St. Louis Post-Dispatch, March 10
Express Scripts went from zero to $67 billion in 32 years, a symptom of American health care costs
Over the years, as successive St. Louis-headquartered companies have disappeared, there were at least colorful, long histories to recount. Not so with Express Scripts, which on Thursday announced a $67 billion merger that will make it part of Connecticut-based Cigna, the nation's fifth-largest health insurance company. Express Scripts is a mere 32 years old.
That it grew so quickly into the nation's 22nd-largest industrial corporation — the largest ever to call St. Louis home — is a testimony to savvy management, but also to the explosive growth of American health care costs, particularly the cost of prescription drugs.
Never miss a local story.
Health care is now 17.9 percent of the American economy; prescription drugs are 17 percent of health care costs and growing faster than any other part. Express Scripts itself has pointed out that since 2008, prices for commonly used household goods have increased 14 percent while prescription drug prices have risen by 208 percent.
In 1986, Barrett Toan, a former director of the Missouri Department of Social Services, and his partners realized that there might be money to be made in managing prescription drug programs for corporate health care plans. Express Scripts became one of the earliest pharmacy-benefits managers. Today it manages prescriptions for 100 million Americans.
Pharmacy-benefits management companies put a lot of corner drugstores out of business. Mom and pop couldn't compete with companies that bought drugs by the truckload. Express Scripts deserves credit for slowing the rate of drug-price increases by insisting on greater use of generic drugs.
Express Scripts also took credit for negotiating rebates from manufacturers of expensive name-brand drugs and passing the savings on to customers. In late 2016, Wall Street critics suggested Express Scripts was keeping the rebates for itself. The company insisted that it passed on 90 percent of the rebates to customers.
No one knows for sure because, like most other parts of the health care industry, the pharmacy-benefits management business is opaque. That no one knows why drugs, procedures, doctors and equipment cost what they do is a big reason Americans pay the highest drug and health care prices in the world.
Politicians, including President Donald Trump, have vowed to do something about it. Instead Republicans went to great lengths to undermine the Affordable Care Act, which at least was trying to slow down rising costs.
So the market will try to do it. Insurance companies have taken over the business, eliminating other middle men in the crowded space between doctors and their patients.
On the horizon, perhaps, is Amazon, the 900-pound retailing gorilla, which may begin selling prescription drugs like it sells everything else.
Rising health care and drug costs are so intractable that, eventually, public outrage will cause the federal government to step in. Express Scripts' 32-year history will be seen as a blip on the way to a real solution.
The St. Joseph News-Press, March 8
'No' on gas tax? Offer better idea
The motor vehicle fuels tax could be on its way out. If so, we need to have something that replaces it.
This is the realistic view of U.S. Rep. Sam Graves, a leader on transportation issues, who this week said he is "a believer'" in the idea of funding highway improvements through a fee linked to how many miles people drive their vehicles.
This doesn't mean this will happen soon, if at all. But it does speak to the gravity of the state and national debates over how to fund needed highway and bridge improvements now and in the future.
No other specifics were offered by Graves, a veteran Republican lawmaker from Tarkio, Missouri, but various approaches have been suggested. These include odometer checks and other ideas that involve GPS, cellular technology or radio-frequency devices that would record distance traveled and bill the vehicle owners.
Some of these approaches might raise privacy concerns, but all have the upside of allowing policymakers to transition away from heavy reliance on the fuels tax.
The U.S. Chamber of Commerce is backing a federal gas tax increase to address a backlog of highway maintenance and improvement projects — in part because the organization thinks a miles-traveled fee is not close to happening. But Graves sees little interest in a tax increase among conservatives in Congress.
"There are a lot of members out there who are just philosophically opposed," he says.
There also is the looming problem of what will happen in the future as vehicles increasingly become more fuel-efficient or instead rely on alternative fuels, such as electricity. The trend for motor fuels usage could head sharply downward despite the ever-present need to maintain and expand the transportation system.
People with fuel-efficient vehicles would pay more under the miles-traveled model, rather than with a gas tax, but the real benefits come in ensuring that all travelers would be paying a proportional share and that the total funds collected would rise as the population increases and travel increases.
Graves, in line to possibly be chairman of the House Transportation Committee, recognizes a new funding model likely is needed, particularly for the future, and is openly talking about an option he sees as viable. This is a model for others in Washington and our state capitals.
Far too many elected officials in the current climate refuse to even discuss how they plan to pay for fixing our crumbling highways and bridges. If they are "no" on a gas tax, they need to offer a better idea.
The Jefferson City News-Tribune, March 8
State must strike a balance with new opioid initiative
Gov. Eric Greitens deserves credit for taking steps to address what is being called an epidemic of opioid abuse in the state.
His latest initiative cracks down on Missouri doctors who over-prescribe the pain medication. Specifically, it targets the estimated 8,000 doctors "whose prescribing habits do not adhere to one or more Quality Indicators pertinent to the use of an opioid."
The Kansas City Star reported they were flagged for not adhering to Centers for Disease Control guidelines that discourage keeping patients on opioids for more than three months, in most cases.
The 8,000 doctors flagged are out of about 19,000 doctors in the state, the Star reported.
The paper said Missouri Medicaid's program, MO HealthNet, covers almost 1 million people. Most of them are low-income children, pregnant women, the elderly and people with disabilities.
While we support the governor's initiative, we have two concerns: It must strike a balance between cracking down on unnecessary opioid prescriptions, while allowing doctors to use their professional discretion to prescribe the medication when necessary.
Flagging 42 percent of the state's doctors seems excessive.
Under new regulations that began last week, MO HealthNet recipients will have to get prior authorization from the state to fill opioid prescriptions past 60 days of use.
The 8,000 doctors will be asked to change the way they prescribe Vicodin and other narcotic painkillers. They'll also be asked to consider referring people on long-term opioids to addiction programs, the Star reported. Those who don't respond after being warned twice could face professional sanctions.
To us, that seems a bit heavy handed, although we recognize the need for action to be taken. Our state remains the only one in the nation not to have a formal prescription drug monitoring program (PDMP).
We hope the state implements the program in a way that addresses the problem with over-prescribing while respecting the professional judgment of physicians.