the industry's densest LED count per square inch and a 5-year warranty, it's the red light panel built for people who are serious about their mitochondrial health.

Josh Golden, SVP of Strategy at Judi Health, returns to the Astonishing Healthcare podcast for a timely discussion about the world of drug pricing and what's shaking things up. Josh shares insights from his two decades of experience working with many of our country's largest employers and navigating [very heavy, sometimes scary] pharmacy benefit manager (PBM) contracts. He explains why the industry still relies on Average Wholesale Price (AWP) despite its known flaws, how Maximum Allowable Cost (MAC) lists have been used to drive hidden pricing arbitrage, and why the market is shifting so rapidly toward transparency and alignment.The discussion covers the need for plan sponsors to understand the true cost of pharmaceuticals and how four massive forces are colliding to form "lightning in a bottle" that will drive systemic change in the pharmacy ecosystem. As reforms across the state and federal levels pressure the industry to adapt, plan sponsors must seek forward-thinking PBM partners that prioritize transparent pricing and decisions that benefit the plan and lead to better care for members.HighlightsJosh emphasizes the sordid history of AWP manipulation and explains why it remains a predominant, yet deeply flawed, pricing benchmark in PBM contracts.PBMs frequently deploy MAC lists to extract hidden value, creating wide pricing variations for plan sponsors, pharmacies, and patients.The healthcare industry is moving toward cost-plus economics, making more realistic and reliable pricing benchmarks even more important.Four major trade winds are accelerating PBM reform: state regulations, retail pharmacy closures, transparent cash prices for expensive drugs like GLP-1s, and plan sponsor class action lawsuits.Related ContentWhat is NADAC & How Does It Differ From AWP?Why this benefit leader switched to a more modern, transparent PBMWhat Is the Role of a Pharmacy Benefits Manager (PBM)?Health Benefits 101: The Importance of a Transparent PBM ModelFor more information about Judi Health and this episode, please visit Judi Health - Insights.

Cost-plus pricing is gaining traction in pharmacy benefits, but how does it really compare to traditional PBM pricing? Madison and Mike cover drug pricing transparency, cost benchmarks, spread pricing and legislative changes impacting plan sponsors. Register for upcoming Employers Health webinars or watch on demand at https://www.employershealthco.com/resource-center/events/ Sign up for our monthly newsletter at https://www.employershealthco.com/#subscribe_cta Find additional helpful benefits strategies and resources at https://www.employershealthco.com/resource-center/articles/

Healthcare stays expensive because the system hides prices and quality from the people paying for care, especially employers. We talk with Katie Talento about how CAA 2026 transparency and Department of Labor fiduciary rules could expose PBM practices, reshape contracting, and give plan sponsors real leverage if enforcement follows.• Why invisible prices and invisible quality break the healthcare market • How incentives and lobbying protect opacity across hospitals, PBMs, insurers and drugmakers • Why Washington lacks ERISA and employer-plan expertise • What CAA 2026 changes for PBM disclosures and fiduciary responsibility • How “check the box” compliance can fail without enforcement • How employers can use machine readable files plus claims data for network analysis • Why cash-pay and direct contracting get blocked by network contract provisions • What near-term reforms could bend the cost curve, including stronger HSA and ICHRA modelsYou can find me at katytolento.com

PODCAST LAS NOTICIAS CON CALLE DE 13 DE ABRIL DE 2026 -  Precio del Gas Natural sube 80% en el mercado internacional - Reuters Irán amenaza que todo barco que se acerque a sus costas sin autorización recibida terribles consecuencias - NYTJusticia recomienda un FEI para Ciary por traqueteos en marbetes y centro de inspección - Jay Fonseca PR Película de Residente y Bad Bunny será en RD - El Vocero Comienzan las vistas hoy por el nuevo sistema de permisos para hacer negocios y construcciones en PR - El Nuevo Día Trump anuncia bloqueo del Estrecho de Hormuz y que sus barcos van pa Irán con bloqueo naval - Reuters Paralización de la canalización del Río Piedras vuelve a disputa y alcalde pide reconsideración a los federales - El Nuevo Día Pierde el pana de Trump en Hungría - Bloomberg Trump pelea con el Papa y le dice débil contra el crimen - Truth SocialPetróleo sube 8% - OilPriceEncubierto asesinado era policía comprando armas para denunciar la compraventa de armas, le costó la vida cuando intentaron robarle con lo que compraría armas a delincuentesVentas de autos cayeron en 20% - Noticel 8 asesinatos este weekend y llevamos 5 asesinatos más que el año pasado, entre los asesinatos, uno en baby shower - Metro Posible que cuatro congresistas sean expulsados de la Cámara, en la historia solo ha habido 6 jamás -  Axios Recuperaron fondos pagados a muertos en casi 90 millones - El Nuevo Día LUMA cuestiona a alcaldes para poner luminarias mientras PR sigue oscuro - El Nuevo Día Junta da el sí al gasoducto de San Juan a Toa Baja - El Nuevo Día Nieto asesinató a su abuelo joyero y prima médico reconocida neuróloga resulta herida en incidente de Guaynabo - El Nuevo DíaSeguirá cerrado el Hope Medical de Humacao opr lo previsible - El Nuevo Día Esperan dramáticas lluvias de hoy a miércoles por vaguada - Primera Hora Sobre 300 cadáveres en PR no se sabe de quiénes son - Primera HoraVan a subirle el sueldo a los cadetes de la policía - El Vocero Gobierno se opone a subir tarifa para fondo de reserva de la AEE - El Vocero Vuelve proyecto para regular las PBM en PR - El Vocero Controversia mayor por créditos de la película Borinqueneers - El Vocero MMM hoy voy pa Martins BBQEl mejor y más sabroso pollo asado a la varita de Puerto Rico. Cocinando diariamente comida fresca saludable y sabrosa con un montón de complementos para escoger, arroces, habichuelas, verduras, mofongo, tostones,....MMMM....Esto si es criolloMartins BBQ, TOMANDO todas las medidas de salud y sabor para mantener la mesa boricua al dia con opciones para llamar, recoger o delivery por UBER Eats, y DoorDash.MMM Hoy como en Martin's BBQAsado...Jugoso...Sabroso#martinsbbq#incluyeauspicio 

This week, Tee sits down with Lou Banas, a certified laser therapist and founder of Pain Therapy USA, to explore photobiomodulation (PBM), also known as red light therapy. This non-invasive approach uses specific wavelengths of red and near-infrared light to support the body's natural healing processes by reducing inflammation, relieving pain, and promoting tissue repair. Lou shares his journey into this field and explains why proper training and certification are critical as PBM becomes more widely available in both clinical and at-home settings. In the conversation, Lou breaks down the science behind PBM, including how light interacts with the body at a cellular level. He explains the role of mitochondrial function, particularly cytochrome c oxidase, in increasing ATP production, as well as how nitric oxide may improve circulation and reduce inflammation. He also discusses the differences between medical-grade laser devices and consumer LED products, noting how power and precision can influence results across a variety of conditions. Lou also shares clinical observations from over two decades of use, highlighting applications ranging from joint pain and sciatica to brain-related conditions such as traumatic brain injury, PTSD, and dementia. Referencing insights from Richard M. Restak, author of The Brain: The Last Frontier, the episode explores how PBM may play a role in advancing brain health and recovery. As research continues to evolve, this therapy shows growing promise as a tool for both physical healing and neurological support. Connect with Lou: Website Phone: 716-868-3968 Email: loubanaslaser@gmail.com   Follow Therese "Tee" Forton-Barnes and The Green Living Gurus: Austin Air Purifiers: For podcast listeners, take 15% off any Austin Air product; please email Tee@thegreenlivinggurus.com and mention that you want to buy a product and would like the discount. See all products here: Austin Air   The Green Living Gurus' Website  Instagram YouTube Facebook Healthy Living Group on Facebook Tip the podcaster! Support Tee and the endless information that she provides: Patreon Venmo: @Therese-Forton-Barnes last four digits of her cell are 8868 For further info, contact Tee: Email: Tee@thegreenlivinggurus.com Cell: 716-868-8868 DISCLAIMER: ALL INFORMATION PROVIDED HERE IS GENERAL GUIDANCE AND NOT MEANT TO BE USED FOR INDIVIDUAL TREATMENT. PLEASE CONTACT YOUR PROVIDER OR DOCTOR FOR MEDICAL ADVICE. Produced By: Social Chameleon

In this episode of the Vital Health Podcast, host Duane Schulthess speaks with Melanie Whittington, Managing Director and Head of the Leerink Center for Pharmacoeconomics and Senior Fellow at the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center. They examine how health economic modeling can more accurately reflect real-world market dynamics, the rising pressure behind IRA and MFN drug pricing, the risks to oncology innovation, the limits of conventional cost-effectiveness frameworks, plus the role of transparency and clearer communication of long-term value in sustaining a healthy innovation ecosystem. Key Topics Market Modeling: Hypothetical models versus real-world pricing dynamics, patent cliffs. Pricing Policy: IRA, MFN, market-based pricing scrutiny, communicating why prices are "worth it". Innovation Incentives: Private capital risk, oncology small molecules, policy-driven pipeline shifts. Value Framework Limits: QALY concerns, rule-versus-tool debates, GRACE, broader treatment impacts. Transparency and Outlook: Net price opacity, PBM negotiations, generics and biosimilars, the next innovation cycle. Opinions expressed are those of the speakers. The Leerink Center for Pharmacoeconomics is a division of MEDACorp.See omnystudio.com/listener for privacy information.

One week out from NCPA's Congressional Pharmacy Fly-In, host John Beckner sits down in the studio with NCPA Director of Congressional Affairs Kaite Krell to discuss this year's policy priorities. Krell provides insights on the ins and outs of the advocacy team's fly-in preparation and shares details on three of our five policy priorities: thanking Congress for PBM reform, Medicaid managed care reform, and the reintroduction of Patients Before Monopolies. Only a few spots remain. To register for fly-in, click here. Part two of NCPA's fly-in policy priorities will be out on Thursday, April 9.

On this episode of the Astonishing Healthcare Podcast, we sit down with return guest Bridget Mulvenna, Vice President of National Business Development at Judi Health, to break down the biggest pharmacy drivers of 2026. Bridget offers insights into how plan sponsors and benefits brokers and consultants can strategically evaluate pharmacy benefit managers (PBMs) by looking beyond unit costs and focusing on drug mix - formulary decisions and the shift to biosimilars, prior authorization approval rates, the generic dispensing rate (GDR), and much more.The discussion covers the growing need to understand what challenges employer plan sponsors face, and why bringing a consultative approach to the table to help solve them is so important. How will moving to a biosimilar-first approach lower net drug costs for plan sponsors? How can a plan cover GLP-1s given their evolution and greater price transparency, expanding clinical indications, and direct-to-plan pricing models? And of course, Bridget shares her views on the sudden acceleration of state and federal PBM reform. As new legislation forces the industry to adapt, plan sponsors must seek forward-thinking platforms already aligned with the changes to provide better pricing and care for members.HighlightsBridget emphasizes the financial advantages of adopting a biosimilar-first approach, which can significantly lower net drug costs for plan sponsors despite smaller rebate checks.GLP-1s are transformative medications - price transparency, expanding clinical indications, and direct-to-plan pricing models will influence future plan designs.Evaluating PBMs beyond unit costs is critical: formulary management, prior authorizations, and other clinical programs have the greatest impact on total pharmacy spend.The rapid acceleration of state and federal PBM reform is astonishing, and alignment with future proof organizations is essential, because there's more to come.Related Content6 recommendations for PBM procurement and Rx benefits optimizationAH102 - PBM Reform Update: Health Policy Changes Slowly, Until it Doesn't, with Lloyd FioriniReplay - PMPM vs Clinical Guarantees: A Pharmacist and an Actuary Explain How to Create Predictability Around Pharmacy SpendAH064 - Empowering Plan Sponsors: Data Access & Analysis, with Bridget MulvennaFor more information about Judi Health and this episode, please visit Judi Health - Insights.

Last year, his independent pharmacy spent $13 million on brand-name drugs for patients processed by the three biggest Pharmacy Benefit Managers (PBMs) which earned a profit margin of 0.01%.In this episode, Halle speaks with Alec Ginsberg, owner and fourth-generation pharmacist at C.O. Bigelow, the oldest surviving apothecary–pharmacy in the United States. Alec is fighting against the forces squeezing independent pharmacies and charting a course for the future of the pharmacist.We cover:How the roll-up of PBMs, health plans, and retail pharmacies changed everythingWhat led him to remove his pharmacy's Rx-filling robotThe dramatic decline of independent pharmacies along with the closures of big box pharmacy storesThe one health policy he would put in place today to save independent pharmaciesThe history of the pharmacist's role and what's nextWhat he really thinks about compounding pharmacies and the Hims vs. Novo lawsuit—About our guest: Alec Wade Ginsberg is the fourth-generation pharmacist, owner, and Chief Operating Officer of C.O. Bigelow Apothecary, America's oldest pharmacy, founded in 1838 and still operating in New York City's West Village. With a Doctor of Pharmacy degree from the University of North Carolina Eshelman School of Pharmacy, Alec bridges the clinical world of pharmacy with the realities of modern consumer culture.At Bigelow, he oversees the brick-and-mortar beauty retail and pharmacy operations, navigating everything from prescription drug shortages to the pressures of today's PBM-dominated marketplace. Beyond the counter, Alec is the founder and writer of Drugstore Cowboy, a weekly newsletter that dissects the intersection of drugs, business, and consumer culture — making the hidden mechanics of the U.S. healthcare system both understandable and entertaining for thousands of readers.His work has been featured across national media, and he's become a trusted voice for translating complex pharmaceutical issues — from GLP-1s to compounding to drug pricing — into plain English. Alec's mission is simple: to make Americans smarter about the pills in their cabinets and the system that puts them there.—Show notes:Drugstore Cowboy - Alec's free and super interesting newsletterC.O. Bigelow - The Nation's Oldest ApothecaryVirtual GLP-1 startups: Pill mills or the future of obesity care?—

If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's podcasts, headlines, and listener-submitted questions.This month, we're joined by Jeff Bak from Imagine360!Together, we react to the latest headlines from March, including the new CMS rule enforcing actual dollar amounts in hospital price transparency files. We also discuss Medicare expanding coverage for GLP-1s to treat obesity, Roche's massive $65M investment in NVIDIA AI chips for drug discovery, and the Department of Labor's new PBM fee disclosure rules. Plus, we react to the shocking story of two insurance executives sentenced to 20 years for a $233 million ACA enrollment fraud scheme.Then, Jeff and I play a game of "Blind Ranking" where we have to rank the worst practices in health insurance (like PBM spread pricing, ER upcoding, and surprise balance billing) without knowing what is coming next. Finally, we answer a listener question about the viability of ICHRAs (Individual Coverage HRAs) as an alternative to brutal fully-insured renewals in 2026.Thank you to our sponsor, Walk On Clinic! Visit walkonclinic.com to learn more about their on-site health clinics.Chapters:0:00 - Intro & Live Show Announcement3:08 - CMS Enforces Dollar-Amount Price Transparency6:54 - Medicare Expands GLP-1 Coverage to Obesity12:15- Roche Buys $65M in NVIDIA AI Chips for Drug Discovery15:45 - The DOL Proposes New PBM Fee Disclosure Rules19:40 - Insurance Execs Sentenced to 20 Years for $233M ACA Fraud22:20 - Game: Blind Ranking the Worst Practices in Health Insurance30:41 - Ask Spencer: Are ICRAs a Smart Option After Huge Renewals?

Bonus episode: we're unpacking the DOL's proposed PBM fee disclosure rules, sharing takeaways from our colleague Jenny Gartman. Learn more in Jenny's blog post: https://blog.ifebp.org/pbm-fee-disclosure-regulatory-and-legislative-update/

The Steve Gruber Show | Blue-Collar Boom: The AI Economy's Biggest Winners --- 00:00 - Monologue 27:56 – Rob Rene, Founder of QE Strong. Rene discusses the “Radiance Revolution” and how a total body reset can also improve overall appearance and wellness. He explains the connection between internal health and outward results. Visit ExodusStrong.com/Gruber to learn more. 38:04 - Monologue 46:59 – Debbie Wuthnow, President of iVoterGuide, a division of American Family Association Action. Wuthnow discusses the SAVE America Act and why Democrats are opposing voter ID requirements. She explains how the issue is shaping election integrity debates nationwide. 57:05 – Brad Close, President of the National Federation of Independent Business. Close highlights what he calls a permanent win for small businesses. He explains how recent policy changes could provide long-term relief and growth opportunities for entrepreneurs. 1:16:09 - Monologue 1:25:01 – Rep. Cam Cavitt, representing Michigan's 106th House District. Cavitt discusses youth treatment reform legislation, including testimony from Paris Hilton and other survivors. He explains how the bill aims to improve oversight and protect vulnerable youth. 1:35:06 – Miguel Rodriguez, Executive Vice President and General Counsel of American Pharmacies. Rodriguez discusses testimony from Michigan independent pharmacists about pharmacy benefit manager (PBM) practices. He explains how these practices can disrupt care and create challenges for both patients and local pharmacies. 1:44:14 – Ivey Gruber, President of the Michigan Talk Network. Gruber wraps up the show with discussion on March Madness and a major healthcare fraud case uncovered in the U.S. The segment highlights both lighter moments and serious developments making headlines. --- Check out our brand new podcast, 'Forgotten America'... The sixth episode is live NOW at Steve Gruber on YouTube! Link below: https://youtu.be/aKxApESBYuo

In this Inbetweenisode, Stacey shares listener feedback and reflects on making better decisions in employer-sponsored healthcare, spotlighting LinkedIn posts by Ken Wosczyna and Michelle Bernabe.  Ken argues Relentless Health Value moves from theory to practical transformation by sharpening judgment, which Stacey ties to how millions of workplace decisions shape the healthcare system and how actuaries and executives can align choices with values.  Stacey emphasizes that good decisions require both transparency and understanding, previewing an upcoming episode with Jerry DiMaso about using transparency files to compare what peer companies pay, and citing examples of misleading "transparency" through complex contracting and financialization (e.g., CABG pricing and PBM tactics).  She also questions what "disruption" means when the status quo already harms access. Stacey highlights direct contracting, Centers of Excellence, and upcoming advanced primary care episodes. === LINKS ===

Welcome to Tech Trends Pharmacy Podcast sponsored by PrimeRx, today's a special epsiode features the original "Pharmacy Badass" CEO of DiversifyRx, and founder of the Pharmacy Profit Summit, Dr. Lisa Faast. PAUSE, Get ready for a discussion on a blueprint on generating new non-PBM revenues and a sneak peak of "Pharmacy Profit Summit 2026 in Dallas, coming March 28 through 29th in Dallas.

The $6 Billion Influence Machine Targeting Your Benefits PlanFeaturing Kyra Hagan, Senior Vice President of Marketing, RxBenefits.Six billion dollars. That is what pharmaceutical companies spend every year marketing high-cost, high-profit prescription drugs directly to your employees — and the clinical and financial consequences are landing squarely on your health plan.Bo sits down with Kyra Hagan, a 25-year healthcare industry veteran and SVP of Marketing at ASHHRA Platinum Sponsor RxBenefits, to unpack the direct-to-consumer advertising machine and why healthcare HR leaders need to understand how it works.

In this episode of Prescription for Better Access, we're joined by William (Bill) Sarraille, a legal expert on drug access and reimbursement. He discusses two developments shaping the pharmacy benefit landscape: the FTC's enforcement action involving Express Scripts and PBM reforms in the Consolidated Appropriations Act of 2026. Bill explains what these policy changes could mean for benefit design, drug coverage, employer-sponsored plans, and transparency in the PBM market. We also explore potential impacts on formularies, utilization management, contracting practices, and patient out-of-pocket costs, along with possible unintended consequences for employers, manufacturers, and patients seeking timely and affordable access to medicines. William (Bill) Sarraille, University of Maryland School of Law LinkedIn Pharmacy Benefit Managers (PBMs) FTC Settlement 2024 Administrative Complaint Cigna Healthcare Fair Market Value in Healthcare Consolidated Appropriations Act of 2026 Part D Plan PBMs No Longer Profit From Rebates But Plans Benefit – Pink Sheet TPA (Third Party Administrators) DOL Proposal Copay Accumulators and Maximizers Amicus Brief, HIV and Hepatitis Institute Questions or comments? Email us at comments@prescriptionforbetteraccess.com. Follow us on X, LinkedIn, YouTube, and Threads.

Welcome to another episode of TWIRx – This Week in Pharmacy, where we break down the most important developments impacting the pharmacy profession. This week's show features leaders from across community pharmacy, health systems, healthcare advocacy, and international patient engagement. From PBM reform to patient-centered care and health system growth in Western Pennsylvania, this episode brings together voices shaping the future of pharmacy. Sponsored by Sykes & Company, P.A. Accounting, tax strategy, and advisory services dedicated exclusively to independent pharmacy operators. Segment 1 Austin Murray Communications and Marketing Director – Sykes & Company, P.A. We kick off TWIRx with Austin Murray from Sykes & Company, discussing the NCPA Consumer Marketing Campaign designed to educate the public about the value of community pharmacies. Austin shares insights on: • The importance of telling the community pharmacy story directly to consumers • Why independent pharmacies remain essential healthcare access points • The evolving state of independent pharmacy nationwide • Continued momentum around PBM Reform • Strategic accounting and tax advantages pharmacy operators should understand in today's challenging reimbursement environment Austin also explains how pharmacy-focused accounting firms like Sykes & Company help owners navigate reimbursement pressure, tax planning, and business strategy. Segment 2 Mark Duman Pharmacy 50 Award Winner – United Kingdom International healthcare thought leader Mark Duman joins TWIRx to discuss one of the most important principles in healthcare transformation: The patient must come first. Mark shares his perspective on: • Why healthcare systems must remain patient-centered • How pharmacy can lead the way in improving patient outcomes • Lessons learned from patient engagement initiatives in the UK healthcare system • Why meaningful healthcare innovation always begins by focusing on the patient experience Mark emphasizes that when healthcare professionals keep the patient as the constant focus, better pharmacy care and stronger health systems follow. Segment 3 Dr. Laura Mark, PharmD Vice President of Pharmacy – Allegheny Health Network Next, we welcome Dr. Laura Mark, Vice President of Pharmacy at Allegheny Health Network (AHN), who shares exciting news about new pharmacy operations facilities recently built in Butler County, Pennsylvania. Todd and Laura also reflect on their shared roots growing up in Butler County, while discussing how AHN is investing in the future of pharmacy. Topics include: • The new pharmacy operations infrastructure in Western Pennsylvania • How AHN is expanding pharmacy services across the Greater Pittsburgh region • The role of health system pharmacy in improving access to care • Strategic positioning for future healthcare growth and integration AHN continues to strengthen its pharmacy operations as a key component of coordinated patient care throughout the region. Segment 4 Eric Pusey Independent Pharmacy Owner – Pennsylvania Closing out this week's episode, pharmacy owner Eric Pusey joins TWIRx to discuss the latest updates on PBM Reform in Pennsylvania. In 2024, Pennsylvania enacted Act 77, a landmark law aimed at increasing oversight and fairness in pharmacy benefit management. Eric explains how the law: • Grants new regulatory authority to the Pennsylvania Insurance Department • Restricts PBM patient steering to pharmacies owned or affiliated with benefit managers • Improves transparency requirements for PBM operations • Establishes payment protections intended to level the playing field for community pharmacies Patient steering practices have long limited competition and reduced patient choice. Eric shares why these reforms represent an important step toward protecting both patients and independent pharmacy providers across the Commonwealth. Listen & Subscribe Stay informed on the business, policy, and innovation shaping the pharmacy profession. Follow TWIRx – This Week in Pharmacy on the Pharmacy Podcast Network, featuring conversations with the leaders and advocates advancing pharmacy practice.

In this episode, listeners get to know the leadership of the California Pharmacists Association (CPhA), exploring their professional journeys, personal backgrounds, and the experiences that shaped their commitment to advancing the pharmacy profession. Susan Bonilla, CEO of the California Pharmacists Association, joins Dr. Sean Kim, PharmD, Vice President of Practice & Professional Development at CPhA, to discuss California's progress in pharmacy benefit manager (PBM) reform. As the largest state in the nation, California continues to play a significant role in shaping policies that strengthen patient access to pharmacy care and improve transparency within the prescription drug supply chain. Bonilla and Kim share insights into the reforms California has achieved, the legislative and regulatory priorities currently underway, and how these efforts may influence PBM reform conversations across the country. The PBM Reform Podcast is sponsored by the American Pharmacy Cooperative, Inc. (APCI). APCI's sponsorship supports the production of this program but does not imply affiliation with the individual guests, nor endorsement of the views, opinions, or insights shared by podcast hosts or guests. APCI does not endorse any statements or content discussed on the PBM Reform Podcast or across the Pharmacy Podcast Network. Please reach out to the APCI Communication's team for additional information. 

In this week's episode of Medicine: The Truth, hosts Jeremy Corr and Dr. Robert Pearl unpack a wide range of developments shaping healthcare in America today, including the TrumpRx drug discount program. From new legislation affecting telehealth and pharmacy benefit managers (PBMs) to the rapid spread of measles and growing public concern about vaccine policy, this month's discussion highlights the policy decisions and scientific debates influencing medicine right now. The episode opens with the latest federal legislation passed to avert a government shutdown. While healthcare was not the central focus of this particular political battle, the bill contains several provisions that affect medical practice. These include extensions for telehealth coverage and hospital-at-home programs, reforms targeting PBM transparency and new requirements designed to address “ghost networks” in Medicare Advantage provider directories. Dr. Pearl explains that while these provisions represent incremental progress, they are unlikely to solve the larger problems driving healthcare costs and access challenges in the United States. Here are the other major storylines from episode 104: Healthcare costs remain nation's top concern: A new KFF poll finds that healthcare expenses rank above food, housing and utilities as the economic issue Americans worry about most. Prior authorization frustrations grow: Many patients report delays or denials of care due to insurance requirements, highlighting persistent tension between insurers, physicians and patients. Drug pricing debates continue: Pearl examines a new prescription drug website initiative and explains why it may have limited impact compared with broader policy proposals such as “most favored nation” pricing. Telehealth's uncertain future: Although the latest legislation extends certain pandemic-era flexibilities, the lack of a permanent solution leaves virtual care programs in limbo. PBM reforms move forward slowly: New policies aim to increase transparency and reduce incentives tied to drug list prices, though Pearl notes that meaningful change will depend on future implementation. Site-neutral payment gains attention: A provision requiring unique identifiers for outpatient services could pave the way for policies that eliminate higher reimbursement for hospital-owned facilities providing identical care. Measles outbreaks surge: Nearly a thousand cases have already been reported in 2026, with the overwhelming majority occurring among unvaccinated children. Trust in the CDC declines: Polling shows confidence in the agency has dropped significantly following changes to vaccine recommendations. Independent vaccine review groups emerge: Medical organizations and states are forming new committees to evaluate vaccine evidence as federal guidance becomes more contested. Early colon cancer deaths rise: The death of actor James Van Der Beek at age 48 highlights the growing incidence of colorectal cancer among younger adults and the importance of earlier screening. FDA confusion over a new flu vaccine: The agency initially declined to review Moderna's mRNA-based flu vaccine before reversing course and agreeing to evaluate it ahead of the next flu season. Younger Americans face worsening health trends: New claims data suggest chronic disease is appearing earlier among millennials and Gen Z, driven by lifestyle factors and reduced connection to primary care. Wearable data reveal health disparities: Apple Watch data show significant differences in resting heart rates across states, reflecting variations in lifestyle, access to care and public health conditions. As the episode concludes, Dr. Pearl warns that growing political conflict around vaccines and biomedical research risks undermining public trust in science. The consequences, he argues, could shape American medicine for decades to come. Tune in for more fact-based analysis and discussion of the biggest stories in healthcare. * * * Dr. Robert Pearl is the author of the new book “ChatGPT, MD: How AI-Empowered Patients & Doctors Can Take Back Control of American Medicine” about the impact of AI on the future of medicine. Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn The post MTT #104: TrumpRx, rising measles cases & the politics of vaccine science appeared first on Fixing Healthcare.

Episode Highlights With KatieWhat photobiomodulation (PBM) is and how red/NIR light affects cellsCore mechanism in plain English: cytochrome-c oxidase, nitric oxide displacement, ATP boost, secondary ROS and Ca² signalingWavelengths and depth: red (630–660 nm) for skin/surface; NIR (810–850 nm) for deeper tissues; why 980 nm behaves more thermallyEvidence overview: where PBM helps most (pain, recovery, tissue healing, some skin outcomes) and where data is still emerging“Free” red/NIR from sunrise and sunset: why the spectrum shifts, circadian benefits, and practical outdoor habitsDevice fundamentals: wavelength, irradiance (mW/cm²), energy dose (J/cm²), distance, and session timeBest-practice protocols: example dosing for skin vs joints/muscle; frequency and cycling (start low, titrate)Safety and cautions: eyes, heat load, photosensitizing meds, pregnancy/active cancer care, implanted electronicsHome tips: avoid staring at LEDs, position perpendicular to target, measure/estimate dose rather than chasing wattageSleep support stack: morning outdoor light + evening low-intensity red environment (not bright blue at night)Skeptic's view: helpful when wavelength/dose are right; underwhelming if misused or sold as a cure-allMy routine: sunrise/sunset outside first; add targeted device sessions for DOMS, skin, or joint recovery and track results over 4–8 weeksResources MentionedBON CHARGEJOOVV red light Red Therapy red lights use code wellnessmama for a discountMito red lightHigher DoseBONCHARGEI like so many of their products - from their red light products to their sauna blankets. Red light has been so helpful for me during my recovery from Hashimoto's. To find out more, go to boncharge.com/wellnessmama and use code wellnessmama for 20% off!

In this episode of Framework Focus, Dr. Dae Lee breaks down the regulatory and reimbursement shifts reshaping long-term care (LTC) pharmacy. With the Inflation Reduction Act (IRA) moving from policy theory to operational reality, Medicare's Maximum Fair Price (MFP) program, Part D redesign, and inflation rebate enforcement are now active forces that LTC operators must navigate. This conversation moves beyond headlines and into real-world implications: cash flow risk, administrative burden, contracting exposure, and strategic readiness for closed-door and combo LTC pharmacies. Key Discussion Points Medicare Drug Price Negotiation Is Now Operational  The IRA authorizes Medicare to negotiate prices for certain high-spend Part D drugs, with the first 10 Maximum Fair Prices (MFPs) effective January 1, 2026. This marks a structural shift in federal drug pricing and directly impacts LTC dispensing economics. Maximum Fair Price and LTC Reimbursement Compression  MFP caps reimbursement on selected drugs, creating potential margin compression if acquisition costs and payment timing are misaligned. For LTC pharmacies operating on tight spreads and high-volume chronic utilization, even small deltas can materially affect profitability. Medicare Transaction Facilitator (MTF) and Payment Timing Risk  The MTF system introduces new payment mechanics between manufacturers, plans, and pharmacies. LTC pharmacies must understand how effectuation and reconciliation work, particularly if payment timing differs from traditional Part D adjudication flows. Cash flow modeling becomes essential. Administrative Complexity and Claims Reconciliation  Identifying which NDCs are subject to MFP, managing claim reversals, handling price disputes, and monitoring plan-level compliance will increase administrative workload. LTC pharmacies will need structured internal workflows to prevent reimbursement leakage. Dispensing Fees and the LTC Service Intensity Problem  Unlike retail, LTC pharmacy includes compliance packaging, emergency kits, cycle fills, consultant pharmacist oversight, and regulatory documentation. Current IRA implementation does not automatically adjust dispensing or supply fees to reflect this complexity, raising sustainability concerns. Congressional Efforts to Stabilize LTC Pharmacy  Legislative proposals such as the Preserving Patient Access to LTC Pharmacies Act aim to create supply fee protections tied to MFP drugs. The episode explores whether policy corrections are likely — and how quickly DC can realistically respond. Expansion of Negotiated Drug Lists  The initial 10 negotiated drugs are only the beginning. Additional rounds of negotiation are underway, expanding exposure across more therapeutic classes. LTC pharmacies must treat MFP as a growing structural feature — not a limited pilot. Part D Redesign and the $2,100 Out-of-Pocket Cap  Beginning in 2026, the redesigned Part D benefit changes liability distribution among plans, manufacturers, and CMS. The new out-of-pocket cap alters plan incentives and may lead to tighter utilization management, formulary shifts, and network recalibration — all of which LTC pharmacies must monitor closely. Inflation Rebates and Market Distortion  The IRA's inflation rebate provisions penalize manufacturers for price increases above inflation benchmarks. While not directly adjudicated at the pharmacy counter, these provisions influence manufacturer pricing strategy, launch pricing behavior, and downstream PBM negotiations — indirectly affecting LTC acquisition costs. Strategic Readiness as a Competitive Advantage  The episode concludes with practical recommendations:  • Conduct an MFP exposure audit across top-dispensed NDCs  • Reassess PBM contracts and network participation clauses  • Model cash flow under delayed reimbursement scenarios  • Educate facility partners on regulatory changes  • Build internal compliance tracking specific to negotiated drugs Why This Matters Now For LTC pharmacies, this is not simply a policy conversation — it is a structural shift in reimbursement architecture. As federal oversight expands and pricing authority evolves, operational precision and legal literacy will define which organizations adapt successfully. About our guest:  Dr. Dae Lee, Pharm.D, Esq., CPBS  Shareholder - Buchanan Ingersoll & Rooney PC  Email: dae.lee@bipc.com  Dae Y. Lee is a pharmacist-attorney and Certified Pharmacy Benefits Specialist™ (CPBS™) who represents pharmacies, healthcare stakeholders, and plan sponsors in high-stakes disputes and regulatory matters involving Pharmacy Benefit Managers (PBMs) and government payors. Drawing on his dual training as a pharmacist and attorney, Dae focuses his practice on defending clients in audits, investigations, enforcement actions and complex reimbursement and compliance matters. Dae routinely represents pharmacies nationwide in PBM and payor audits, including Fraud, Waste and Abuse (FWA) investigations, extrapolation disputes, overpayment recoupments, credentialing denials, network suspensions and terminations. He advises pharmacies on compliance with applicable state pharmacy fair audit laws, PBM provider manuals, and reimbursement standards, with the goal of minimizing financial exposure while preserving network participation and business continuity.

Photobiomodulation (PBM) is a light-based therapy that uses specific wavelengths to interact with body tissues, influencing cellular activity without heat and supporting recovery across both medical and general wellness settings Europe recently released its first formal clinical guide for PBM in oncology, marking a shift toward standardized use of light-based supportive care across cancer treatment centers Clinical research shows PBM is most strongly supported for managing oral mucositis and radiation-related skin damage, two common cancer complications that can interfere with eating, speaking, and treatment continuity Beyond cancer care, PBM has been studied for wound healing, nerve pain, musculoskeletal recovery, skin health, and hair loss, with consensus reviews supporting its safety when properly applied Effective PBM depends on correct wavelength selection, dosing, and device quality, with red and near-infrared light delivering biologically active energy when used within established therapeutic ranges