The next drug pricing target: pharmacy benefit managers - Axios
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The next drug pricing target: pharmacy benefit managers

Richard Saxon / Flickr Creative Commons

Pharmaceutical companies have a big target on their back. But there's also a push to shine more light on the intermediaries known as pharmacy benefit managers and how they fit into the national furor over drug prices.

Why it matters: These intermediaries are getting some of the money from drug sales, so they may be part of the chain that's leading to higher drug costs. Read on to find out what might happen.

David Balto, a former antitrust attorney with the Justice Department and Federal Trade Commission and a critic of pharmacy benefit managers, has been in touch with Democratic leaders about regulating the companies. Balto wouldn't say who those legislators were, but it's likely the 19 senators who wrote to President-elect Trump in December about drug prices, including Bernie Sanders and Elizabeth Warren, will be interested.

A possible bipartisan issue: A spokesperson for Republican Sen. Chuck Grassley, who hasn't been shy about taking a critical eye toward the health care industry, said the senator is "looking at all factors that might contribute to higher drug prices, including the role of PBMs."

Why now: Employers, unions and health plans hire pharmacy benefit managers to create pharmacy networks and negotiate down prices from drug makers. They've hit criticism in the past. Balto, who represents consumer groups and independent pharmacies, argues that pharmacy benefit managers "don't do anything other than build the network and move information and money."

Last year, pharmacy benefit managers were partially blamed for the rising price of EpiPens. Mylan, which makes the EpiPen, circulated a chart that said pharmacy benefit managers and other actors in the supply chain were eating big slices of the cost pie. Pharmacy benefit managers, in particular, pocket sizable sums of the drug rebates they negotiate. Hence, the higher price.

PBMs aren't having it: Mark Merritt, chief executive officer of the Pharmaceutical Care Management Association, the PBM lobbying group, told me that nobody was buying Mylan's chart or the testimony of Heather Bresch, Mylan's CEO. "It was a load of bull. She was trying to distract that she had made a simple pricing decision."

Merritt added: "Drug pricing is not well understood by just about anybody. You and your compadres in the press get it wrong all the time."

But drug pricing economics is extremely complex: Even experts at the Medicare Payment Advisory Commission, which advises Congress on health care policy, think pharmacy benefit managers are overly covert. "There is a real complexity in how PBMs operate and where they get their revenues," the commission said in a June 2016 report. "Because rebate amounts are proprietary, it is difficult to know with certainty."

Why this won't go away: New York Gov. Andrew Cuomo unveiled new regulations for the benefit managers this month, such as requiring them to be licensed and disclose reasons why certain drugs are promoted. If the federal government doesn't look into those companies, more states could.

Balto said pharmacy benefit managers operate in a "regulatory-free zone" and rules like those in New York will help. But Merritt countered that regulations will raise drug costs, and the New York measure could be illegal based on the Employee Retirement Income Security Act, the federal law that governs many pension and health plans.

Size and scope: CVS, Express Scripts and OptumRx dominate the pharmacy benefit manager space, processing about 75% of all prescription drug claims. Although they have relatively small profit margins, they are handling a lot of money. Express Scripts, for example, banked $2.5 billion in profits in 2015 off of $102 billion in revenue.

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Farenthold faces new allegations from male staffer

Texas Rep. Blake Farenthold. Photo: Jacquelyn Martin / AP

A former communications director for Rep. Blake Farenthold told CNN that the Texas congressman's office was such "an intensely hostile environment" that he was "[driven]...to physical and emotional distress."

Why it matters: The House Ethics Committee is already investigating Farenthold for separate sexual harassment allegations, which were reportedly settled by the Office of Congressional Ethics in 2014 for $84,000. Rekola shared his allegations with the office of Rep. Susan Brooks, the chairwoman of the committee.

  • In 2015, when the former staffer, Michael Rekola, was about to leave town for his wedding, Farenthold told him: "Better have your fiancee blow you before she walks down the aisle — it will be the last time."
  • Rekola said he was "disgusted," and gave his two weeks notice upon returning from the wedding. Farenthold denied making the comment.
  • Rekola told CNN that Farenthold called him a "f---tard," and another staffer confirmed that he regularly referred to aides that way. Farenthold told CNN he called aides that it "in jest," but that in hindsight, "it wasn't appropriate."
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PBS suspends "Tavis Smiley" for sexual misconduct

Tavis Smiley of PBS, talks with Lower 9th Ward resident Carolyn Parker for Smiley's late-night PBS program. Photo: Bill Haber / AP

The late-night show "Tavis Smiley" was suspended by PBS after an investigation of Smiley that resulted in "multiple, credible allegations of conduct that is inconsistent with the values and standards of PBS," Variety reports.

  • Per Variety, the investigation revealed sexual relationships with subordinates, and a "verbally abusive and threatening environment" created by Smiley.

Why it matters: Another powerful man has been taken down by allegations of sexual misconduct, joining dozens of other men.

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Microsoft taps AI, Reddit to make Bing smarter

Microsoft AI and Research chief Harry Shum, speaking in San Francisco Wednesday. Photo: Ina Fried/Axios

Microsoft announced a bunch of new partnerships Wednesday as it aims to show itself as a leader in the field of artificial intelligence. It's also adding a bunch of AI-powered features to its own products, including its Bing search engine along with a deep integration of content from Reddit.

Why it matters: AI is one of the hottest areas in tech and Microsoft is competing with Google, Facebook, IBM and others for talent, mindshare and deals.

Partnerships: Microsoft announced efforts with a range of companies, including Reddit, UPS and China's Cheetah Mobile. In the Reddit deal, Microsoft's Bing search engine will use content from the online discussion community, including its popular "Ask Me Anything" Q&As.

Internal efforts

  • On the Bing front, Microsoft is using AI to deliver answers that combine information from multiple sites. That can allow results that compare different arguments on an issue, explore the differences between two things or just deliver a summary of facts from more than one place, with footnotes showing where the information came from. It is also making Bing more conversational and allowing people to search within images.
  • With Cortana, Microsoft is trying to help its digital assistant stand out from a crowded pack that includes Apple's Siri, Google's Assistant and Amazon's Alexa. Microsoft's case is that it is the only digital assistant that stretches across work and personal life. To that end, Microsoft said Cortana can now understand calendar and other data from Google's Gmail. It's also building Cortana into Android apps, including the CM Launcher app from China's Cheetah Mobile.
  • Microsoft is also expanding its use of AI in Office 365. A new insights feature will automatically make charts showing trends within a complex spreadsheet. Within word, AI will help make sense of acronyms within a document using other documents within the company. Microsoft already prioritizes which e-mails to read first, but a new feature will help find the action items within Outlook.
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The debate over inequality

Last week, we reported that the wage inequality gap in the U.S., a primary source of the polarization among Americans, has been shrinking: For five straight quarters, wages have been growing the most for U.S. workers with only a high school diploma.

Data: Indeed analysis of BLS monthly jobs data; Chart: Axios Visuals

But readers pushed back:

  • "Surely you're kidding?" wrote James Harvey, executive director of the National Superintendents Roundtable. The percentage wage increase is better for high school graduates, he said, but the dollar increase still favors the rich: a 3.3% raise for someone making $20,000 a year is $660—only an eighth of the $5,000 raise going to someone earning $500,000 and getting a 1% increase.
  • In a phone call, Upwork CEO Stephane Kasriel told me, "The 1% is doing a lot better, and for the 30% and 40% at the bottom, it keeps getting worse."

Quick take: The times do indisputably favor the rich:

  • When adjusted for inflation, U.S. wages are up only 10% from almost a half-century ago.
  • Meanwhile, wealth held by the top 1% has surged: it rose to 38.6% of the total in 2016, from 36.3% in 2013, the Fed said in a report in September, while the bottom 90%'s wealth has fallen for almost three decades—last year, it was 22.8% of the total, compared with 33.2% in 1989.
  • FoW reader W.Spackman linked to this July report by Deloitte, which said income inequality today is comparable with the Gilded Age of robber barons, in the 19th century (Figure 3).

And Charlie Allenson, a FoW reader in New York, made another point: "Many of those chronically not working are not getting back to work. Namely, those more 'mature' workers. Ageism rolls on. Personal example: People look at my website and love my work. They meet me, see the gray hair and suddenly they're going in a 'different direction.' This is a constant for me. And it sucks."

But there are in fact signs of an improvement in the fortunes of ordinary people, and wages and salaries are among them, says Jed Kolko, chief economist at Indeed.com, the jobs listing website, who wrote the blog post on which we were reporting. In an email exchange, Kolko told me:

  • Harvey and Kasriel are correct to single out the vast concentration of income at the top, comprised largely of non-wage earnings like capital gains, interest and dividends—which combined are how the wealthy make most of their money.
  • But wages earned for work are another lens into the inequality story, and in that realm, the gap indeed has narrowed.
  • The shrinking wage gap is important to watch because wages and salaries are a large component of pre-tax money income, which includes interest, dividends and income from property. The Bureau of Labor Statistics puts the proportion at 76.8%. (see pages 8-9 in this BLS report).

The Fed, too, has noted the trend favoring less-educated workers. According to a Fed report released in September, income rose from 2013 through 2016 for all income groups, after accounting for inflation, which was a change from the prior three years, when income was stagnant. But the highest growth — an average of 25% — was among families without a high school diploma; in the 2010 to 2013 period, income fell for these workers, the Fed said.

Thought bubble: Inequality is not an absolute metric. If it were, ordinary people could legitimately lash out about wealth at the top regardless of how they themselves were faring. The rise of wages at the bottom and in the middle is slow, and the trend could halt—that is a point that Kolko makes. But it remains notable that the numbers are no longer going only in one, inexorable direction—there are metrics pointing to growing wages and salaries, and more jobs, for those whom the economy has been leaving behind.

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Bitcoin: 'This is a casino, not an investment'

Illustration: Lazaro Gamio / Axios

Bitcoin is up about 1,700% since the start of the year. Some attribute the surge to ordinary, if enthusiastic, investment, along with the forces of supply and demand. Others say it's a bubble, and that it will ultimately burst. Joe Borg, president of the North American Securities Administrators Association, a grouping of state securities officials, suggests it's the latter. "This is a casino," he tells Axios, "not an investment."

The bottom line: Borg, who is also director of the Alabama Securities Commission, says he could be wrong and that those who say bitcoin is just "another type of investment" will be proven correct. But he sees worrying signs of a classic investment mania.

Among the signs:

  • People have told him they have taken out home equity lines of credit to buy bitcoin.
  • Those doing so, he said, are mostly millennials and young baby boomers.
  • "They seem to think anything electronic is a game," Borg said. "There are entrepreneurs who run Facebook, and they put this in the same category."

Thought bubble: If bitcoin collapses, which has been the normal course in big, sudden investment manias, the price is highly unlikely to go to zero, meaning a lot of people will still be in the money. But lots of people will lose, too, including perhaps some who have taken out those home equity lines of credit.

That there is a fever is indisputable. It is global, and especially heavy in Asia. Ordinary South Koreans are the most aggressive bitcoin investors, in addition to Hong Kong Chinese, Japanese and Vietnamese, report the WSJ's Steven Russolillo and Eun-Young Jeong. Together, they account for almost 80% of global bitcoin trading. Other reminders of fevers past:

  • Most of these Asians buying bitcoin are the general public, not professional traders.
  • At the point last week when bitcoin went above $17,000, it was almost $25,000 in South Korea, almost 50% higher, the WSJ said. In other words, the trade is chaotic to the point of irrationality.
  • At the FT, Izabella Kaminska writes today that even central banks are "getting drunk on the collective cryptocurrency/blockchain Kool-Aid."

A point that increasing numbers of observers are making is that bitcoin is only an investment, with no other real-life, large-scale utility, at least at present: bitcoin and other cryptocurrencies are too slow and cumbersome to serve as money, their original purpose.

  • In a speech today in Sydney, Phillip Lowe, the governor of the Reserve Bank of Australia, makes the point: "The current fascination with these currencies feels more like a speculative mania than it has to do with their use as an efficient and convenient form of electronic payment."
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Jones gets 'gracious' call from Trump, invited to the White House

Doug Jones is greeted by a supporter before speaking during an election-night watch party Tuesday, Dec. 12, 2017, in Birmingham, Ala. Photo: John Bazemore / AP

Senator-elect Doug Jones of Alabama on Wednesday said had "a very gracious" phone call with President Donald Trump, in which he was invited to visit the White House and congratulated for his stunning campaign victory.

“It was a very gracious call. I very much appreciate it. He congratulated me on the race that we won. He congratulated me and my staff in the manner in which we handled this campaign and went forward. And we talked about finding that common ground, to work together. And he invited me over to the White House to visit as soon as I get up [to Congress],”
— Doug Jones at a press conference
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Here's the DOJ's letter that delayed the Waymo-Uber trial

In a letter to the judge overseeing Waymo's lawsuit against Uber, the Justice Department says that a former Uber employee suspected the company helped its then-CEO covertly communicate with a startup the company eventually acquired. A document detailing the employee's original concerns will be released on Friday.

Why it matters: The Justice Department's notice to the court led to a second delay to the trial between the two companies. The ex-Uber employee's concerns, which he communicated to the company back in May after being fired, were never mentioned in the case until that point, raising questions about whether the ride-hailing company was purposefully hiding.

  • This is also the first confirmation of a Justice Department criminal probe into Uber, beyond rumors and media reports.

However: Another Uber employee testified last month in court that the presentation he gave on secretive communications, referenced by the former employee and Justice Department, was purely hypothetical. In fact, he and his team had no idea that Kalanick and the startup's founder communicated without leaving a trace until Bloomberg published an article detailing their tactics months later. Uber also argued in court that the former employee sought to extort money from the company after getting fired for poor performance.

Note: The case was referred in May to the U.S. Attorney's Office for a potential criminal probe.

Here's the full Justice Department letter:

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Why Republicans should worry about 2018

Doug Jones is the first Democratic senator Alabama has elected since 1992. His surprising victory continues a trend we've seen in other elections this year — Democratic voters are turning out in significant numbers and independent voters are leaning more toward Democrats. Axios' Alexi McCammond breaks down why that should worry Republicans heading into 2018:

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Trump: We are "days away" from passing tax cuts

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President Trump delivered his closing arguments on tax reform Wednesday afternoon, just hours after GOP lawmakers reached an agreement on an overhaul package. Trump emphasized how passing tax cuts was a key campaign promise, and said "now we're just days away" from keeping it.

Key quote: "But we need your help to get Congress across that finish line. We'll have very little Democratic support, probably none, and that's purely for political reasons. They like it a lot, and they can't say it ... some day we have to come together and do bipartisan — and hopefully it can happen soon."

More from Trump:

  • "I'm here today to tell you that we will never let bad things happen with respect to the economy of our country."
  • If Congress gets him a tax bill before Christmas, the IRS said Americans will start seeing lower taxes and bigger paychecks beginning in February.
  • "Somebody else called me and everybody else the 'Deplorables.' We're proud to be the Deplorables, and we're doing well."
  • Go deeper: The Republicans' looming Christmas deadline.