SopranoRX: The PBM Mafia, Revisited (2024)

Welcome to the Frontier Psychiatrists. What follows is an ambitious piece of writing. This took over three months and 50 hours to write. I’m a child and adult psychiatrist. I have come to believe understanding healthcare payments is the key to understanding why healthcare is so careless and awful.

This article was published on July 10th, 2023. Since then, the issue of PBMs has received extensive coverage, including this past weekend's coverage by the NY Times. Pro Publica launched its PBM accountability project. The FTC added yet more oversight to its agenda. Quoting Lina Khan:

The stakes of corporate monopolization are highest in healthcare. Despite the enormously consequential role they play, PBMs operate in complex and obscure ways that have let them fly under the radar….

So far, the PBMs have not fully complied with our orders to turn over documents and data. FTC orders are not suggestions, and we won’t hesitate to use the full extent of our legal authorities to mandate compliance.

We are undertaking this work with enormous urgency and focus. And if we find evidence of illegal practices, we will not hesitate to act.

There have been lawsuits against health plan sponsors, notably the trustees of Johnson and Johnson, for breach of fiduciary duty under ERISA. This issue has come to a head, and I look forward to readers revisiting this article with me in the light of myriad changes in the PBM landscape over the past year.

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…This is an argument. Dear readers, I’m attempting to convince you that Big Healthcare is a racket. It will start with history. Next, I’ll define the problem. Then, I will do some light exploring the scope of the scam. We will understand how the racket works. I will provide an alternative! If we are lucky, I will have a solution for you all individually. Finally, I will explain the legal strategy I see starting to solve this problem.

It will start, however, with a definition:

racketeering: engaging in a pattern of illegal scheming and activity for profit. A “racket” is a fraudulent and often illegal activity that is often carried out by means of extortion or intimidation.

The history of organized crime in America can’t be told without understanding the role of Italian immigrants. They brought a code of silence from southern Italy to America:

Omertà (/oʊˈmɛərtə/, Italian pronunciation: [omerˈta]) is a Southern Italian code of silence that places importance on silence in the face of questioning by authorities or outsiders1

”The Mafia” thrived in America thanks to Omertà. This code successfully kept them operating well beyond the reach of the law for years. Like the Spartans at Thermopylae, standing shield to shield, when people are unwilling to sell each other out, they do not break.

A group that selects antisocial psychopaths and follows a code never to rat each other out? Talk about an HR nightmare. They break the rules! How does one make rules they will follow?

The Italian American Mafia cracked the code. Omertà created an organization without leaks or rats2. If the government went after you, your family would be taken care of, as long as you didn’t squeal.

Absent informants, the government couldn’t follow the playbook, which relied on informants “telling on” criminals. The English tradition of respect for Law? This wasn’t a shared value with the Italian Mafia—something needed to be done.

In 1970, The R.acketeer I.nfluenced and C.orrupt O.rganizations (RICO) Act became law. Many of its enforcers were, of course, also Italian immigrants:

The power of RICO lies in its conspiracy provision, based on an enterprise rationale, that allows tying together apparently unrelated crimes with a common objective into a prosecutable pattern of racketeering.3

In addition to the criminal theory, the perennial favorite theory of government is that they can freeze assets, etc.:

RICO rules of procedure allow the government to freeze the assets of the defendant prior to the case even going to trial. The reasoning was that making the government wait until a guilty verdict was entered would allow time for these assets to be well hidden.

After RICO, saying, “I was only driving the getaway car,” wasn't good enough. That person could also be charged with conspiracy to commit murder, which had the same penalties as murder. You couldn’t do the accounting; anything to help the conspiracy became a tremendous personal risk. Law enforcement found the weakest links in the chain—not everyone was a “made guy.” It worked, then and now, to grind the Italian-American Mafia to a halt:

This story’s racketeers? They’ve gotten smarter, more adept, more difficult to crack—and vastly more profitable. Transparency is the enemy of good scams. With Transparency, one can tell. So there is a code, culture, and penalties for speaking out against organizations making all the money. Some people have much to lose. And this time, It’s all legal!

The most effective corrupt organizations take over regulation as well. Big Health needs to convince the doctors to stay quiet. The culture of Medicine is obedient, careful, and used to keeping the secrets of our patients. Repurposed, this is better than Omerta—we don’t need to protect their families! That becomes expensive, given the increase in premiums!4

The Mafia had five families. Big Health has three Pharmacy Benefit Managers (PBMs).

These organizations are at the center of the conspiracy. The amount of money is staggering:

What does a company that makes hundreds of billions and grows at 8.8% per year have as a product? Money, moving around. Legally. When it would otherwise be a crime to do so. Their explanation is, predictably, more complex:

They don't make drugs. They don't sell drugs. I thought we had insurance companies that were trying to keep costs under control. Or something? It is probably simple; they must do this:

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It is a protection racket—play nice, or we will let you get sick and die. Oh, and we will also reduce drug costs by increasing the portion of the cost paid to the PBM instead of the portion paid to the pharmaceutical manufacturer. And Improve the Quality…of our balance sheets. It’s not money laundering at all— that looks much different:

When the mafia asks for protection money? They would offer you the opportunity to pay them. And in theory, they would protect you from harm. Now, they were not offering sincere protection against external threats. You could be pretty sure that if you didn't pay them off, you would get your windows broken, ribs, or kneecaps by people who look suspiciously like the same people offering to protect you.

The heart of any protection racket is a threat. Pay up, or else.5 The threat to life or limb needs to be serious. Better yet, they should be willing to do awful things to your family. Insurance companies are not threatening your family. They're offering to protect your family. And your business. From a horrible, terrifying thought. What if you get sick, or someone in your family gets sick, and you can't get medical care?

That sounds pretty scary. It works better to be assured that the threat will be catastrophic. That would mean that in healthcare, there would be no way that anyone could be expected to pay. The costs? They have to destroy your life.

If this sounds hyperbolic, here are some numbers from My Life:

This is the cost of one medicine I should take every month. They categorically refuse to pay for the other additional medicine that works great, which I can’t afford. No regular person can add $ 7,000 or more to their monthly budget. When I made a note of my complaints, after hours of reporting to the internal compliance department6, then commenting publicly, I got this threatening letter from A PARTNER at Troutman Pepper:7

No access to treatments that you need? That would be terrifying. The mob also had lawyers— and the good sense to not use them as “cleaners” while acting as counsel. Big Health has less restraint… I complained about the ADA compliance of their website—sometimes my vision goes wonky thanks to my psoriatic arthritis—It wouldn’t be a problem with optimal treatment I can not afford. They responded with more legalese posturing that doesn't hold water—Again, drafted by a PARTNER8 at the firm:9

If only. Big Health companies have figured out that controlling prices can shake you down for protection money (“premiums”) and endlessly hurt you and your family unless you pay more and more. Because even if you pay the protection money, you're still going to go broke—nothing counts toward the deductible. Complain? Legal threats.

“It seems like you haven't met your deductible yet.”

Because you, your family, and employees, even if they pay up on premiums, will still need to pay it all over again for their treatment under this system. You might never meet the deductible—50% never do each year, and climbing.

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That is Dr. Hitman to You

I want to introduce you to some more cold-blooded contract killers, like this doctor from UnitedHealthcare, who is a serial killer when it comes to setting up the denial of claim process:

Dr. Muney and his team had solved the problem once before. At UnitedHealthcare, where Muney was an executive, he said his group built a similar system to let its doctors quickly deny claims in bulk.

In response to questions, UnitedHealthcare said it uses technology that allows it to make “fast, efficient and streamlined coverage decisions based on members benefit plans and clinical criteria in compliance with state and federal laws.”

This is an automated system to deny claims on the first pass. They get someone with a medical license to sign off on it, so it’s on their license in a Pro Publica investigation:

Dr. Dopke…rejected 121,000 claims in the first two months of 2022, according to the scorecard.

Dr. Richard Capek, another…medical director, handled more than 80,000 instant denials in the same time span, the spreadsheet showed.

Dr. Paul Rossi has been a medical director…for over 30 years. Early last year, the physician denied more than 63,000 PXDX claims in two months.

PX-DX is corporate shorthand for procedure-to-diagnosis. It’s an algorithm that auto-denies things or at least flags them so that human doctors can deny them…

However, my argument is not about insurance denials or prior authorization. It’s about the economics that drives those decisions straight to hell. As humans, we don’t want fraud10; we don’t want spiraling costs; we don’t want to die in pain and misery, unable to afford care. However, as stated above, the real mobsters go legit…and write the rules. They play by the ones they like and pay fines on the ones they don’t. Omertà allowed for this11.

Where is the big money?

“PBMs are modern gangsters,” Yost said in a statement announcing the suit. “They were designed to protect and negotiate on behalf of employers and consumers after Big Pharma was criticized for overpricing medications, but instead they have absolutely destroyed transparency, scheming in the shadows to control drug prices on all sides of the market.”

That is not me…it’s the attorney general of Ohio.

“This particular PBM egregiously charged for services it didn’t deliver,” Yost said in a statement. “Its repeated breaches cost Ohioans millions, and we want our money back.”

Sorry! This is from a PRIOR lawsuit against Cigna, which was after a lawsuit against Optum, and CVS Caremark…so, all of them?

In 2019, Ohio’s largest Medicaid managed-care provider, Dayton-based CareSource, fired CVS Caremark as its PBM and hired Express Scripts in its place.

CVS Caremark and Express Scripts are the two of the three largest PBMs in the United States. Yost’s office is suing the third — OptumRx — as well.

In that case, the state is seeking repayment of $16 million that it says Optum improperly billed the Bureau of Workers Compensation. One of the claims in that case is that the PBM didn’t provide the agency with discounts guaranteed under its contract.

Ford has filed suit against Blue Cross…es…plural…all of them — under the Sherman Act12, for antitrust claims!

Ford seeks to recover treble the amount of actual damages as determined by the difference between the supra-competitive premiums and fees that Ford was charged as a result of the conspiracy, and what Ford would have paid absent Defendants’ anticompetitive conspiracy

The problem, for the rest of us, is that health care is following a code that is not unlike Omertà. Unfortunately, it is not only about silence; it is about bullsh*t. A code of politeness that conceals the intentions of everybody involved, including the people working in big health. It is a conspiracy of doublespeak.

Let me illustrate:

• “We’ve been talking about rebates going away for a long time,” he said. “We would prefer that—but from a competitive standpoint, you have to stay relevant.”

• “We welcome competition ... expect more of it in the years to come and are confident that we ourselves are key disruptors,” Merlo CVS CEO said.

I’m going to reference data. Before I do… I’ll point out that when PhRMA, the pharmaceutical industry lobbying group, thinks PBMs are a scam, they know from whence they speak:

Pharma Lobbying Groups have their well-funded mission, with all its built-in bias. It is a little staggering that anyone figured out how to beat pharmaceutical companies at their own game, however:

One could be tempted to ask if the three PBMs are making offers one can’t refuse. It also seems relevant to note that the above Big Three PBMs are also, at the same time, the same companies as the larger health insurance companies…and something…looks fishy:

Sorry..that is 2014. I’m sure nothing has changed…moving along.

Let’s ask a former PBM Chief Medical Medical officer if he thinks they provided savings. From

:

How about “affordable”? It’s true that PBMs negotiated lower prices than the manufacturers wanted, but we typically kept most of those rebates along with a percentage of the total cost. Ultimately, for us to make any money, patients had to spend money at a pharmacy. No drugs, no margins or profits. Our motives were murky at best.

This is especially effective because it's illegal for Medicare to negotiate drug prices:

The law that established the Medicare Part D benefit, which covers retail prescription drugs, includes a provision known as the “non-interference” clause, which stipulates [HHS secretary] “may not interfere with the negotiations between drug manufacturers and pharmacies and PDP [prescription drug plan] sponsors, and may not require a particular formulary or institute a price structure for the reimbursem*nt of covered Part D drugs.”

…Which is pretty sweet. The government can have “no direct role” in negotiating or setting the price of drugs13. The payers set the price they will pay and profit based on a percentage of total spend, after expenses—including whatever they pay a wholly-owned subsidiary for figuring out what the price they pay themselves should be!

Big health insurers Cigna, CVS/Aetna, and UnitedHealth now own the three biggest PBMs, which collectively control 80% of the PBM market. At all three insurers, the PBMs are contributing as much if not more to profits than the health plans they operate.14

It’s a good racket — from

—former Cigna Communications Executive:

In 2022, Big Insurance revenues reached $1.25 trillion and profits soared to $69.3 billion.

That's a 300% increase in revenue and a 287% increase in profits from 2012, when revenue was $412.9 billion and profits were $24 billion.

Intergalactic Expense is Not Enough

To put the amount of money in any perspective is almost impossible given the scale, so, with a sense of irony that is as unsettling as it is uncanny, I am going to attempt that descriptive moonshot…using our literal shot to the moon:

If one were paying for interplanetary travel, the trip from Earth to Saturn, at $1 a meter, would be affordable next year if costs go up at current rates — it’s 1.38 trillion meters away. I’m using this humorous example as an exaggeration; space exploration is nowhere near as expensive as PBMs.

The interstellar-ness of Big Health money is hard to fathom. I will help. If we tabulate an inflation-adjusted cost of the entire Apollo Program…

We can add the entire historical coat of the Space Shuttle program:

Then add 10 Hubble Space telescopes; you are still only at…

$409,000,000,000 …which is less than the total revenue…back in 2012 …for Big Health PBMs. For that Kind of money, we could also…

• We could send 5 million people into space with Jeff Bezos every year.

• We could hand all 8 billion people on earth $156.

• Literally, anything.

It's one percent of all the money.15

But Wait! There are more… expenditures. Here is the total spending from 2021 we have data on from the AMA:

…but 80% of the drug pricing is determined by…PBMs. These are the same companies demanding that costs be controlled on these drugs. Prior authorization demands are placed on physicians for drugs for which the payer does not get the right rebates. The counterparties to these negotiations are the same company. It’s like playing aggressive speed chess against oneself while complaining the game is rigged!

The PBMs’ hundreds of billions also have the ability to “reprice” costs on other parts of the spending in the system. It’s…what do you call that? Oh, right. A kickback:

A kickback is an illegal payment intended as compensation for preferential treatment or any other type of improper services received. Paying16 kickbacks is a corrupt practice that interferes with an employee'sor a public official’s ability to make unbiased decisions. Kickbacks are often referred to as a type of bribery.

The Italian mafia is less revenue generating, although they are the largest company in the nation:

Italy's four organized-crime syndicates -- Sicily's Cosa Nostra, the Camorra in Naples, Calabrian 'Ndrangheta, and the Sacra Corona Unita in Puglia -- together make up a "huge holding company with a total [sales] turnover of about $165 billion and profits approaching $90 billion.”

They are…the biggest company in Italy. "Everyday, organized crime takes about $203,000 a minute."

The above graft from the Italian Mafia would compare poorly, in scale, to the over 8 million dollars per minute extorted from workers here in America by Big Health. That is just under 39,000% more than the actual mafia shakedown in Italy.

All illegal drug trafficking also sucks wind compared to Big Health:

the [global] yearly worth of illicit narcotics sold worldwide at between $426 billion and $652 billion.

Ok, it’s a ton of money. But it can’t be a total scam? PBMs have to do something useful?

Sorry, that was insincere. Their professed purpose is to determine “tiers” for medicines that the same company payers can later automate denials on for being “too expensive.” This means endless complexity that can allow “payers” to deny claims most profitably.

The Shell Game is a Scam, Not a Real Attempt to Locate the Pea

I have been offered a choice I can’t refuse before as a physician: either spend hours on the phone doing a prior authorization for the generic drug…or prescribe the brand-name version (that is vastly more expensive for the employer and thus member) but has a “preferred tier,” and we can all go about our day. Tiers are a protection racket for pharmaceutical companies and patients and debt collectors who break our legs with compound interest.

Imagine Agents from The Matrix, circa 1999, with flip phones, great leather outfits, and cool sunglasses. Now, replace everything cool about it with blank stares and the word “value.” If the Agents gave up on pretending and hosted endless “Reimagining Human Batteries” Conferences, it would be more sincere than the Big Health podcast conversations like “Until It’s Fixed.”17

We’re always moving in the direction of value. We can never get there. This “never” is important to understand; just like the mob, Big Health really can not stop putting the squeeze on you. It is a violation of their fiduciary duty to their shareholders. These are among the most profitable companies. They can run a pilot here due to the acquisition there, but they can not violate their shareholders' trust. There is nothing wrong with what they are doing for their shareholders. They generate value every day. They go to bed. They add more value every night. They add value in the morning with their cereal. At no point is anyone stopping them in the hall, shaking them, and screaming “what are you doing?!”18

Safe Harbors…Are For 🏴‍☠️

Pharmacy Costs Rising and the PBM game are the historical keys to profit. For example, pharmacy benefit managers have a safe harbor law. A safe harbor is where a pirate ship can dock and not have the pirates on board arrested.19

PBMs exist, with the safe harbor, put medicine in “Tiers” at the pharmacy—in exchange for $450b in rebates moved out of your pocket. Here is what this does:

It distributes costs to you, the consumer. And your “plan20.” There is no balance sheet rationale for a payer to pay for your meds when they make more money if they don’t pay. You need to hit your deductible first! Big Health Mafia also determines what counts toward that deductible. It is as if protection money didn’t count toward your protection until they determined it did, which was never-ish.

The health plan, of course, also takes money out of your paycheck indirectly. The PBM in the above graphic says your plan is the 75% cost sharing of a specialty drug, a benefit plan that pays the pre-tax cost, and the shifted 25% of the cost-sharing to you—after taxes—at $250k or more a year. That “controls costs for the plan.”

For you, it is knee-cap-breaking. The tiers are a bidding war between rival pharmaceutical companies. They are based on who coughs up the biggest rebates for the privilege, and theoretically to the pharmacy about safety, assuming doctoral level pharmacists need that nudge to assure anything.21

It’s a scam. No one needs a tier. They need cheaper drugs. Do you know who does that? Mark Cuban—manufacturing wildly expensive drugs for a lot less and contracting out PBM markups:

The Cost Plus Solution!

Big health-owned PBMs have taken drug pricing and turned it into a legal money extraction machine. The same laws, however, could allow fair pricing! The incentives matter—if you are trying to make more money for the company by driving medical costs up, it makes sense to do what the Big Three Families—sorry, PBMs— do. If you want to sell savings there are different business models—because you make money on selling more drugs for less money like a real business.22

It makes zero sense to make drugs cost less if you pay yourself. The name “Cost Plus” makes zero sense if you aren’t a pharmacy insider, so a brief overview is needed. Drugs—let’s use one pill—have a coat to manufacture. They have a cost to ship. They have other contributors to marginal costs—most of the money used to be in brand name drugs, which could be more money because of a patent and exclusive license. This was a good model for Pharma! It wasn’t good enough for PBMs. They negotiate prices in a direction for those brand-name drugs, but it's not necessarily down. They also negotiate prices on generic drugs on your behalf, using math that is too complicated for anyone to understand. The name of the game is bafflingly complex. The Big Three PBMs price drugs at the pharmacy that you pay—and so does your plan, which, again, is also you—by using the following math:

That was a joke. The math is way too complicated! The terms used are these:

And the workflow to get to a price follows this rubric:

“Drug Prices are Complicated!”

So the term “Cost Plus” is pharmaceutical, which means “we charge what it costs to buy a pill plus something, and that is it.” The NADAC (national average drug acquisition cost) plus something fixed amount of dollars. Some renegade hackers asked:

Wait a minute, can we sell a pill for what it costs plus a little bit more and call it a day?

Yes! That is a PBM, too, legally. In a previous life, my team asked the founder of CapitalRx: What is the least we could add? “$1.99.” The product based on that thinking is the discount card below….

It has been reborn thanks to a veteran-founded organization—Rethinking Heroes—that has picked up the tab so you can have your own personal Cost Plus Drug Pricing:

Yes, You Can Use This Card Below At Your Pharmacy!

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Who is The team who brought that functional product to save money? Former Debt Collection CEO Jerry Ashton founded it. As seen on John Oliver, he already blew up $7 billion in medical debt with #ripmedicaldebt:

My initial concept for that discount card started as performance art, but that was in 2020. Before the law, you will learn about, in the end, making it more consequential…more foreshadowing!23

Spoiler alert: You can ask your pharmacist to tell you how much your prescription would be “with your insurance” and its co-pay and how much it would be without your insurance with the above cost plus discount card. The answer is likely to surprise you!

Bonus: if the cost of the drug out-of-pocket ends up being less with that card than your co-pay, your health plan—which I will again remind you is also you—for the privilege of paying more for the drug at the pharmacy counter. Then, you will also be paying the pharmacy benefit manager for the privilege of jacking up the cost through your co-pay, which is higher than the cost of the drug.

Yes, pharmacy benefit managers negotiated rates on generic medications. Yes, pharmacy benefit managers “negotiate rates” on generic medications in which the co-pay is higher than the actual cost, plus some extra money. And then your health plan is paying for that drug again on top of what you just overpaid. This is called, and I promise you, this is not a joke; it's an actual industry term, a clawback.

Big Healthcare, Meet The Enforcers

If the above sounds like a scam, that's because it's a scam. If nobody would say “yes” to pay more than $1.99 above the cost of the pills, for example, Wellbutrin XL 300mg:

GoodRx offers “discounts” too…but it's not as good, mostly24, as a cost plus less extra money rate because they are making money on kickbacks from the PBMs also:

To answer the obvious question, there is no reason you should pay more for something than you need to. There is no explanation following “it could cost $20— but we're gonna charge you $119” — that should be acceptable to someone acting in your Fiduciary Interest.

RICO was the legal framework to dismantle the Mafia. Omertà was built on the culture of Italy—a culture that valued silence over speaking out. Italian Americans working on the side of law enforcement, like the legendary Joe Pistone, understood the culture of the Mafia and used it to take the crooks down. The Culture of Obedience, endless doublespeak, complexity, and mind-numbing profits can’t be undone by outsiders. It’s too powerful. We need heroes from inside that culture to tear it apart, using its own internal logic.

The Big Health Mafia used complexity to shake us down. In turn, it will be taken down by those who ran the scam. Omertà cracked because the government got in. Big Health has a more serious threat…former insiders speaking out.

Insiders like

. He was a C-Level Executive and acted as the gatekeeper for their CEO while

represented Cigna on several industrycommittees and task forces, including the strategic communications committee at the industry’s largest PR and lobbying group, America’s Health Insurance Plans.

And testified before Congress that the Big Health Mafia told disgraceful lies:

Informants like Dave Chase (a founder of Health Rosetta):

It’s a sad equation: Poor financial incentives + we all want care + decades of small decisions = where we are today.

He lobbied for our RICO equivalent, strategically buried in the Combined Appropriations Act of 2021 (CAA)—a legal update that makes Fiduciary Duty25 the legal duty and personal liability of most employers in America. They aren’t all Made Guys, after all.26

Insurgents like Mark Cuban have built an integrated drug manufacturing, mail order pharmacy, and PBM that has no incentive to scam itself:

Just like RICO created the framework to allow the government to go after people who weren’t Made Guys—who could be cracked under pressure—new laws like the Fiduciary Rule under Ca 2021 (CAA) create a new legal framework.

If you have asked yourself, “How is the above legal?” because it seems like a criminal conspiracy, I would agree. Our RICO Equivalent in health care continues to allow PBM kickbacks to be renamed “rebates.” However, these violate your employer’s Fiduciary Duty to act in your interest.

Follow the logic—for the Big Health Plans, it’s legal to have brutal kickbacks built into their PBMs that scam individuals by making them pay more for drugs when they could be paying less, even using the cost-plus discount card in this article! However, it is no longer legal because it violates ERISA—which makes health benefits pre-tax— to EVADE TAXES by paying for benefits that aren’t beyond. And for the benefits broker who sold it to them. The Department of Labor (DOL) has outlined penalties. These penalties are civil. However, the DOL has also made it clear there are criminal penalties also possible:

Upon a conviction for a willful violation of ERISA’s reporting and disclosure requirements, a fiduciary may be subject to fines and/or imprisonment for not more than ten years. There is also a provision in ERISA that applies to any person, not just ERISA fiduciaries, that makes coercive interference with ERISA rights a criminal offense punishable by fines and/or imprisonment for up to ten years. In addition, outside of ERISA, there are a number of criminal statutes that apply to any person, not just ERISA fiduciaries, including criminal statutes for embezzling from an ERISA plan, making false statements in ERISA documents, and taking illegal kickbacks in connection with an ERISA plan.

And there, you have the health benefits version of RICO…any person, even a Made Guy in Big Health, that offers coercive interference, makes false statements, takes illegal kickbacks—and I really can’t wait to see the arguments that the above PBM racket isn’t that—is a criminal act offense punishable by up to 10 years—per violation—in the pokey. Mobsters eventually turned into rats for less. Are the contract killers working at PBMs less tough than Junior Soprano? I can’t wait to find out. It’s not a crime to sell endlessly marked-up drugs. It is a crime to evade taxes by buying that product. That is my argument. My daughter’s argument is, frankly, more straightforward:

A legal framework where people who aren’t Made Guys in the Big Health Mafia—that is, every employer and anyone who exerts a coercive influence in the protection racket in America—have PERSONAL and plausibly CATASTROPHIC liability, both civil and criminal.

More employers are catching on and filing lawsuits for their claims data. I hope my ERISA Counsel readers will use RICO as the actual law to break the corrupt influence of PBMs. Please feel free to submit this article for discovery if needed.

[Author’s addendum as of 2024:—there is currently a civil action against the Mayo Clinic for fiduciary breach using RICO as the legal argument.]

Now, employers need to attest to breaking the silence27 on a shakedown that has gone on for too long.

Meanwhile, that cost-plus pharmacy card will work at most pharmacies. Give it a shot. And every time it would have been “more to use your insurance,” feel free to screenshot that receipt and report the fraud.

Q.E.D.

—Owen Scott Muir, M.D.