Too bad the statistics in the article are so dated. I notice the doctors’ income data dates from 1999.

Doctors incomes were much lower in the 1950’s. They skyrocketed when doctors used their control of the number of medical school pupils to increase their compensation.

This is a supply and demand issue. Unlike lawyers, doctors control how many people enter their line of work. This allows them to control supply. Unlike other services, when you are sick, you must have a doctor. It can be a life or death issue. This means demand is fixed while doctors control the supply. There is no “free” market in medical care.

The doctor who complains about his hours should remember that the long hours doctors sometimes work are a direct result of decisions made by the profession.

A great tragedy in all this is how we import many of our doctors from countries that have desperate need for better medical care.

A mark of how powerful doctors have become is the utter lack of discussion of this issue. Congratulations to this website for even mentioning the issue.

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For the reasons made obvious as you read, the Board of Veterans’ Appeals, so-called veterans’ court, once again, are determined in frustrating my efforts in appealing my claim, by a still further delay. Is there something about this case that warrants this delay?
Could the reason be, of the well over 1.1 million VA prescriptions, some veterans are being over-charged?
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My claim, VA violation of 38 USC 1722A was denied by the Board of Veterans Appeals. I then filed with the United States Court of Appeals for Veterans Claims (CVA). On 7/11/2007 was remanded back to the Veterans Board of Appeals (BVA). The BVA lost and rebuilt the file, that being the reason for the remand. After repeated checking, as of 6/9/08, now 11 months later, this remand, has not been returned to the BVA. So they say. It is obvious they may have lost it again in order that this claim, or I, would go away. Disappear. Perhaps I’ll die? Case closed!
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VA prescriptions are dispensed in supplies of 90 days. However, for those unfamiliar with my claim, to explain these over-charges by the VA in violation of 38 USC 1722A, this example will be at it’s simplest and most understandable throughout my explanation, . Let’s say that you are at the VA, standing in line getting your prescription. The vet in front of you is getting the exact same prescription. She picks up her 30 day supply of 30 pills. Her copay for a 30 day supply of 30 pills is $8. You also are dispensed an $8 supply of 30 pills of the same exact prescription. Being that your condition is not as severe, your prescription requires you to split this 30 pill $8 supply. After you sit down at your kitchen table and split your 30 pill supply, now you have 60 split pills, a 2 month supply. But hold on! Except your co-payment cost for this 30 pill, $8 supply, now that it has been split, has increased. It now carries a co-payment of $16. This explains how veterans’ has been overcharged by the VA since 2002. Shafted again (3/13/07) by the Board of Veterans Appeals in their phony denial. Do you see anything wrong? You should!
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“Pursuant to Section 20.1404(b) (2002), the motion alleging clear and unmistakable error in a prior Board decision must set forth clearly and specifically the alleged clear and unmistakable error, or errors, of fact or law in the Board decision, the legal or factual basis for such allegations, and why the result would have been different but for the alleged error.”
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The two persons listed on the denial that had crafted, and fashioned up the logic that follows? Board of Veterans’ Appeals counsel M. Taylor, and Veterans’ Law Judge, Judge John E. Ormand. I will show you exactly where, in their efforts to mislead, and to rewrite the law. This is the kind of garbage veterans have to put up with! Let’s look at the reasoning in their BVA denial.
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Cited on the cover page of my denial was, “THE ISSUE. Whether the veteran is obligated to pay the Department of Veterans Affairs (VA) a copayment for each 30-day or less supply of medication provided by the VA on an outpatient basis in an amount established under 39 C.F.R. § 17.110.”
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“Criteria & Analysis by the Board of Veterans Appeals.” 3/13/ 2007
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Here the Board understands the problem. “The record reflects that the appellant is prescribed a 12.5 mg daily dose of his medication. Because the medication is not dispensed in a 12.5 mg tablet, his physician has instructed him to split a 25 mg tablet in half to achieve the proper daily dosage. Thus, he receives a 30-day prescription consisting of fifteen 25 mg pills, each of which he splits in half to take one half of a pill per day. The appellant contends that the standard co-payment is excessive in light of the pill splitting.” However, no where in my claim did I mention the word ‘standard’, nor was the word ’standard’ mentioned in 38 USC 1722A, or Federal Register, Final Rule. Here, in introducing ’standard’, supposedly for the purpose of establishing two (2) ‘standard’ co-payments, counsel Taylor purposely has rewritten the law, in order to mislead.
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“In addition, the Board notes that the reference to the cost of medication contained in 38 U.S.C.A. Sec. 1722A clearly pertains to VA’s cost in dispensing the medication, not the cost to the appellant.” Is there a difference? My claim…clearly pertains to VA’s co-pay cost in dispensing medication, and it’s inflated cost to the appellant! Which is the “excess of the cost” for the ’standard’ co-payment, and is then arbitrarily increased, to those veterans required to split their 30-pill, $8 supplies. Dispensed exactly the same, and in like manner, as all other VA dispensed ’standard’ co-payment and abundant 30-day $8 supplies of 30-45-60-90 pills.
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Counsel Taylor references remarks from the July 16, 2001 Federal Register. “Also, as we stated in the proposal, under 38 U.S.C. 1722A, VA may not require a veteran to pay an amount in excess of the actual cost of the medication and the pharmacy administrative costs related to the dispensing of the medication. VHA conducted a study…and found that the VA incurred a cost of $7.28 to dispense an outpatient medication even without consideration of the actual cost of medication..”
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Dispensing! Where there is no difference in the prescription, supply amount, handling, or dispensing time, a 30 pill supply is dispensed, with a $16 co-payment. Interestingly, in the same exact manner as all 30-day, 30 pill $8 supplies are dispensed, as explained in the Federal Register! No splitting of pills was involved in the dispensing procedure. However, of an exact same $8 dispensed supply, automatically these ’standard’ 30-day $8 co-payment whole pill supplies are increased 100% (2 month split pill supply).
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Counsel Taylor, citing, “1722A clearly pertains to VA’s cost in dispensing”. Counsel Taylor just does not get it! Nor does Judge Ormand. Their is no difference! No difference in dispensing two supplies that are exactly alike in prescription and supply, or to the cost related to dispensing! However, counsel Taylor is emphatic in making the point, conclusive, that it clearly pertains to the cost in dispensing? Or is it the ISSUE, the ” 30-day or less supply”? For some unknown reason, which counsel Taylor did not elaborate on, a second exact duplicate supply increases, double the co-pay cost? Although, counsel Taylor may have tried, but failed.
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“38 USC 1722A; (a)(1) Subject to paragraph (2), the Secretary shall require a veteran to pay the United States $8 for each 30-day supply of medication furnished such veteran under this chapter on an outpatient basis for the treatment of a non-service-connected disability or condition. If the amount supplied is less than a 30-day supply, the amount of the charge may not be reduced.” Which then also means, if the amount is not less than 30-day supplies, as described in paragraph (1) the Secretary may not require a veteran to pay an amount in excess of the cost for medication provided to a veteran as described in paragraph (2).
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Citing my argument, BVA’s counsel Taylor, quotes inaccurately. An intentional selection and placing of the word, “of” in order to confuse, and again, to mislead. 38 USC 1722A “Copayment for medications. Paragraph (2) The Secretary may not require a veteran to pay an amount in excess of the cost of the Secretary for medication as described in paragraph (1).”
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The correct reading is, “(2) The Secretary may not require a veteran to pay an amount in excess of the cost to the Secretary for medication described in paragraph (1).”
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“The appellant has not cited to, and the Board is unable to find any authority allowing for a deviation from the standard copayment.” The Board is right! I too, am unable to find that authority.
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Where the Board got it wrong! Of all what you have understood and read so far, what follows puts to rest any doubts as to the 30-day medication over-charges in my claim, and refutes the reasoning of the Board of Veterans’ Appeals in their reading of 38 USC 1722A. Of everything that has been explained, BVA counsel Taylor’s reference to 38 USC 17.110, (addressed in my claim) is the key to explaining, what counsel Taylor and Veterans Law Judge John E. Ormand, and the VA failed to, or did not, want to comprehend, or consider in their thinking, in understanding 38 USC 1722A.
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The Board counsel Taylor, referenced 38 USC 17.110; Copayments for Medication. “..a veteran is obligated to pay a copayment for each 30-day or less supply of medication provided by the VA on an outpatient basis (other than medication administered during treatment).”
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Counsel Taylor made it a point to reference 17.110. Veterans’ do know we have to pay a co-payment. THE ISSUE was obviously a “30-day or less supply.” The Board’s main argument to my claim, is their erroneous interpretation of what the law is. “Each 30-day or less supply”, is suggesting to them, an across the board 30-day 15 pill supply is less. However, “..each 30-day or less supply”, refers to only one (1) condition. Veterans who may visit a VA facility on a one time basis as an outpatient. For emergency room care, or see a doctor for a cut finger, brief illness, etc. I wish counsel Taylor would explain another circumstance in which a veteran may be charged an “excess of the cost”? Please enlighten us. I know of no other “excess of the cost” than what I claim.
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Counsel Taylor better not again, bring up 15 pills is less than a 30-day supply! The reality is, a veteran who falls under the 17.110 meaning, “obligated to pay a co-payment for each 30-day or less supply…on an outpatient basis (other than medication administered during treatment.)”, refers to medication, in a dispensed 30-day supply of 15 pills, for treatment on an outpatient basis. The veteran in fact is not receiving less than a 30-day supply, this is his full 30-day monthly supply during outpatient treatment! For this reason, as described in 1722A, paragraph (2) is the basis for my claim. A 30-day, 30-pill, dispensed supply, for treatment, whether or not it is split, according to 1722A carries the maximum co-payment of $8. Which the Board refuses to recognize, but rather relies on a “each 30-day or less” argument. “The secretary may not require a veteran to pay an amount in excess of the cost, for medication described in paragraph (1).” $8 for each dispensed 30-pill, 30-day supply co-payment, includes supplies of the abundant 30-day supplies of 45-60 or 90 pills, and as well for all veterans’ under treatment, receiving a same exact dispensed 30-pill supply. “Other than medication administered during treatment”, a prescribed 2 month supply (split pill).
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Counsel Taylor in an effort in re-enforcing the Board’s position cites “(b) The Secretary, pursuant to regulations which the Secretary shall prescribe may-…(1) increase the co-payment amount in effect under subsection (a);..” Pursuant to regulations? Means according to the law! To regulations as written. Where is this regulation mentioned in the Code of Federal Regulations, this “standard” co-payment you talk about, for $16 split pill supplies? Where, counsel Taylor, does it mention increased co-payment cost for one of two (2) exact duplicate 30-day prescription supplies? Other than my example, where is it mentioned 15 pills is less than 30-day supply? “The Administrative Procedure Act requires that agencies publish administrative regulations in the Federal register before they can be legally effective.” Where?
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The VA, and the BVA , they want me to pass on, disappear. When that happens, veterans you lose. They don’t want you to win. However, this claim will live on, when other veterans think it’s important enough of a veteran’s issue to file a claim. Turned down by the RO, it’s (BVA) $50 filing fee is well spent. A younger veteran, whose prescription requires splitting, and over-charged, can file right now, and can keep playing the same silly game that the VA and the BVA insists on playing, just as long as they can.

Here is something that actually DESERVES to be taxed — and the legislature, which is busy taxing everything under the sun, doesn’t do it!

For-profit medical insurance has priced itself out of the marketplace and enriched shareholders. They’ve killed the goose that laid the golden egg and expect a place at the table — sorry sunzabastards, in my book.

I’m still waiting for the US to declare that medical care is a basic human right, free of political and economic constraints. Other countries have done that, and gone on to universal coverage.

Alas, I won’t live to see the defeat of the corporatocracy. But between now and then, I intend to work for wresting medical and health decisions away from the corrupt health insurance industry. That’s why I sold my Aetna stock…

Recently, you may have heard or read in mass media sources about the issue of pharmacy benefit managers who have clients that are prescribed biologic medications and then are required to pay a great deal of money for such meds due to the placement of these meds on their PBMs. This is due to their status on the PBM, which is known as Tier 4 status, which requires patients to pay higher co-pays for these meds. Tier 4, which also includes lifestyle meds, is determined by the PBM based on variables such as rebates and discounts from the manufacturer, which are intended to be passed on to the PBM clients. However, in some cases, the PBMs fail to do this, and have been penalized for their self-interest above patient interest as required when this activity is discovered. Regardless, because of the tier 4 status of biologics, very sick patients have to pay a great deal of money for these meds. PBMs, by the way, are pharmacy benefit managers, which were created for the pharmaceutical needs of employees normally and is a benefit along with their insurance through their employer.
First of all, biologic meds are specialty meds created differently than other typical meds, and therefore are have a unique molecular complexity that are designed for serious illnesses such as anemia or multiple sclerosis. Because of their uniqueness and exclusivity, they are very expensive- costing thousands a month for the payers. In addition, generics are not authorized to be produced as of yet for these types of meds. Their cost of these biological meds is contributed more for the complex process of their creation, as the material costs are typically less expensive than traditional molecular medications.
Biologics began to be used primarily in the 1980s and now presently make over 60 billion a year, with about 20 percent growth in this market annually. With anemia patients, oncology and dialysis clinics are targets for such meds in this category, as anemia is associated with their treatment and conditions for such diseases.
Yet, some claim that biologic meds benefit patients to only a certain degree, as they extend life of such patients, such as those on chemotherapy or dialysis, by only a few months, so the high cost of the meds is questionable and has been analyzed by others, yet no substitutes exist for biologics, so that’s why the producers of these drugs can charge so much for these products. Efficacy of these biologic meds have also been questioned as well in other treatment aspects aside from life extension.
Then there is the issue of fraud with kickbacks and overuse of some of the biologic meds used to treat anemia in dialysis clinics in particular. On a few occasions, doctors and clinics have been penalized for overusing the meds and for kickbacks in the form of discounts of the manufacturers. Ironically, the dialysis process was never patented, yet the many centers that exist have proven to be very profitable, more for some than others. An example is the situations where dialysis doctors, called nephrologists, have been accused of over-dosing patients with biologic meds to increase their income through their discount arrangement through the manufacturer of such meds, such as those biologics for anemia, and this arrangement is being investigated by regulators and encouraged by the representatives of such meds.
Presently, there are many that approach the FDA to aggressively insist that generic biologics be allowed into the market for the benefit of these critically ill patients, and this would be of great benefit for such patients, and this can be done, as far as the generic creation of these meds. And this situation illustrates one of many flaws in the U.S. Health Care System- when the sickest have to complicate their illnesses by possible financial stress, such as the case with biologic meds. Relief is needed, and should be demanded by the public. After all, why be so sick, and then be financially burdened?
“A little learning is a dangerous thing.” —- Alexander Pope

Dan Abshear