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The simple corporate scheme behind massive US Brand Drug Prices

My 7-year whistleblower effort
"People Before Profits"

PBM Express Scripts: PROFITS TRIPLED TO $4.5 BILLION in just 4 years, while REVENUES DECLINED AND PRESCRIPTIONS PLUMMETED? How Possible?

There is only one explanation – A massive increase in secret “fees” from their drug company collusion “partners”, directly tied to skyrocketing U.S. brand drug prices/price increases, FOR DOING FAR LESS WORK.

Below are the shocking financial numbers for the top pharmacy benefit manager (PBM), Express Scripts, from their own financial statements on file with the Securities and Exchange Commission (SEC).

Express Scripts is now part of Cigna, after more mergers (including CVS/Aetna)  that only worsen the public harm, while serving to increase the secrecy of the ongoing simple pharma/health insurer/PBM “fee” price collusion scheme.

Remember, pharmacy benefit manager (PBM) is just a long-winded term for the insurance company that is supposed to manage the drug part of our health plans. Their main purpose is supposed to be getting us all lower drug prices (i.e., rebates, another name for discounts) from pharmaceutical companies. Unfortunately, rather than doing their job, they have been secretly colluding with drug companies to massively raise U.S. brand drug prices and profits for themselves, while passing the costs on to us. The simple scheme began long ago with Medicare Part D. Very sad and very harmful, but true.

After recent mergers, all the dominant PBMs are now part of the four dominant broader health insurers (United Health/Optum, Cigna/Express Scripts, CVS/Aetna and Humana) that control 80-90% of  private US drug plans and Medicare Part D. You can now mostly just use the term dominant health insurer and ignore PBM.

And even if these big four health insurers are not listed by name on your health/drug plan, one of them is likely involved as a partner behind the scenes with your prescriptions. Lots of side partnerships as well. Check your insurance card or other fine print.

Express Scripts’ Financial Information

                                            Revenues           Prescriptions                Profits                 Employees

2013                                   $104 billion          1.2 billion                 $1.8 billion              29,975

2014                                   $101 billion          1.06 billion                $2.0 billion             29,500

2015                                   $102 billion          1.04 billion                $2.5 billion             25,900

2016                                   $100 billion          1.0 billion                   $3.4 billion             25,600

2017                                   $100 billion          0.99 billion                 $4.5 billion             26,600

Change 2013-17                     -4%                     -18%                               +150%                  -11%

The obvious question:

How could Express Scripts have nearly TRIPLE ITS PROFITS TO $4.5 BILLION in just four years from 2013 to 2017.…

– While its number of prescriptions for patients dropped -18%?

While its number of employees dropped -11%?

While its total revenues dropped -4%?

By the way, Express Scripts revenues and prescriptions were falling because it was losing market share to the other dominant health insurer/PBMs, especially CVS and UnitedHealth.

So Express Scripts was losing clients and business in a big way, but still had no problem massively increasing profits? Really?

Common sense would tell you that this would not be possible in a legitimate market.

And you would  be dead right.

So how could this have happened?  – Again, nothing complicated.

All due to the simple, but secretive, pharma/health insurer/PBM “fee” scheme at the center of my false claim (qui tam) whistleblower cases – the two largest healthcare whistleblower cases in history.

Express Scripts is getting paid a lot more money from drug companies, for doing a lot less work – all driven by massive price increases on U.S. brand drugs, which account for 85% of Express Scripts’ sales

By the way, no surprise or mere coincidence that this bizarre surge in Express Scripts’ profits began in 2013, just following its merger with Medco (the prior largest PBM) in 2012. That is when the PBM industry became super-concentrated and the price collusion “fee” scheme with pharma accelerated across the nation.

How does the “fee” scheme work? I already sound like a broke record on this website, even though it is less than two months old.

Pharma “fees” paid as a “percent” of uniformly and massively increasing “sticker” or “list” U.S. brand drug prices, especially for top-selling multiple sclerosis, diabetes, cancer, rheumatoid arthritis drugs.

By law, these pharma “fees” are supposed to be for helping patients. More patients, more support and more “fees”. Right? A very basic concept. Makes sense.

Instead pharma and Express Scripts shockingly decided to structure these secret national “fee” contracts as a “percentage” of massive brand “sticker” prices and price increases.  All began a long time ago with Medicare Part D.

How am I sure? Because I heard it directly from the industry insider’s doing it! A long time ago now and it has gotten a lot worse. Now a national crisis.

In October 2013, I attended an industry “fee” conference (the only one I am aware of) for two days at which 50-60 pharmaceutical/PBM executives, and their close legal and consultant advisers, admitted the whole thing in colorful detail.

I sat in the front row with another colleague and took 80 pages of notes while aghast. I had already been following these drug and health insurer/PBM companies closely for 20 years as a professional analyst at that point and never heard of these secret “fee” payments before. And these company are still hiding it to this day, with a lot of help unfortunately.

Read about this shocking insider conference  in the whistleblower documents at this link: /wp-content/uploads/2020/03/SDNYComplaintFeeConference.pdf

Here are a couple of the definitive firsthand insider comments I heard at the conference which verified the simple scheme:

Secret “pharma fees” (as a percent of brand drug “sticker” prices) were the PBM’s “main source of income”
“When would the government be ‘dangerous enough to understand how industry works”
“I hope the conference was not being recorded”

Just these three firsthand insider quotes sum it up, but there are lots more.

To my shock and dismay, the Justice Department admitted repeatedly to me and my attorney that it never interviewed under oath any insiders from the conference in its 4-year investigation of my whistleblower cases.

As a non-insider at these companies, these firsthand witnesses from the definitive insider conference were the reason I filed the whistleblower cases promptly in the public interest starting in January 2014, with the Justice Department’s support.

Making the simple scheme even more ridiculous and abusive, for many of the old top-selling U.S blockbuster brands, Express Scripts and the others have gotten massive increases in “fees” routinely for drugs that are plummeting in use by physicians and patients.

Biogen’s Avonex (multiple sclerosis): 10-fold “sticker” price increase (to $100,000/patient now) with “fees” to health insurer/PBMs attached, while Rxs are down -60-70% over the past decade. Really?

Hard to imagine Biogen’s and numerous other pharmaceutical companies’ executives doing this with any kind of conscience?

Even harder to imagine these executives deceiving all intentionally for a decade-plus while accelerating the scheme amid wide-ranging patient/public harm and outcry?

And getting away with such a preposterously simple scheme causing massive patient and public harm for 15 years? Perhaps the most shocking of all.

Same ridiculous dynamics for many other old blockbuster U.S. brands, including Amgen’s Enbrel (rheumatoid arthritis), Teva’s Copaxone (MS), Novartis’ Gleevec, Eli Lilly’s Humulin (insulin), Pfizer’s Viagra (impotence) and Premarin (hormone), etc.

So, Biogen and many others paying the PBM/health insurers 5-10 times as much in “fees” for “supporting” half or less as many patients and prescriptions over more than a decade now? Really?

And what other magic did Express Scripts’ management perform to generate massive profits and pump its stock price, while its business was in free fall between 2013 and 2017?

Again, simple. Massively cut spending for “supporting” patients and get rid of employees.

Easy to do when your surging profits are just for passing through pharma’s price increases to your own trusting clients, patients and taxpayers whom you have pledged to protect, while doing far less work.

Express Scripts cut its “support” costs (called S,G&A in the financial world) by 30%, from $4.6 billion to in 2013 to $3.3  billion in 2017.

As Dire Strait famously said: Money for Nothing.

Less than nothing in this case! More Money for far less work!

And to further help its earnings per share (EPS) and the stock price central to massive Express Scripts’ executive compensation packages?

Use a lot of the free money from the pharma “fees” to buyback massive amounts of stock.

Express Scripts’ shares outstanding decreased 30% from 2013 to 2017.

While its corporate profits surged 150% in just four years as its legitimate business was plummeting, Express Scripts’ EPS went up even more!

Express Scripts EPS went up 230% between 2013 and 2017 –  for a business in sharp decline! Really?

In the end, I return to the remarkably simple nature of this secretive financial scheme and national crisis orchestrated by just a handful of misguided executives.

It really is just printing illicit money, profits and huge stock compensation packages for a very few executives, while they guard the secret like King Tut’s tomb.

I remind people that 99% of the hardworking people in the pharmaceutical and health insurance industries know nothing about this highly centralized secretive scheme harming all Americans across the nation.

And based on their own feedback,  very few health insurer/PBM employees are benefiting from the massive profits or like what is going on at these companies.

In July 2015, Express Scripts was ranked as “the worst company to work for in the United States”, according the reviews of its own employees on the Glassdoor career website. CVS was ranked the 12th worst company to work for in the country. See link: https://www.pharmacytimes.com/news/express-scripts-cvs-rank-in-worst-companies-for-workers

Quite an accomplishment for both Express Scripts and CVS, since Glassdoor includes the self-reported employee reviews for 400,000 companies around the world.

The prices of these old MS, cancer, rheumatoid arthritis and insulin drugs are now 5-10-fold or more higher in the U.S. compared to major European and other countries.

There are no PBMs outside the United States.

These brand drugs were the same price in the U.S. and Europe when this simple “fee” scheme began when these dominant PBMs were entrusted by Congress and the American people to manage the vital Medicare Part D program.

Instead, the PBMs chose to secretly partner with pharma to massively raise U.S. brand drug prices for profit rather than protect American citizens.

That about says it all regarding the real “value” that PBMs are providing to U.S. patients and taxpayers, despite their endless self-promotional public rhetoric to the contrary.

Money for Nothing.

No – Money for Far Less than Nothing.

Money for Severe Harm.

I would greatly appreciate your sharing this blog post and the website. Thanks for your interest.  

I remain hopeful that other experienced healthcare professionals will eventually help end this abuse. Unfortunately, that has not happened yet despite my repeatedly contacting many of them.

Regardless, the main goal of my efforts and this website is to inform and engage the broader American public.

Please share this with any and all. We are all being harmed and are in this together.

“PEOPLE OVER PROFITS”

I would be glad to speak with any interested party. I can be easily reached by email at info@drugpricetruth.org.

John R. Borzilleri, M.D.




2 thoughts on “PBM Express Scripts: PROFITS TRIPLED TO $4.5 BILLION in just 4 years, while REVENUES DECLINED AND PRESCRIPTIONS PLUMMETED? How Possible?”

  1. Pingback: » PBM: why your prescription COSTS TOO DAMN MUCH ! PHARMACIST STEVE

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