Connect with us

West Virginia

Contractor for W. Va. public employees system pays itself way more for some drugs than necessary – Ohio Capital Journal

Published

on


Express Scripts, the company that handles drug transactions for West Virginia public employees has — in some cases — paid itself more than 100 times as much for the most expensive class of drugs than it could have paid if it had gotten them elsewhere, according to pricing data obtained by the Ohio Capital Journal. 

Express Scripts — which is the subject of an antitrust suit in Ohio — did not dispute the data, but a spokesperson said that the company uses its heft as a pharmacy middleman to save customers money. And both Express Scripts and the West Virginia Public Employees Insurance Agency said that one can’t just look at reimbursements for select drugs and draw conclusions about the plans’ overall performance. 

Neither responded to some specific questions about Express Scripts’ practices.

In a rapidly consolidating marketplace where just a few players control an ever-wider swath of transactions, Express Scripts is not alone in awarding its own pharmacies huge markups. Similar instances have been found in other insurance systems in other states.

Advertisement

Paying itself and its competitors

The West Virginia Public Employees Insurance Agency, or PEIA, uses St. Louis-based Express Scripts as its pharmacy benefit manager. In that capacity, Express Scripts agrees to cover medications in exchange for discounts from drugmakers. It reconciles claims at the pharmacy counter. It bills the state. 

And crucially, it  determines how much to reimburse pharmacies that fill prescriptions for the agency.

When it comes to “specialty” drugs — think medicines for diseases such as cancer that can cost thousands of dollars a month — Express Scripts requires PEIA members to get their medicines from its own mail-order pharmacy, Accredo, or from a network of 20 specially qualified pharmacies.

Those pharmacies are located only in patches of West Virginia. There are six in Huntington, two in Morgantown, one in Gallipolis, Ohio, but none in Charleston, the capital city where many state employees and retirees live, according to a list provided by the West Virginia Department of Administration. The others are scattered in small communities across the state.

So it’s unclear how many PEIA members have much of a choice about using a pharmacy other than Accredo when they or their family members are unlucky enough to need a specialty drug.

Advertisement

But it is clear that for at least 23 specialty drugs, Express Scripts has at times paid wildly more to its own mail-order pharmacy than it would have if it used prices listed on publicly available databases.

Fruth Pharmacy owns 17 stores in West Virginia, six in Ohio and one in Kentucky. Late last year, President Lynne Fruth received Accredo pricing information obtained through the PEIA patient portal that contained some eye-popping numbers.

For example, at least sometimes Express Scripts’ Accredo charged West Virginia taxpayers $4,300 for a month’s supply of the prostate cancer drug abiraterone. That’s 110 times as much as the $39 you would pay if you were charged the price on a database kept by the federal government — National Average Drug Acquisition Cost, or NADAC, — plus a $10 dispensing fee.

In the case of the brain cancer drug Temozolomide, the Express Scripts-owned pharmacy charged $12,000 a month more than a Kentucky Medicaid patient would have to pay, according to the Fruth analysis, done by Andy Becker, Fruth’s vice president for pharmacy.

Express Scripts was paying its mail order pharmacy $13,118 a month in taxpayer money for the drug on that day. But a maximum-allowable cost list published by the Kentucky Department of Medicaid priced the drug at $900, according to Becker’s analysis. 

Advertisement

In all, it listed 23 drugs for which public pricing was available. Of those, Express Scripts/Accredo upcharges ranged from $109 a month to $12,000. Markups on 17 of the drugs exceeded $2,000 a month.

Who benefits?

The Capital Journal shared the analysis with Express Scripts and West Virginia state officials.

While the size of the markups might appear to be startling, Express Scripts spokeswoman Justine Sessions said they only represent a small selection of the prescriptions her company handles for PEIA.

“Choosing isolated examples of individual medications among the thousands covered by PEIA’s plan does not provide meaningful insights about the overall medication cost, affordability and safety that we help ensure for them and their members,” Sessions said in an email. 

In an interview, Fruth said that she didn’t believe Accredo was taking losses on other drugs that came anywhere near matching the markups it was getting on those in Becker’s analysis.

Advertisement

“If it’s OK for you to pay $11,000 for a $900 drug, show me somewhere that you’re dispensing an $11,000 drug and paying only $900 for it,” she said. “I’m absolutely certain that you can’t show me that.”

Analyses show that having only a few drugs responsible for large profits is not unusual.

The drug-pricing analysis firm 3 Axis Advisors in 2020 examined Florida Medicaid data and found that for generic medications, just 1.3% of the drugs dispensed accounted for nearly half (48.3%) of the markups over the prices listed on the NADAC database. In other words, huge markups on a tiny slice of drugs accounted for a huge portion of the profit being taken out of the program.

Also, the Wall Street Journal in September analyzed the cancer drug imatinib and determined that CVS Caremark and Express Scripts — the two largest pharmacy benefit managers — were paying well over 100 times as much for the medication than was Mark Cuban’s Cost Plus Drug Company, which charges a straight 15% markup plus $10 in shipping and dispensing fees. The big PBMs were in many instances paying those high prices to their own mail-order pharmacies, according to the analysis. 

In the case of the West Virginia Public Employees Insurance Agency, it’s unclear what portion of expensive specialty drugs are being filled by Express Scripts’ Accredo pharmacy, and what portion is being filled by the members of the 20-store specialty network. 

Advertisement

When asked for a specific breakdown, Express Scripts’ Sessions didn’t provide one, saying instead, “The large majority of specialty pharmacy claims are dispensed by network pharmacies other than Accredo.”

Becker of Fruth Pharmacy said his company and others are reluctant to join the network. They suspect that while Express Scripts is reimbursing its own mail-order pharmacy lavishly, it reimburses competitors at rates that don’t meet their costs.

“They’re not going to pay you $1,000 for a $50 drug,” Becker said. “They’re going to pay you $20 for a $50 drug.”

Express Scripts spokeswoman Sessions was asked whether Express Scripts reimbursed its own mail-order pharmacy the same amount for the same drug on the same day as it does and those in its specialty network.

“We offer in-network pharmacies competitive reimbursement rates,” she said.

Advertisement

Congressional concern, investigations and a lawsuit

Sessions said her company’s contract with the tax-funded West Virginia Insurance Agency guarantees savings.

We ensure that customers receive the best discount on each fill — regardless of where they choose to access their prescriptions,” she said. “Because we offer pricing guarantees that help to control drug spend across drug categories over an annualized period of time, our clients often pay less for drugs overall. Should we fail to meet the pricing guarantees, we make up the financial difference for our clients, which can translate into savings for members.”

But members of the U.S. Senate and other public officials have been questioning such statements.

In the wake of the Wall Street Journal’s reporting last year, U.S. Sens. Elizabeth Warren, D-Mass., and Mike Braun, R-Ind., wrote Cristi Grimm, Inspector General of the Department of Health and Human Services. 

They noted that each of the nation’s big-three pharmacy benefit managers is part of a “vertically integrated” health giant that also combines a major insurer and pharmacy — at least of the mail-order variety. They are: Cigna/Express Scripts, CVS/Aetna and UnitedHealth/OptumRx. 

Advertisement

The latter two companies have been also buying up doctors’ offices and if Cigna/Express Scripts is successful in buying Humana, it will be getting into that business as well

When Braun and Warren say the businesses are vertically integrated, they mean they’re major players in multiple sectors that do business with each other, raising concerns about self dealing. For example, an in-network CVS/Aetna doctor could write a prescription that would be filled at an in-network CVS pharmacy, which would be reimbursed by CVS Caremark, which controls pharmacy networks. Since CVS would be paying itself at each step, it would remove the incentive to keep costs down.

Referring to the high prices for specialty drugs that the Wall Street Journal found the companies paid themselves, Braun and Warren wrote, “One key factor driving these high prices appears to be the fact that insurers own other key links in the drug supply chain: pharmacy benefit managers (PBMs) and pharmacies.”

They continued,”Cigna/(Express Scripts), UnitedHealth/(OptumRx), and CVS/Aetna each own or are affiliated with the country’s three largest PBMs, which in theory negotiate drug prices with pharmaceutical manufacturers on behalf of insurers and set prices at the pharmacy. However, when those same insurers and their vertically integrated PBMs also own their own specialty pharmacies, they can profit handsomely. That’s because insurers are not just the payers at the end of the transaction; instead, through their PBMs and pharmacies, they are also the recipients of those funds.”

Regulators and law enforcement are taking note.

Advertisement

In 2022, the Federal Trade Commission announced a major investigation into the practices of the big pharmacy benefit managers.

Then last May, Ohio Attorney General Dave Yost sued Express Scripts, Humana and others under state antitrust law, essentially accusing them of colluding behind a veil of secrecy to fix prices and punish companies that go against them. In the suit, Yost also goes after Ascent, a Switzerland-based “group purchasing organization” formed by Express Scripts’ parent company in 2019. Critics say the purpose of its formation is to avoid scrutiny of its drug-pricing practices. 

CVS and UnitedHealth have formed similar companies in recent years. The FTC last year added those companies to its antitrust probe.

GET THE MORNING HEADLINES DELIVERED TO YOUR INBOX

Advertisement



Source link

Advertisement
Continue Reading
Click to comment

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

West Virginia

West Virginia delegate candidates in Wood County split on top issues, from manufacturing to health care rules

Published

on

West Virginia delegate candidates in Wood County split on top issues, from manufacturing to health care rules


PARKERSBURG, W.Va. (WTAP) – Candidates running for seats in the West Virginia House of Delegates in Wood County say their top priorities if elected range from job creation and workforce development to health care policy changes and infrastructure, as they make their case to voters ahead of the election.

Incumbent Delegate Vernon Criss, a Republican running in House District 12, said jobs would be his top focus, arguing Wood County has been left out of state efforts to attract manufacturing.

“It would be jobs,” Criss said. He pointed to what he described as $340 million available through a high-impact, jobs-related manufacturing fund for companies returning to West Virginia, saying the governor “has refused to use these dollars to help the county.” Criss also cited restoring highway funding and funding for drinking water and sewer projects as priorities.

Criss said he would also push for foster care legislation in the next session, noting the governor vetoed a foster care bill this year that he said would have helped families and relatives caring for children in the system.

Advertisement

In House District 13, Republican candidate Melissa McCrady said her leading priority is repealing the state’s certificate of need program, which she said restricts medical facilities and practices from opening in the state.

“The main issue that I would prioritize is the repeal of the certificate of need,” McCrady said, calling it a program that limits a “free market” approach to health care by requiring approvals before certain services can expand.

McCrady said she would also like to repeal the inventory tax on businesses, which she said makes West Virginia less attractive for economic growth. She also said she supports religious and philosophical vaccine exemptions for children and adults in response to future outbreaks.

On education, McCrady said she wants to give teachers and families more voice in Wood County and reduce what she called burdensome requirements and restrictions placed on classrooms. On jobs and cost of living, she said reducing taxes and regulations and allowing the market to develop would create more opportunity for residents.

Incumbent Delegate Scot Heckert, a Republican running in House District 13, said his top issues include “infrastructure, accountability” and school funding.

Advertisement

“Top issues right now is infrastructure, accountability, for the school funding,” Heckert said. He said policy changes depend in part on what he hears from residents, but added he believes the school aid formula should be reviewed and that traditional public schools, homeschooling and charter schools should be held to the same set of rules.

Heckert said the state needs to do more to support teachers and address long-term retirement funding costs. On jobs and workforce development, Heckert said building a workforce is essential and suggested the state should look at incentives and assistance programs to encourage employment.

Asked about transparency and accountability, Heckert said constituents can contact him directly.

“Any constituent of District 13 can call me anytime,” he said, adding, “You can’t have one without the other.”

Criss and McCrady also emphasized transparency as a priority. Criss said the budget process should remain open to the public, while McCrady said she wants to be accessible through office hours and multiple communication channels.

Advertisement

Candidate for House of Delegates district 12 Charles Hartzog was not available to be interviewed.

Voters in Wood County will choose their delegates in House Districts 12 and 13 in the upcoming election. Details on early voting and Election Day locations are available through the county clerk’s office.

Editor’s note: The video for this story will be added once it airs. Please check back for the updated video.

Copyright 2026 WTAP. All rights reserved.



Source link

Advertisement
Continue Reading

West Virginia

Former PAAC House residents find hope and housing after sudden closure

Published

on

Former PAAC House residents find hope and housing after sudden closure


An abrupt closure at a Charleston recovery home last week left residents searching for a new place to stay, but members of the local recovery community stepped in to help keep many of them on track.

PAAC House closed its doors Friday after funding issues left employees unpaid for nearly a month, displacing 14 residents, many of whom were still in early sobriety.

For former resident John Boso, the closure came after weeks of uncertainty.

“Services started dropping off, we’d have less counseling, less things going on,” Boso said. “And then before we know it, it’s like, you’ve got to find somewhere else to go.”

Advertisement

Caroline Paxton, a founder of the nonprofit True Freedom, said the sudden disruption raised immediate concerns about residents’ stability.

“I think especially in early sobriety, that’s really stressful for anyone. And so our biggest concern was we want to make sure they were able to continue to stay sober and continue on this like recovery journey,” Paxton said.

Paxton and fellow True Freedom founder Michael Paxton said they already knew many of the men through the nonprofit’s meetings. When they learned the residents had just four days’ notice to find new housing, they began working to secure placements — a process that often involves applications, interviews and fees.

They connected with HopeWorks, a recently opened home, and worked to fast-track interviews the next day. HopeWorks Director Catherine Tyler said she fortunately had many beds open and their transition has been smooth so far.

“They’re doing great so far,” said Tyler. “They are already buddies from the PAAC House, and I think that’s going to be really good for them.”

Advertisement

Six of the men were able to stay together, something former residents said has been critical to their recovery.

“It’s awesome that we’re all together,” one resident said. “Brotherhood was the biggest thing we had going for us. That was the only thing we were sure of.”

The men said despite the sudden closure, due to securing placements they have been able to continue attending meetings and focusing on recovery.

Several residents said they feared the disruption could have pushed them backward in their recovery.

“I was hopeless thought I was going to go right back to the life I was living then bam Mike and Caroline to the rescue it was great,” Alden Smith said.

Advertisement

“I thought I had come all this way for nothing,” said Christian Taylor.

Michael Paxton said helping the men find stability has been worth every effort.

“Just to know these guys, know that they’re safe and they have a place they’re loved. You know, they still have another chance at life,” he said.

Those involved encouraged anyone struggling with addiction to reach out to True Freedom.



Source link

Advertisement
Continue Reading

West Virginia

West Virginians weigh in on two races for unexpired terms to state Supreme Court – WV MetroNews

Published

on

West Virginians weigh in on two races for unexpired terms to state Supreme Court – WV MetroNews


West Virginia voters will play a heavy role in shaping the state Supreme Court, which has two of five seats on the ballot.

Although this is a primary election for many other races, it’s the final say-so for these two seats on the state’s highest court.

One election is for an unexpired term to fill the seat formerly held by Justice Beth Walker, who retired last year. The term expires in 2028. Two candidates are running for this seat.

The other election is for an unexpired term to fill the seat formerly held by Justice Tim Armstead, who died last year. Candidates are running to fill out the term that expires in 2032. Five candidates are vying to fill this seat.

Advertisement

Former Walker seat, two years on term

Thomas Ewing was appointed by Gov. Patrick Morrisey to fill the unexpired term until the election.

“What I’ve done is public record,” he said on MetroNews Talkline.

“I’m not running from that. It’s sort of my resume or my statement to the voters. I’ve demonstrated to you how I’ll do this job.”

Ewing served as circuit court judge in Fayette County for eight years before being appointed to the Supreme Court last year.

Advertisement

As a circuit judge, he presided over the Fayette County Adult Treatment Court. He also established and presided over several other programs, including the Fayette County Family Treatment Court, the Fayette County Teen Court and the Fayette County Truancy Diversion Program.

“I think it’s important to continue to have someone with circuit court experience on the Supreme Court,” he said.

He grew up in Hico and is a graduate of Midland Trail High School. He graduated college from Glenville State, where he was captain of the basketball team, and then the West Virginia University College of Law.

From 2004 until 2018, he practiced law with the firm Kay, Casto & Chaney.

“For me, my personal integrity matters, and if you don’t have personal integrity, if you don’t hold yourself personally accountable, then I don’t see how you can uphold the integrity of the judiciary,” he said.

Advertisement

Bill Flanigan is the other challenger for the seat vacated by Walker.

Flanigan is a Wheeling attorney and a Republican member of the West Virginia House of Delegates representing Ohio County. The Supreme Court race is nonpartisan.

“What I tried to do as a legislator and what I want to do on the court is that our laws should be written in a way that are clear and precise, easily applied and within the purviews of the Constitution as it was originally constructed,” he said on Talkline.

He was first appointed to the House of Delegates in 2016 as a Republican representing Monongalia County, but a cancer diagnosis at that time prevented him from seeking election to the seat.

Advertisement

Flanigan and his family moved from Monongalia County to Ohio County so his son could participate in a program for students with dyslexia. After moving to Ohio County, Flanigan was elected to the House in 2024 and currently serves that district.

Flanigan earned his bachelor’s degree from Salem Teikyo University and his law degree from the West Virginia University College of Law.

“I fell in love with the Constitution. I fell in love with the law — how it affects us, what it does for us and how it can apply to each of us as citizens,” he said.

Former Armstead seat, six years on term

Advertisement

Gerald Titus III was appointed by the governor to fill the unexpired term until the election.

“For me, courts, judges should not legislate, should not wade into policy issues — they should let those leaders lead and simply apply the law,” he said on Talkline.

“My job is very simple. It doesn’t mean it’s easy. There are times that it’s weighty and challenging. But for our government to function properly, I think the court plays a vital but limited role.”

Titus, a Charleston attorney, has 22 years of experience in law practice.

Before his appointment to the Supreme Court, he was an attorney with the Charleston-based law firm Spilman Thomas and Battle

Advertisement

He previously served as an assistant U.S. Attorney for the Southern District of West Virginia, where he worked in the Violent Crime Division.

He is a graduate of Washington and Lee University in Virginia, where he earned both a bachelor’s degree in politics and American history and his law degree.

“I just found myself in a place where I wanted to do more, where I wanted to put that experience to use. I’m in the absolute prime of my legal career. I feel like I have the most to give now as I ever will,” he said.

Laura Faircloth is a veteran attorney who has served as a circuit judge in the Eastern Panhandle for nearly a decade.

Advertisement

She was first elected in 2016 to the 23rd Judicial Circuit covering Berkeley, Jefferson, and Morgan counties and then was elected in 2024 to the newly created 27th Judicial Circuit, which serves Berkeley and Morgan counties.

“I am the only independent registered to run in this contested election in division one. I’m also the only woman who is running,” Faircloth said on Talkline, referring to her personal voter registration.

“I’m not a good old boy, and I don’t subscribe to backroom politics, which is where deals are made oftentimes. That’s never going to happen in my courtroom, and it will not happen if I’m a justice on the Supreme Court of West Virginia.”

Before her time on the bench, she led her own six-person law firm in Martinsburg.

She earned a bachelor’s degree in political science from Shepherd University and got her law degree from the WVU College of Law.

Advertisement

“We are like umpires in a baseball game: We call fouls, strikes and balls. We call outs and safe. And that’s it. And to do anything more is trying to assume a role that we are not permitted to assume because the sanctity of the judiciary is not to allow that,” she said.

Todd Kirby is is a circuit judge in Raleigh County and a former Republican member of the House of Delegates.

In the House, he represented the 44th District in Raleigh County starting in 2023.

He was appointed to the bench by then-Gov. Jim Justice in July 2024 to fill a vacancy and successfully won election to the seat that same year.

Advertisement

“There’s a long history of West Virginia Supreme Court justices having served in the Legislature,” Kirby said on Talkline.

Earlier this year, Kirby appeared at a Health Freedom Day rally at the West Virginia Legislature that focused on school vaccination requirements. But he said his appearance was an expression of his principles and should not be interpreted as him taking a stance on specific cases that might come before the court.

Kirby recused himself from a school vaccine exemptions case in Raleigh Circuit Court last year because of votes he had taken at the Legislature.

Kirby opened his own law practice in Beckley in 2011. His career has been heavily focused on child welfare, including serving as an assistant prosecuting attorney in Raleigh County handling child abuse and neglect cases. He has also worked as a guardian ad litem and as an attorney representing foster parents and respondent parents.

He graduated from Marshall University and got his law degree from Liberty University.

Advertisement

“My area of expertise has been the law and of course now as a circuit court judge. I feel like I have the experience as an assistant prosecutor, as an attorney for respondent parents, for foster kids, as guardian ad litem, my time on the House Judiciary Committee,” he said.

“My conservative credentials and my background, I feel like I’m the right candidate for the state at this time in its history.”

H.L. “Kirk” Kirkpatrick  is a senior status judge and a long-time circuit court judge in Raleigh County with more than 30 years of experience on the bench.

“I decided I had plenty of life in me and I could serve West Virginia by serving on the Supreme Court,” Kirkpatrick said on Talkline.

Advertisement

He was first appointed to the bench in Raleigh County by then-Gov. Gaston Caperton in 1995 and was then elected in 1996. He served as the chief judge of the Raleigh County circuit and retired in December 2024.

“I look at myself as a referee,” Kirkpatrick said. “We are required to be impartial and be fair and apply the law in a fair manner.”

Kirkpatrick administered the Raleigh County juvenile drug court for 10 years. He also served on the state Judicial Investigation Commission, which is responsible for enforcing the Code of Judicial Conduct for judges and justices.

After retirement, he was appointed as a senior status judge, a role that allows him to be recalled for temporary assignments.

That way, he presided over the high-profile murder trial of Natalie Cochran, a pharmacist convicted of using insulin to fatally poison her husband. He also filled a vacancy on the Fayette County Circuit Court when Thomas Ewing was appointed to the Supreme Court.

Advertisement

He is a graduate of the University of Kentucky and earned his law degree from West Virginia University.

“My strong suit is my experience,” Kirkpatrick said. “I’ve presided over every conceivable type of trial and case from speeding ticket appeals to murder trials. I’ve handled just about anything that could come down the pike.”

Martin “Red Hat” Sheehan is a veteran Wheeling attorney with 45 years in the legal profession, during which he says he has done a little bit of everything.

Sheehan is a former assistant U.S. attorney and federal prosecutor. He has been in private practice since 1990.

Advertisement

He is the former chairman of the Ohio County Republican Executive Committee and has previously run for a seat in the West Virginia House of Delegates as a Republican.

Sheehan, speaking on Talkline, said he has been motivated by a backlog in the judicial system.

“I think that’s the big issue for me in this particular campaign is to try to get action by the court in a more timely way,” Sheehan said.

“The court loses its moral authority to help the circuit courts to manage their caseloads as well by not being able to take care of its own house.”

Sheehan notably sued the West Virginia Judicial Investigations Commission in federal court, challenging a rule that prevents judicial candidates from speaking publicly about issues likely to come before the court. He argued the rule is unconstitutional.

Advertisement

“I think I’m dedicated to trying to get something done,” he said. “The problem is it’s very hard for the judges to campaign. I’ve also brought suit, somewhat unsuccessfully at this time, to declare a couple of cannons in the judicial code unconstitutional because they limit the ability to have contact with the public as candidates.

“What you’ll see is, everybody running for the Supreme Court says they’re people of integrity, people of experience, whatever, and nobody is talking about any serious issues about how to fix things at the court.”

Sheehan got his bachelor’s degree from Tufts University and his law degree from Duquesne.

While he appears with the nickname “Red Hat” on the ballot, he was previously known on ballots as “Red Shoes” because of his choice of flamboyant footwear.

Advertisement



Source link

Continue Reading
Advertisement

Trending