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Eliminating the Rx Middleman

Prescription Medicine

You might not realize it, but every time you fill a prescription at the drugstore, you’re dealing with a middleman. It’s a practice that’s been going on since the late 1960s, when health insurance companies added coverage of prescription drugs and sought help managing claims from businesses known as pharmacy benefit managers, or PBMs. But in the days since, PBMs have exploded in influence and consolidated in power. Today the three largest PBMs—Express Scripts, CVS Health, and OptumRx—have more than 180 million customers and control about 80 percent of the market. Between 2007 and 2016, the three companies’ operating profits skyrocketed from $3.4 billion to $12.4 billion.

Ge Bai, an expert in health care finance at the Johns Hopkins Carey Business School, thinks some of that profit should stay in consumers’ pockets. The problem, she says, is that not only do PBMs receive an administrative fee from insurers but they also negotiate with drugmakers to include their products on lists of covered drugs in return for rebates, which they often pocket. Essentially, Bai says, PBMs are serving two conflicting customers—being paid both by manufacturers for getting on formularies and by plans for managing their drug benefit.

Bai suggests cutting the cash flow between PBMs and the drug manufacturers and passing on any savings to insurers or employers, a change that may result in lower out-of-pocket costs for patients while helping eliminate the influence of the middleman.

rx middleman
Mirko Cresta

Increasing Gun Safety

Firearms Policy

According to results of a national online survey commissioned by the Johns Hopkins Center for Gun Policy and Research, more than half of U.S. gun owners do not store their firearms in locked safes, cabinets, or gun racks, or use trigger locks—often in homes where there are children present. The findings point to “a real public health emergency,” says the center’s Cassandra Crifasi. “Household gun ownership can increase the risk of homicides, suicides, and unintentional shootings in the home, but practicing safe storage for all guns reduces these risks.”

What’s behind these practices? Feeling uneasy about safety: Gun owners who said their storage decisions were influenced by concerns about home defense were 30 percent less likely to practice safe storage for all their firearms.

But firearms safety training courses offer hope. Gun owners who said the courses influenced their behavior were twice as likely to practice safe storage for all their guns. “Requiring gun purchasers to take safety training classes, as a handful of states already do, might lead to more gun owners storing their guns safely,” says Daniel Webster, director of the gun policy center.

Cautionary Vacancy

Public Safety

When vetting Airbnbs for your next getaway, there’s one set of essential amenities you might be overlooking: safety features.

According to new research from Johns Hopkins, many Airbnb listings lack basic safety features, including smoke detectors (one in five), carbon monoxide detectors (nearly half), fire extinguishers (over half), and first aid kits (nearly two-thirds). “Because most Airbnbs are in residential homes, we expected closer to 100 percent coverage in smoke alarms and more to have CO alarms,” says Johns Hopkins public health researcher Vanya Jones, a co-author of the study.

To keep your stay safe, check the list of amenities on Airbnb listings for safety features like smoke alarms and first aid kits and walk through other safety precautions as part of the check-in procedure. “These are simple tips that can be lifesaving,” Jones says.

cautionary vacancy
Laurent Cilluffo

Improving Care for Transgender Patients


Gender-affirming procedures are on the rise—and insurance programs are increasingly covering them. As LGBTQ acceptance has grown, so has access to surgeries for transgender people: The total number of procedures, such as genital and breast surgeries, increased nearly fourfold between 2000 and 2014, according to one of the first studies to examine patient care among the transgender community.

Out-of-pocket costs for the surgeries are also dropping after the Affordable Care Act banned discrimination because of gender identity. Only 39 percent of patients self-paid during 2014, compared with about 65 percent who did so from 2006 to 2011. Medicare, Medicaid, or private insurance covered the rest. The study also found that the surgeries are safe: There were no reported in-hospital deaths resulting from the procedures during the observed time frame.

The overarching goal of studying LGBTQ health care is to normalize treatment for transgender patients, says Joseph K. Canner, co-director of Johns Hopkins Surgery’s Center for Outcomes Research. “Eventually, we can move from bean counting about how many gender-affirming surgeries have been done to patient- and clinic- reported outcomes, putting these procedures in the same sphere as virtually all other types of surgeries,” Canner says.

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