Anyone who has a regular medication regimen is usually quick to lament how costly it is. Well, you know, drugs are expensive, especially in America! But, what is the industry structure that determines and manages the price? The answer is found in a middleman enterprise known as the PBM, an acronym for Pharmacy Benefit Management. This acronym can also double as an oxymoron for patients who need medications because they are not benefiting from this interference in the system. Profit By Middlemen might be a more honest label.
The Center for Health Information & Policy (CHIP) is a nonprofit entity engaged in health care research, public education, and advocacy. The mission of CHIP is to educate the public about the health care system in the U.S., and advocate for better health care for all Americans. Our purpose is to continuously research the state of public health and medical delivery systems, inform citizens about the status of those systems, and to lobby for policies that will improve them.
Current Projects Prescription Drug Costs We are currently investigating why prescription drugs cost so much in the United States. Our research will be organized into a series of blog post and documents that dig into U.S. drug patents… Read More
News and Updates
Watch this page for articles from other publications about issues and reports on the state of the healthcare industry in America
The CHIP team is providing the list of acronyms and terminology that is commonly referenced and invoked by the medical industry. Additional entries will be made as they enter the medical lexicon.
A-Z GLOSSARY OF TERMS AND ACRONYMS
AHCA – American Health Care Association
Biohumanism – The objective of biohumanism encompasses the beneficial guidance of ethics, morals, socioeconomics, and cultural conventions for the purpose of establishing the highest possible standards of conduct and the continuous improvement of life on earth for all humans.
Financial Engineering – As it relates to senior care corporations, the practice of creating a complex structure of business entities, in some cases shell companies, to obfuscate capital flows.
Financialization – As related to the Medical-Industrial Complex (MIC), implies the primary focus of every verticality in this sector is to leverage and increase the flow of funds for the benefit of industry businesses.
Home Office Allocations – Uncontrolled and unaudited internally assessed charges and fees added to facility operating expenses.
HPRD – Hours Per Resident Day. This is a vital measurement that reveals the level of patient commitment and care provided by an SNF property.
KDADS – Kansas Department of Aging and Disability Services
MA Medicare – (MA) Medicare Advantage references the choice by seniors to receive their healthcare insurance through a for-profit medical insurance carrier such as Aetna and United Healthcare.
Medical-Industrial Complex – The commonly accepted definition of an industrial complex is socioeconomic concept wherein businesses become entwined with social and political systems or institutions to bolster a profit economy from those systems. Such a complex pursues its own interests at the expense of society and individuals. This is an appropriate description of the entire health services ecosystem in America today.
Ombudsman – while the definition of this term states that this role is one of advocacy for the general public and individuals in the case of conflicts with institutional organizations and other concentrated power centers, it is commonly reported by individuals who seek assistance through ombudsmen that the outcome of the investigation and related arbitration more frequently favors the institutions accused of misconduct, or worse.
PBM – Pharmacy Benefit Management, an organization that is essentially a middle man business wedged between the pharmaceutical manufacturer, the insurance company that covers part of the prescription cost, and the retail outlet that fills prescriptions. A Wikipedia contributor defines the PBM business model as hired by medical insurance organizations to negotiate prices with pharmaceutical companies. PBMs charge fees for this service, and also make profits in the margins between prices they negotiate with pharma companies and what they charge insurance companies. They are not required to be transparent and typically have signed agreements with pharma companies preventing them from disclosing the pricing they provide to a PBM. (See Rent Seeking below)
REIT – Real Estate Investment Trust, a financial enterprise organized as a trust company for the purpose of pooling investor funds and deploying those funds to purchase income producing properties of all classifications.
Related Parties – An amalgamation of LLC and other legal business structures that are collectively linked under an overarching entity.
Rent Seeking – an economic concept that occurs when an entity seeks to gain added wealth without any reciprocal contribution of productivity.
RUG – Resource Utilization Groups, a categorization of specific sources, such as physical therapy, that are accounted for as an SNF classification.
SNF – Skilled Nursing Facility
Stock Buybacks – The practice of corporations purchasing their own publicly traded shares to increase the per share valuation by reducing the number of shares outstanding.
Tax Arbitrage – The practice of profiting from differences that arise from the ways various types of income, capital gains, and transactions are taxed.
TM Medicare – (TM) Medicare refers to Traditional Medicare which is a direct relationship by a senior with government provided healthcare services. There is no association with private insurance carriers such as “advantage” plans, and often the insured will find it necessary and advantageous to add suplimental coverage.
The U.S. health care system is complex and dynamic. It been declining into catastrophic failure mode for at least the past decade. We struggled to manage and survive a systemic collapse of the economy along with medical systems due to an inept response to a deadly pandemic during 2020 and 2021.
The previous president, bureaucrats, and legislators knew this danger was coming but did not have the capacity to respond. A successful response to a rapidly moving scourge requires: (1) a plan, (2) a strategy, (3) adequate equipment/supplies, (4) technology (5) trained personnel, and (6) and competent, honest leadership willing to implement the plan. The turn of the century administration in office called for the implementation of each of these item but was ignored and neglected.
The consequence of that neglect was devastating. There was no plan, no strategy, adequate personal protective gear, enough ventilators, bed capacity and other equipment and supplies needed in a pandemic. The question is why? Public health and infectious disease experts have been warning for decades that pandemics would grow more severe and more frequent (Laurie Garrett warned us with an article titled The Coming Plague going all the way back to 1993). Indeed, since the 1980s, we have seen the HIV, H1N1, SARS, and Ebola outbreaks spread across the planet. It is not as if there have not been dire health scares in our past that could have informed us of the critical need for preparedness in the future.
We should not forget that something serious was going on in China in December of 2019. The Chinese economy was practically brought to a halt and serious isolation practices were implemented as only an authoritarian government can implement population control. The disease quickly spread to other Asian countries. Singapore, South Korea, Taiwan, and Japan implemented extensive organized and effective prevention efforts. Singapore, South Korea, and Taiwan had prior experience with the SARS epidemic and undertook impressive campaigns to keep the outbreak from overwhelming their medical systems. They succeeded.
Why was the United States so blasé and even sanguine about a novel virus that prompted massive public health efforts in China and other Asian nations? Even after known infestations the U.S. government remained seemingly unconcerned. Or did it?
Who Knew What & When Did They Know It? Let’s not forget…
Republican chair of the Senate Intelligence Committee, telling some donors in a private meeting that the coming pandemic could be as serious as the global flu pandemic of 1918. He was not at all as laid back and buoyant as he was in public at that time. The donor meeting occurred on February 27th. The audio of the Senator warning his wealthy supporters about the coming plague can be heard at: https://media.crooksandliars.com/2020/03/44593.mp3_standard.mp3.
Senator Burr is known as a leading legislative figure in the development of a national plan to thwart pandemics. He is not a neophyte in public health policy. Furthermore, he was present at a “closed door” COVID19 briefing presented by the Trump Administration National Security Council on January 24th – over a month before his dire warning to his donors. The contents of the briefing have never been disclosed to the public. In a search of the Senate Intelligence Committee website, no evidence could be found that a meeting regarding COVID 19 was held (https://www.intelligence.senate.gov/, “HEARINGS” tab).
Senator Burr was not expressing the same alarm in public he imparted to his close political allies. Furthermore, the President of the United States declared at a South Carolina rally on February 28th – one day after Burr’s ominous statements caught on audio – that the corona virus was a Democratic Party hoax.
Throughout February and most of the month of March, Trump and his powerful ancillary propaganda machine consisting of Fox News, an assortment of well-funded and well-organized Christian nationalist organizations, and most of the Republican Party repeated the corona virus hoax lie. A phalanx of right-wing virus deniers, conspiracy theorists, and Fox bloviators were egged on by the president who at best was recognizing the disease did exist, but it was primarily China’s problem and wouldn’t amount to much in the U.S.
Minimizing by The CDC, NIH, HHS, and the FDA at Senate Health, Education, Labor, & Pensions Committee Hearing
On March 3rd, Trump Administration officials responsible for pandemic preparedness, presented their views on potential threats to public health by the COVID19 outbreak at an open hearing held by the Senate Health, Education, Labor, & Pensions Committee. Dr. Robert Kadlec, Assistant Secretary for Preparedness and Response, HHS had the following to say:
“The potential global public health threat posed by this virus is high, but right now, the immediate risk to most Americans is low. The greater risk is for people who have recently traveled to an affected country or been exposed to someone with COVID19.” Page 3.
Millions of Americans died during the Covid19 pandemic. Nursing homes were disproportionally affected. Nearly four years later, many health experts are saying a high percentage of those deaths should have never occurred. As has become normal response to such serious negligence and consequent damage, no one has ever been held accountable.
Should we be concerned about the H5N1 (bird flu) virus that is now infecting Americans? Will we be prepared of it shows signs of aggressiveness? Ask your senator and congressman as soon as possible!
Make no Mistake about It, Project 2025 is Powerful, it is Well-Funded, and it is Religiously Extremist, Misogynistic, and White Supremacist.
Last August, this headline appeared in the Washington Times: “Recruiting is underway for Trump-like ‘wrecking ball’ to shrink government and fire federal workers”[1]The wrecking ball to which the article was referring is a cadre of extremist right-wing individuals who will, if Trump wins in November, see to it that their allies staff his administration. The powerful, anti-Democratic Heritage Foundation has initiated a movement dubbed “Project 2025,” – a network of Christian Nationalist, states’ rights’, anti-choice, school censorship, and anti-constitution organizations steeped in religious zealotry and as far out on the right of the political spectrum as any movement in U.S. history.
The Heritage Foundation is claiming that 100 organization on the hard right have signed onto their project in preparation for ending U.S. Constitutional government as we know it.[2] They are intent on scrapping the form of federalism intended by the framers and accepted by the American people as it has evolved since 1789. The list of organizations signing on includes Moms for Liberty, Turning Point USA, Hillsdale College, Liberty University, Susan B. Anthony Pro Life America, Dr. James Dobson Family Institute, Family Research Council, and other reactionary groups.
Most people who pay attention to politics have heard of at least one or more of these fanatical groups. Adherents of the Moms for Liberty have been running around censoring books in school libraries. They are allied with DeSantis’s project to undermine public education and replace it with a revisionist, false history and toxic religious indoctrination. Turning Point USA was formed and led by Charlie Kirk a rabid disseminator of disinformation and supporter of Donald Trump and his tripe about stolen elections, insurrectionists as patriots & hostages, and other dangerous nonsense. He has successfully organized chapters on at least 400 college campuses.
These types of anti-American organizations have moved from the unthinkable to the normal in the past few decades. Even more diabolical and violent groups are lurking in the shadows of this cabal. The violent, neo-Nazi Proud Boys and other Hitler sympathizing white male organizations are operating on the perimeter of the movement and tolerated at meetings of CPAC and Turning Point USA.[3]
Project 2025 is in Sync with the Ultra Conservative, Six Member Supreme Court Majority and the Republican Party
The current six-member majority on the U.S. Supreme court is acting not as jurists but rather as idealogues with sympathies for the dominant and dogmatic religious leaders of the Republican Party and a very mentally disturbed Donald Trump. Mainstream legal scholars are horrified by their actions and are speaking out about it[4] – to no avail. Not only is the overtly ideological majority on the court signaling that they will seriously weaken federal agencies,[5] they are expressing a considerable amount of sympathy for reducing women to second class status,[6] and interfering with privacy rights of gay and heterosexual married couples.[7]
It also appears that the S.C. majority has piled weight on the scales of justice for Donald Trump who is attempting to forestall his criminal trials by claiming total immunity for anything he did as president. This is an absurd claim rejected by a unanimous three judge panel of U.S. Court of Appeals for the District of Columbia Circuit. Nevertheless, the S.C. decided to hear the case and help stall justice for the American people who need a decision prior to the November 4th election.
Rarely in U.S history has the Supreme Court issued rulings that retract previously granted liberties. However, this court is intent on remaking law to reflect their favoritism toward a fundamentalist Christian theocracy with concentrated power in the hands of ultra-conservative white males.
What Project 2025 Means for the Elders of America
Like other vulnerable groups in American society, the elderly are falling prey to economic predators. This is consistently becoming a bigger problem, but it is happening without adequate federal regulation. This is particularly the case for elders institutionalized in “nursing homes.” Lax oversight of the nursing home industry prior to 2020 and the spread of COVID led to 2000 patient and 200 employee deaths. This was preventable and shouldn’t have happened. Nevertheless, the media, white-washing commissions, government agencies, and the legal system have displayed no propensity to hold the industry accountable for its neglect.
While the scourge was killing and isolating nursing home patients, the right-wing media and politicians and pundits appearing on their networks were claiming that masking, isolating, and preventative behaviors in general weren’t necessary because as Bill O’Reilly mused on Fox News: “The [U.S. death] projections that you just mentioned are down to 60,000, I don’t think it will be that high. 13,000 dead now in the USA. Many people who are dying, both here and around the world, were on their last legs anyway.”[8]
O’Reilly’s attitude reflects a far wider viewpoint about the value of older Americans than our government and politicians would care to admit – even beyond the confines of the radical right. However, the strength of an underlying theological dominionist[9], government-hating religiosity – combined with grievances against liberal, women, gay, ethnic, transgender, and other non-white male outgroups – does not bode well for programs such as Social Security, Medicare, and humane care for frail elders. Crazy religious views of the extreme right have incorporated a glorification of private corporations and privatization of government services. This is an outgrowth of their hatred of liberal programs from the New Deal forward and the political liberalism that era implies.
Summary
Religious fanatics want to run America. They have made significant inroads in doing just that (think school vouchers). The Christian extremist alliance with violent, neo-Nazi organizations is even more disturbing. Under the influence of the Heritage Foundation for the past fifty years and now its Project 2025, this coterie is infecting the mainstream of U.S. political discourse and jelling into a real threat to our constitutional form of government.
Coverage of right-wing fanaticism by the mainstream media has been problematic. The Heritage Foundation was formed by wealthy individuals on the far right in the 1970s. At the time, it was considered too radical for the normal American politically centered zeitgeist. By the 1980s, representatives of the organization were invited as guests on moderate news outlets such as PBS News Hour and it became a go to entity for print media seeking what they believed to be normal conservative views.
The MSM tends to engage in a misguided form of “fair and balanced” coverage of political groups with the chutzpa to push unthinkable views hard enough and long enough to become accepted into the Washington, D.C. establishment. The undeserved respect these entities receive inside the D.C. beltway – including by the press – creates a form of induced ambiguity in mass communication and voters’ thought processes. The real danger and odious facets of the Heritage Foundation and Project 2025 are minimized in leading new outlets out of respect for their success in becoming part of the normal political establishment.
I’m worried about the level of energy exerted by moderates in pushing back on the well-organized and aggressive organizations constituting Project 2025. Furthermore, there should be vocal opposition to the media myth about a “divided country” as if there are two equally legitimate sides in U.S. politics. In truth, American political views can be characterized as a broad, ambivalent middle with loud minorities on the fringes. The loudest and most effective fringe voice these days is on the right. Is it even fringe any longer?
[7] In Dobbs v. Jackson, Clarence Thomas expressed interest in overturning the right to contraceptives – a right granted in Griswold v. Connecticut, 381 U.S. 479 (1965) – and the right of gay people to marry, which was accorded in Obergefell v. Hodges, 576 U.S. 644 (2015).
[9] Along with misogyny and white supremacy, Dominionism is one of the more perverse political philosophies driving the Christian Nationalist movement. Proponents of this weird and dangerous philosophy are increasingly successful in persuading the Republican Party to seriously consider and adopt their ideas. Dominion theology includes a belief in a Christian nation ruled on biblical tenets – whatever those may be. Many of the opponents of imaginary “woke education” would replace it with false teaching about the framers’ intent, which they claim was to create a “Christian Nation.”
Anyone who has a regular medication regimen is usually quick to lament how costly it is. Well, you know, drugs are expensive, especially in America! But, what is the industry structure that determines and manages the price? The answer is found in a middleman enterprise known as the PBM, an acronym for Pharmacy Benefit Management. This acronym can also double as an oxymoron for patients who need medications because they are not benefiting from this interference in the system. Profit By Middlemen might be a more honest label.
