JustCare

Tag: CVS

  • Primary care through CVS? Financial incentives pose a serious concern

    Primary care through CVS? Financial incentives pose a serious concern

    Lucia Ryll shares her opinion in MedPage Today on the risks posed by CVS’ latest move into primary care. Ryll recognizes the obstacles many people face accessing primary care, including delays that can result in poor health outcomes. She questions whether CVS Health offers a solution in the form of primary care doctors at its clinics, given CVS’ financial incentive to maximize profits.

    CVS Health now has nearly 10,000 retail stores. It also operates just over 1,000 MinuteClinics. Caremark, its Pharmacy Benefit Manager (PBM) serves 105 million people. It sells 6,000 CVS-branded medical products. And, it provides health insurance to 34 million Americans. Enlisting a large team of primary care doctors to deliver primary care at CVS clinics is its latest business initiative.

    CVS’ expansion into primary care will be through its MinuteClinics renamed HealthHUBs. With this expansion, CVS will engage primary care doctors to provide care to individuals, sell these individuals medicines through its pharmacies, cover medicines through its insurance plans and build its formulary (list of covered drugs) through its PBM. What does that mean for individuals who rely on CVS for these services?

    No question that it could mean easier access to primary care for people, as most people live close to a CVS.  But, financial incentives could get in the way of CVS providing people with high-quality care.

    CVS as insurer should have an incentive to keep people out of the hospital, to keep its spending down. But, will it deny access to hospital care inappropriately, because hospital care is expensive, in order to maximize profits? CVS could do so through prior authorization requirements and mandates for people to receive less costly treatments, perhaps requiring a telehealth visit or a visit to a HealthHUB before going to the hospital.

    And, who knows what incentives CVS will give the primary care doctors at the HealthHUBs. These primary care doctors might be financially disincentivized to refer patients out of network even if they need out-of-network care. They also might be financially incentivized to prescribe patients drugs on the CVS Caremark formulary rather than lower-cost drugs. Physicians are human and subject to the same financial incentives as everyone else.

    What’s most concerning is what we are seeing throughout Medicare Advantage–a financial incentive to keep people in poor health from enrolling. The CVS Health plan might find that it maximizes profits by avoiding enrolling people with complex and costly conditions.

    Yes, it’s fair to think that CVS has the leverage to bring down health care costs and improve quality in our health care system. But, there is no sign that it’s willing to do so. In fact, a whistleblower lawsuit that Just Care reported last week indicates that CVS is in it for CVS, failing to include generic drugs on its formulary or to stock them in its pharmacies when brand-name drugs generate greater profits for CVS. With these brand-name drugs, CVS profits at the expense of its enrollees who are forced to pay more out of pocket for their drugs.

    Bottom line: CVS’ for-profit vertical integration easily could undermine access to quality care, lead to poor health outcomes and drive up healthcare costs for enrollees in its health plan. There’s virtually no transparency into what CVS is doing. Who will ensure that CVS is held accountable for bad acts?

    Lyll suggests that global payment models, through which a healthcare system is paid a flat rate could be helpful. But, with little transparency as to how CVS operates, there’s cause for serious concern. No data, there’s no way to know whether there’s value. And, a fixed payment to a healthcare system leaves it up to the system to decide what to pocket for itself and what to pay for. That’s a scary situation, as we have seen over and over again, with chain nursing homes among other health care businesses.

    I’m with Susan Rogers, MD,  “[CVS] is not a system designed to improve healthcare while saving money. There is no way that a system with middlemen whose mission is to make money can do so with providers whose mission is to deliver healthcare that is needed and not deny that care to increase profits. This is a system that will destroy the core of patient physician relationships when decisions are made driven by making profit, not by what doctors feel is indicated.”

    Here’s more from Just Care:

  • Whistleblower says CVS won’t cover some low-cost generics

    Whistleblower says CVS won’t cover some low-cost generics

    Ed Silverman reports for Stat News on a whistleblower lawsuit against CVS. The lawsuit alleges that CVS won’t cover some low-cost generics, driving up costs for people in the CVS SilverScript Medicare Part D prescription drug plan, while boosting CVS profits. It sounds like CVS is engaged in a big bait and switch with its Medicare enrollees.

    We don’t have the numbers, but many people throughout the US in the CVS SilverScript Medicare Part D plan complain about being forced to buy a higher-cost brand-name drug rather than the generic drug equivalent if they want CVS to cover their medication. CVS kept at least twelve popular low-cost generics off its formulary. The generic drugs treat a multitude of conditions, including high eye blood pressure, dementia, ulcerative colitis and hepatitis C.

    For example, a Part D SilverScript drug plan did not cover a generic form of Advair, an asthma medicine, on its formulary. Instead, CVS required people to buy the brand-name medicine at a much higher cost.

    CVS is charged with keeping its Medicare Part D enrollees from getting generic drugs in order to profit more from covering brand-name drugs beginning in 2015. You would expect CVS to do everything in its power to maximize profits. So, why doesn’t the Centers for Medicare and Medicaid Services (CMS) require all Medicare Part D plans to cover all generic alternatives to any brand-name drug they cover? Moreover, why doesn’t CMS require Part D plans to cover drugs their enrollees secure through Mark Cuban’s Cost Plus Pharmacy and other outlets, when they offer the lowest price for generic drugs?

    CVS can profit more from covering brand-name drugs because their manufacturers send CVS rebates for including their brand-name drugs on its formulary. CVS could redistribute these rebates to its enrollees through lower premiums and copays. But, it can also keep the rebate money for itself. I’ll leave it to you to guess what it does.

    Because CVS owns retail pharmacies, a Part D prescription drug insurance plan, and a Pharmacy Benefit Manager, CVS has myriad ways to boost profits. For this reason, back in 2012, it agreed to maintain a firewall between its different businesses to keep it from engaging in activities that could undermine competition. The lawsuit claims it broke that commitment.

    The lawsuit further claims that CVS developed formularies with fewer generic drugs for patients in Medicare’s Extra Help program, for whom the federal government pays most or all of the copays. These people would be less likely to notice that they were forced to get a brand-name drug, since getting a brand-name drug would have little effect on their copays.

    At the same time that CVS did not offer generic substitutes on its formulary, it also allegedly kept these drugs from being stocked in its pharmacies. What better way to ensure people bought brand-name drugs and not their generic drug equivalents?

    SilverScript is also charged with not making enrollees aware of higher costs associated with brand-name drugs or with using their Part D drug coverage rather than paying cash for drugs.

    Here’s more from Just Care:

  • FTC investigates CVS Caremark and other Pharmacy Benefit Managers

    FTC investigates CVS Caremark and other Pharmacy Benefit Managers

    Given the number of cases against corporate health insurers for violating their contractual obligations with Medicare, the issue is not whether there will be more, but which health insurers will be found culpable, when, and will the federal government protect enrollees from the bad actors. The FTC is now taking a deep look into the largest Pharmacy Benefit Managers (PBMs), all of whom are linked in one way or another to a health insurance company covering Medicare benefits. What would the FTC or anyone else need to find for Congress to step in to remove PBMs and private insurers from the administration of Medicare benefits?

    Pharmacy Benefit Managers are middlemen that work in collaboration with the Medicare Part D health insurers. PBMs negotiate rebates and fees with drug manufacturers. They also decide which drugs go on the health insurers’ list of covered medicines, where people can buy their prescriptions, what they pay out of pocket, and a slew of related policies. PBMs pay pharmacies to fill prescriptions for Part D enrollees.

    Most recently, the law firm of Frier Levitt announced a significant victory on behalf of a minority and woman-owned specialty pharmacy, Mission Wellness, against CVS Caremark. CVS Caremark is a Pharmacy Benefit Manager (PBM) serving the Medicare population through Medicare Part D. Mission Wellness prevailed on its claim that CVS Caremark imposed unreasonable “direct and indirect remuneration” or DIR fees on it.

    In arbitration, Frier Levitt obtained an award of more than $3.6 million for breach of contract. CVS Caremark was ordered to return all the DIR fees it had received from Mission Wellness as well as to pay attorneys’ fees and interest. But, to date, CVS Caremark has not paid the amount awarded.

    If you think that the CVS Caremark breach of contract does not affect you, think again. When a Medicare contracting entity fails to pay health care providers what they are due, providers reconsider whether they will continue treating people with Medicare. Mission Wellness lost money as a result of the DIR fees, while it was a member of CVS Caremark’s Part D network.

    You might wonder why CMS isn’t looking out more for people with Medicare and hasn’t cancelled its contract with CVS Caremark. According to Frier Levitt: “Caremark refused to provide the required discovery throughout the arbitration, including discovery necessary to “audit” Caremark’s calculations of medication adherence, which serves as the basis for its recoupment of DIR fees.  Even after being sanctioned by the Arbitrator, Caremark refused to provide the basis for the DIR methodology.”

    Right now, the FTC is investigating CVS Caremark and other PBMs in the Medicare Part D program regarding recoupment of DIR fees. The biggest PBMs are part of corporations that include health insurance companies and pharmacies. The FTC wants to know what fees PBMs charge pharmacies that are not in their networks, what they do to incentivize patients to use their pharmacies, their prior authorization policies, how rebates and fees from drug manufacturers affect which drugs are on a formulary and what people pay, and more.

    Here’s more from Just Care:

  • Chain pharmacies found responsible for opioid crisis

    Chain pharmacies found responsible for opioid crisis

    After a six-week trial and five days of deliberation, a federal jury in Ohio recently found that three very large chain pharmacies were responsible in a significant way for the opioid crisis in two Ohio counties. Jan Hoffman reports for The New York Times that CVS Health, Walmart and Walgreens were found accountable for opioid overdoses and deaths. The insurers covering the opioids that were dispensed should also be found accountable.

    Germany never had an opioid crisis. The federal government in Germany controls the drugs that insurers cover and restricted coverage of opioids by health insurers. It’s unfathomable that corporate health insurers in the US, allegedly in business to manage people’s care, approved coverage of opioids in millions of cases where alternative non-addictive pain relievers were available to treat pain.

    Thousands of lawsuits have been filed across the United States against pharmaceutical companies for fueling the opioid public health crisis and creating a “public nuisance.” California and Oklahoma judges have not bought the argument, saying that the opioid manufacturers were not directly linked to the overdoses and deaths.

    Unfortunately, most of these lawsuits are still working their way through the system. And, opioid overdoses and deaths are on the rise. Many of those overdoses were of illegal opioids such as heroin and fentanyl bought on the street. But, those purchases are a bi-product of people becoming addicted to opioids that were legally prescribed.

    Over the summer, Nassau and Suffolk counties in New York State settled an opioid case with Walgreens, Rite Aid, CVS and Walmart for $26 million.

    In the Ohio case, the chain pharmacies claim that they will appeal. As far as they are concerned, they were just doing what they are supposed to do, fill legal prescriptions. In the process, of course, but left unsaid, they were profiting wildly.

    Of note, the lawyers defending the pharmacies in the Ohio lawsuit laid blame with manufacturers and doctors but did not blame the health insurers approving coverage of the opioids. CVS Health, Walmart and Walgreen are also insurers or linked to them.

    Here’s more from Just Care:

  • Amazon will now sell prescription drugs

    Amazon will now sell prescription drugs

    It’s official. After months of talk about Amazon’s move into the pharmaceutical space, Amazon has announced that it will now be selling prescription drugs across the US through Amazon Pharmacy. And, big pharmacies, like CVS Health, are feeling the hit, with their stock prices falling. Time will tell whether Amazon will take over the prescription drug retail market.

    For the last several years, Amazon has been seeking licenses from states to be a wholesale distributor of prescription drugs. And a couple of years ago, Amazon bought PillPack, which delivers prescription drugs to people in packages that help them know when to take different drugs.

    Amazon now plans to sell prescription drugs directly to individuals online and in collaboration with pharmacies across the nation. Many local pharmacies as well as big chain pharmacies are likely to be hit hard. Without a doubt, Amazon will aim to price its prescription drugs below its competitors to squeeze them out of the market.

    Of course, if Amazon is successful and the competition withers on the vine, Amazon will be sitting pretty. It will have the market power to raise prescription drug prices and profit handsomely. Even if Congress does not step in to regulate drug prices, which is particularly unlikely with Mitch McConnell as Senate Majority Leader, the only possible downward pressure on prescription drug prices could come from the federal government lifting the ban on drug importation for personal use.

    Amazon Pharmacy starts off with a strong foundation of 100 million Prime customers to whom to market its prescription drugs. It will offer Prime customers a discount drug card program–as much as an 80 percent discount on generic drugs and as much as 40 percent off on brand-name prescriptions, for people who pay out of pocket and not through their health insurance.

    Amazon also will help people understand the difference between their out-0f-pocket costs with and without insurance. In some cases, copays are so high that it will be less expensive for people to buy their drugs without relying on insurance.

    If you use Amazon Pharmacy, you will be able to benefit from its drug prices at 50,000 retail locations around the country as well as online. It will be interesting to see how sizable Amazon Pharmacy discounts will be relative to drug copays for people with insurance. Even without Amazon in the market, sometimes the copays are higher than the full retail cost of the drug. Amazon plans to work with Evernorth, a Pharmacy Benefit Manager, to administer its prescription drug retail program.

    Here’s more from Just Care:

  • Could Walmart be where you go for health care?

    Could Walmart be where you go for health care?

    Until Congress steps in to regulate our health care system effectively, it appears that corporations are going to take advantage of the great potential revenue in the health care sector, even if they have little experience delivering care. Last year, Walmart opened a health superstore in Dallas, Georgia, strange as that might seem. Now, Health Care Dive reports that Walmart is planning to open Walmart Health superstores around the country.

    Walmart is investing millions to deliver health care. The superstores are expected to provide urgent care, dental care, therapy, and diagnostic services as well as primary care services. Pricing is intended to be affordable and significantly less than what CVS Health charges. But, prices are not set yet, and there is likely to be variability.

    Right now, in Georgia, an adult primary care visit is $40. An adult dental checkup is $50. And, an eye appointment is $45. The store charges $1 a minute for therapy services.

    Visits to Walmart Health in Georgia are for primary care about half the time and specialty care the other half. People who come for primary care often then continue to come for chronic care management.

    The value of health superstores to Walmart extends beyond the revenue from delivering health care services. As a result of offering these services, Walmart has found that it fills more prescriptions and gets additional sales.

    At the moment, there are six Walmart Health venues. There are five in Georgia. And, there is one in Arkansas. Before the year is out, there will be seven more Walmart Health locations in Georgia and two in the Chicago metropolitan area.

    In the first months of 2021, Jacksonville, Florida will see seven Walmart Health superstores. And, Walmart Health superstores will sprout up soon in Orlando and Tampa. Next up for Walmart, health insurance policies.

    Meanwhile, CVS and Walgreens are also hoping to provide more health care services and build their patient base. CVS plans to grow from 275 HealthHUBs to 1,775 HealthHUBs by the end of 2021. It also has 1,100 walk-in MinuteClinics. Walgreens is putting $1 billion towards installing doctor’s offices in 500-700 retail stores over the next five years. These stores will have doctors on hand to provide patients primary care.

    Here’s more from Just Care:

  • Coronavirus: Second-quarter profits double for big health insurers

    Coronavirus: Second-quarter profits double for big health insurers

    Reed Abelson reports for The New York Times that second-quarter profits doubled for big health insurers from the same period in 2019. The Affordable Care Act imposes a limit on the profit that health insurers can keep.  But, people with health insurance are not likely to see money back any time soon.

    Because few people sought medical care for anything other than COVID-19 between April and June, insurers paid few claims. But, they collected the same premiums they always collect. So, the pandemic has served them very well so far.

    The Trump administration has suggested that the health insurers with outsize profits, such as UnitedHealth Group, Anthem and Humana, speed up rebates. But, it has no authority to require them to do so. It also suggested that they lower premiums. Again, it has no authority to require them to lower premiums.

    Because insurers are not legally allowed to change their premiums during the year, the Centers for Medicare and Medicaid Services is giving them the right to do so. Big whoopee. Insurers are not going to lower premiums, even if they can, since that would work against the interest of their shareholders.

    The Affordable Care Act (ACA) allows health insurers to keep 15-20 cents on the premium dollar, depending upon the type of insurance they are selling, individual, small group or large group. They must pay out the other 80-85 cents for medical care. Still, holding on to extra premium money for as long as possible benefits them financially. And, the ACA gives them three years to hold on to the money.

    The ACA effectively protects insurers that charge excessive premiums from having to return the excess money quickly on the theory that health care costs fluctuate and premiums might be inadequate to meet insurer expenses later on. For example, if people start going to the hospital and doctor at twice the rate they have been, insurers would have a cushion to pay those claims. Of course, the laws on premium-setting also protect insurers. They can relatively easily raise their rates next year.

    CVS Health, which owns Aetna, saw its net income increase in the second quarter by $1 billion. Last year, its second quarter net income was $2 billion. Anthem saw its net income increase $1.2 billion in the second quarter. UnitedHealth, the largest health insurer in the US, saw its net income rise by $3.3 billion.

    Taxpayer money for Medicare and Medicaid private health plans–Medicare Advantage and Medicaid managed care–has likely been paid to private health insurers in exchange for providing far less care than projected. If Medicare Advantage plans are able to keep the payments that they received for the first half of the year, they would be making out like bandits. The same is true for Medicaid managed care plans.

    The pandemic is hurting most hospitals and doctors. Many hospitals and doctors are struggling to generate the revenue to stay in business. And, private health insurers owe them nothing. Proponents of a single government health insurance system–one without private health insurers designing insurance policies–explain that in such a system hospitals and doctors would be on a global budget with guaranteed revenue in good times and bad.

    One as of yet unanswered question is whether employees at companies that are self-insured are seeing reductions in their insurance premiums. And, if not, why not? Their employers should be paying out less in claims.

    The marketplace is clearly not able to ensure that Americans are getting the health care they need at a fair price. “We’re looking at the fact that health care can’t be regulated by the marketplace,” said Representative Pramila Jayapal. It’s time for Medicare for all.

    As of now, Vice-President Biden is opposed to Medicare for all. It would be great if these enormous insurer profits led him to rethink his position.

    Here’s more from Just Care:

  • CVS charged with healthcare fraud

    CVS charged with healthcare fraud

    Just a couple of years ago, a whistleblower charged CVS with $1 billion in Medicare drug fraud. Now, CVS has been sued for overcharging Blue Cross Blue Shield for generic drugs. Healthcare Dive reports that Blue Cross Blue Shield  is seeking millions of dollars in damages.

    Blue Cross Blue Shield claims that, for more than ten years, CVS charged it a higher price for certain drugs than CVS was charging the general public for these drugs if they were paying cash for them. CVS denies the charges against it. It says they are without merit.

    While Blue Cross Blue Shield had negotiated the price it paid for these generic drugs with CVS, Blue Cross claims it should have benefited from the lower price that CVS charged people who paid cash for them. Put differently, Blue Cross argues that the cash price should be the highest price it pays. And, it says that CVS used a discount program to keep Blue Cross from knowing the cash price.

    The CVS membership program provides discounts on certain generic drugs to anyone who signs up. It also gives discounts to people who do not sign up, according to the Blue Cross lawsuit. The Blues argue that this membership program set the true cash price for the drugs, also referred to as the “usual and customary [U&C] price.” By concealing these prices in the membership program, insurers, including the plaintiffs, were not alerted to, and did not pay the lower U&C, or cash price. 

    According to the lawsuit, CVS “tried to find a way to both broadly offer discounts to retain critical pharmacy customers, including cash paying customers, and also avoid the unprofitable result of reporting the discounted prices as the U&C price.”  

    CVS argues the membership program prices were not the U&C prices. And, its membership program prices were neither concealed nor fraudulent.

    Blue Cross Blue Shield is not the only company that has filed suit against CVS for fraudulent overcharges. The Sheet Metal Workers union and the state of Mississippi have also sued CVS for this behavior.

    Here’s more from Just Care:

  • Real risk of medication errors at CVS and other chain pharmacies

    Real risk of medication errors at CVS and other chain pharmacies

    Ellen Gabler writes for The New York Times about the risk of medication errors from using chain pharmacies, such as CVS and Walmart. At a larger level, Gabler’s story highlights the dangers of for-profit health care. With a desire to maximize revenues, health care corporations aim to do more for less. But, in the process, more too often means more harm to Americans.

    Medication mix-ups have become increasingly common at chain pharmacies, which dispense about 70 percent of drugs in the US, along with supermarkets and megastores. Pharmacists have given people blood pressure medicine instead of asthma medicine, ear drops instead of eye drops and chemotherapy drugs instead of antidepressants. The chain pharmacies are very busy and understaffed, while under tremendous pressure to meet company quotes.

    To drive profits, chain pharmacies expect pharmacists to push refills on patients who don’t need them and dispense more drugs than people need. For example, CVS pharmacists have been requested to dispense three-month supplies of some medicines–more pills means more money–to people with mental health issues. The American Psychiatric Association worries that dispensing so much medicine can lead to overdosing.

    State pharmacy boards are hard-pressed to oversee these chain pharmacies to the extent necessary. They have little power to begin with. Often, representatives of the chain pharmacies sit on their boards. This creates conflicts of interest. Pharmacists fear losing their jobs if they speak up about issues. State legislatures do not seem to have the ability to regulate the pharmacies appropriately either.

    Chain pharmacies, such as CVS, deny there is a problem. Shockingly, there is no way to know the frequency or gravity of medication errors. As with most health care information, reporting is not what it needs to be and a lot of errors never become public. They are settled between pharmacy and patient, with an agreement on the part of the patient to not disclose the settlement terms.

    But, one Institute of Medicine study on medication errors conducted in 2006 found that they hurt at least 1.5 million Americans a year. And, Gabler compiled a long list of grievances filed by pharmacists to state boards, suggesting that pharmacists face grave difficulties ensuring they are filling prescriptions appropriately.

    At the end of the day, it’s probably advisable to steer clear of chain pharmacies. In addition to evidence suggesting that they put you at greater risk of receiving the wrong medicines, they tend to be the most expensive place to get your drugs.

    If you do use a chain pharmacy and your pharmacy misfills your prescriptions, do what you can to publicize it. Call your local newspaper and ask for an investigation. No company wants these errors broadcast. Over time, it could help lead to the company addressing the problem or new consumer protections.

    Here’s more from Just Care:

  • Facebook, Uber and Walmart, among others, expand further into health care

    Facebook, Uber and Walmart, among others, expand further into health care

    Health care has become such a lucrative enterprise that health care businesses are expanding and non-health care businesses are moving into health care, reports Healthcare Dive. Before you know it, Facebook might be reminding you to get your flu shot, Walmart might be providing your flu shot, and Uber might be taking you to your doctor’s appointment. As more corporations push health care, what does that mean for health care costs?

    Recently, Walgreens partnered with UnitedHealthcare to assist people with Medicare. Walgreens will answer questions about United Healthcare’s Medicare Advantage plans and steer its customers to enroll in these private plans. Walgreen’s will also help its customers already enrolled in UnitedHealthcare’s Medicare plans to schedule medical appointments and other services.

    These partnerships are designed to generate additional revenue for both Walgreens and UnitedHealthcare, while expanding access to care for their customers. UnitedHealthcare makes tremendous profits from its Medicare Advantage members. But, it can cost UnitedHealthcare more than $1,000 to enroll each new member.

    Presumably, Walgreen’s services can give UnitedHealthcare excellent marketing reach and save UnitedHealthcare enrollment and retention costs. The partnership should also earn significant revenue for Walgreens both from helping to secure new memberships for UnitedHealthcare and attracting more customers into Walgreens.

    CVS Health, which offers insurance through Aetna, is opening 1,500 HealthHUB stores. CVS Health is allocating about a fifth of its retail store space in these pharmacies to health care services, including preventive care and wellness.

    Walmart has opened its first health superstore in Dallas, Georgia, an underserved community. Walmart offers a range of primary care services, including dental care, vision care and psychiatric and behavioral health counseling. It also offers lab services and imaging, along with nutrition and fitness classes. Walmart also now has 16 centers of excellence across the country that offer hip and knee replacements for its more than one million employees.

    Kroger, a grocery chain, is offering more health care services through its new 360care program. It claims to be expanding access to care at lower cost through partnerships with local hospitals. It has more than 200 “LittleClinic” locations in nine states. It is also testing a program to help customers with depression.

    In South Carolina, Publix, a grocery store chain, partnered with a hospital in an effort to make it easier for its customers to get health care services and prescriptions. Publix has arranged to provide prescription drugs to patients upon discharge. It also is offering video-conferencing telehealth services for people in non-emergency situations.

    Costco is testing a partnership with Instacart to deliver prescription drugs to its customers.

    Meanwhile, Facebook has launched a preventive care tool. And, Uber has gotten into the business of taking people to the hospital and doctor’s office.

    These ventures show the increasing corporatization of health care. And, the range of companies that stand to profit from it. These companies will likely drive up health care spending further. Their services are designed to increase access to care, creating more volume and, with it, higher costs.

    Here’s more from Just Care: