I had the pleasure of meeting Chris Deacon at Health Rosetta in Denver. She is an attorney by profession and was responsible for the Employee Benefits Plan for the State of New Jersey (800,000 members). She is the author of “The Great American Healthcare Heist” https://www.amazon.com/stores/Chris-Deacon/author/B0F8RBX2DV?ref=ap_rdr&isDramIntegrated=true&shoppingPortalEnabled=true
She is a vital voice for the reformation of the broken business of healthcare in America.
Here are the technical questions employers should be asking Cigna and their PBM right now:
1. Double Dipping: What portion of plan costs are attributed to PBM administrative fees, spread pricing, and network “performance” fees on specialty scripts filled at Shields-managed pharmacies? Is there a reconciliation showing the combined take from PBM + Shields?
2. White Bagging & Site-of-Care Shifts: Are prior authorization and formulary rules forcing site-of-care shifts (e.g., “white bagging” into Accredo or Shields)? Can we see the cost-per-infused claim under buy-and-bill vs white bagging?
3. 340B Interference: Are our claims at Shields-partnered 340B hospitals subject to differential reimbursement or spread capture? Is Cigna applying contract pharmacy exclusions or clawbacks on 340B claims?
4. Limited-Distribution Drugs (LDDs): What contracts govern our plan’s access to LDDs? Is Accredo or Shields listed as a mandatory LDD channel, and if so, how is pricing validated against open distribution models?
5. Rebates, GPO, and Maximizers: Are rebates for these drugs flowing through Ascent Health Services (Cigna’s GPO)? If so, do we see pass-through at invoice level? Are copay maximizer or accumulator programs applied to our population, and who captures that value?
6. Contractual Protections: Does our PBM agreement include:
▪️ a no-steerage clause (preventing Cigna from self-dealing between Accredo and Shields),
▪️ disclosure of all specialty network fees, and
▪️ audit rights across both pharmacy and medical benefit claims?
To make this issue more “real” for you, lets take an employer with 1,000 employees. At an average of $15,000 per employee per year, that’s about $15 million in total health plan spend.
Roughly a quarter of that is pharmacy spend ($3.75 million). Half of pharmacy spend is specialty drugs ($1.9 million).
Now add in “double dipping”: If the PBM takes just 5% in hidden fees, that’s about $94,000.
If Shields (as the hospital specialty pharmacy manager) takes another 5%, that’s another $94,000.
Together, that’s nearly $200,000 a year siphoned off in hidden layers of profit — for just 1,000 employees.
Scale that up to 10,000 employees and we’re at $2M or 100,000 employees and we’re at $20M- that’s real money. All flowing through quietly, without line-item visibility.
Employers can’t afford to take these transactions at face value. The dollars at stake are real, and they’re coming directly from your plan assets.
Ask the hard questions.
