Guess who’s back grabbing headlines? Pharmacy benefit managers — those companies that serve as middlemen in the prescription drug pipeline. Plans to reduce the cost of medicines often target so-called PBMs as primary culprits behind the nation’s out-of-control drug prices.

But consumers often don’t notice or understand PBMs and how they factor into determining costs at the pharmacy counter. This , brought out from our vault, details the emergence of these multimillion-dollar corporations and the impact they have on medication costs and patients’ access to treatments.

For more information on drug pricing issues, check out this chart and these videos:

KHN also offers other videos examining hot topics such as , , and how the health law could be disassembled through the .

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High-risk pools are a key concept that helped House Republicans pass their replacement for the Affordable Care Act. That bill, the American Health Care Act, which still must pass the Senate to become law, allows states to opt out of the requirement for insurers to cover people with preexisting conditions and set up high-risk pools for these people instead. A late amendment to the bill added $8 billion* in additional funding over five years for these potential pools, and that change garnered enough new Republican votes for AHCA to pass the House. This video explains high-risk pools and shows why they haven’t worked well in the past.

The first video in KHN’s “” series ±ð³æ²¹³¾¾±²Ô±ð»åÌý. The second dealt with . Scroll down for the full transcript.

For more information on high-risk pools, check out:

• The Kaiser Family Foundation: 
• ³ó±ð²¹±ô³Ù³ó¾±²Ô²õ³Ü°ù²¹²Ô³¦±ð.´Ç°ù²µ:Ìý

* The $25 billion cited in the video for high-risk pools referred to an earlier GOP replacement proposal. The total amount of money for high-risk pools and other “stability” measures for states to share is $138 billion in the version of AHCA that passed the House.

Video Transcript: One of the main goals of the Affordable Care Act was to help people get insurance who couldn’t get it before. Particularly people with pre-existing health issues who buy their own coverage.

Before the health law passed in 2010, insurers could just say no and not sell policies to sick people at any price. Even minor problems could get you turned down.

Now, that’s illegal. And insurers can’t charge sick people more either. The health law also says everybody has to buy insurance – that mandate is supposed to help bring more healthy customers to insurers.

But that piece of the law isn’t working very well right now. Insurers say too many sick people have been buying insurance, and not enough healthy people have been joining them.

That can help cause premiums to rise, and insurers to lose money. Some companies say they are losing too much and have stopped offering coverage in the health exchanges.

One way Republicans say the system could be fixed is by returning to something called a high-risk pool.

The idea is to let all the sick people buy their policies in a separate insurance pool, and then have insurance companies and states and the federal government all chip in to pay for their care and keep their premiums low.

Before the Affordable Care Act, 35 states had high-risk pools.

The federal government had one, too, as a transition to the health law. But none of them worked very well.

The biggest problem? Both premiums and other costs remained too high for many people with health conditions to afford. The federal program ran out of money almost a year before it was scheduled to end.

Sometimes the pools got so expensive for states that they had to impose waiting lists for coverage.

And often, to keep costs down, risk pools set up waiting periods before they started paying bills for the very illness that made people high risk.

Republicans say their new risk pools plan would be better than the old ones. Their plan says it would keep premiums low, and no wait lists would be allowed.

But it’s not clear that the $25 billion in federal funding they propose would be enough, or that states would step in to help fund the pools.

So high risk pools are another idea that sounds good, but that’s very hard to make work in the real world of health care.

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After capturing the White House, Republicans put repealing the health law at the top of their to-do list. But since they can’t get around a Democratic filibuster in the Senate, they are forced to use an arcane legislative tool called budget reconciliation to disassemble parts of the law. KHN’s and explain the process.

For more information see:

Video Transcript:

Led by President Donald Trump, Republicans have promised to repeal the Affordable Care Act. They have control of both houses of Congress and the White House, but they still have one big obstacle in that effort.

In the Senate, opponents could stage a filibuster — the right of the minority to try to talk a bill to death and keep senators from voting. It takes 60 votes to stop a filibuster. Republicans have a majority but only 52 seats. And Democrats say they won’t help take apart the health law they voted to pass seven years ago.

Instead, Republicans are vowing to use a budget procedure called “reconciliation.” It comes from a 1974 law called the Congressional Budget and Impoundment Control Act. Lots of major health laws have been passed using reconciliation, including those guaranteeing the right to emergency room care, creating the Children’s Health Insurance Plan, and allowing private plans as an alternative to traditional Medicare coverage.

Here’s how reconciliation would work. First, Congress has to pass a budget resolution.

That budget document has to be agreed on by the House and Senate, but it doesn’t go to the president for his signature.

The budget resolution does two main things. First, it sets spending targets for federal programs Congress funds every year. Those are known as appropriations.

But there are also programs funded by the federal government that don’t need annual approvals from Congress. These include tax cuts or increases and so-called entitlement programs like Medicare and Medicaid.

So the budget resolution also instructs the congressional committees in charge of those programs to propose changes in the law that would “reconcile” how much those programs cost with the targets set by the budget. This is what Republicans would use to order changes to the Affordable Care Act.

When the committees report back their proposed changes, they are assembled into a budget reconciliation bill.

In the Senate, budget reconciliation has its own special rules that make it easier to pass. Debate is strictly limited, and the bill only needs a simple majority to pass.

But there are limits, too. Budget reconciliation bills can only change things that directly impact the federal budget — either adding to or reducing federal spending.

For the Affordable Care Act, that means Congress could use budget reconciliation to eliminate spending, like the help people get to pay their premiums or funding to states to expand the Medicaid program for the poor. It can also repeal the taxes that help pay for those benefits, including the tax penalties for individuals who fail to have insurance.

But Congress can’t use reconciliation to change parts of the health law like provisions requiring insurance companies to provide certain benefits or sell coverage to people with preexisting conditions. Those don’t directly affect federal spending.

That has led insurance companies to complain that they will go broke if they still have to sell to sick people, but healthy people won’t have any incentive to get covered. In that case, they say, only sick people will buy insurance, and premiums will skyrocket.

And the new Republican Congress seems set on using the technique to take apart the health law. Whether that’s a good idea may depend on whether you favor or oppose the Affordable Care Act.

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KHN’s coverage of prescription drug development, costs and pricing is supported in part by the .

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While recovering, he did something that only a small percentage of patients do: He signed up for a medically supervised cardiac rehabilitation program where he learned about exercise, diet and prescription drugs.

“I had never exercised before,” said Oikonomides, 69, who says he enjoyed it so much he stayed active after finishing the program.

Despite evidence showing such programs substantially cut the risk of dying from another cardiac problem, improve quality of life and lower costs, fewer than one-third of patients whose conditions qualify for the rehab actually participate. Various studies show women and minorities, especially African Americans, have the lowest participation rates.

“Frankly, I’m a little discouraged by the lack of attention,” said Brian Contos, who has studied the programs for the Advisory Board, a consulting firm used by hospitals and other medical providers.

The law also creates incentives for hospitals, physicians and other medical providers to work together to better coordinate care.

Cost Undermines Participation

Oikonomides, who lives in Charlottesville, went for three decades without another heart attack after his first, but recently had bypass surgery because of blockages in his heart.

He is again rebuilding his strength at the University of Virginia Health System. “I attribute my 30 good years of life to cardiac rehab,” he said recently while pedaling on a stationary bike in a light-filled gym at one of the university’s outpatient medical centers, a heart monitor strapped to his chest.

But many patients still face hurdles.

Uninsured patients simply can’t afford cardiac rehab. And for those with some form of coverage, “the No. 1 barrier is the cost of the copayment, which is frustrating,” said Dr. Ellen Keeley, a cardiologist at UVA, who strongly encourages her patients to enroll.

Medicare and most private insurers generally cover cardiac rehab for patients who have had heart attacks, coronary bypass surgery, stents, heart failure and several other conditions. Most coverage is two or three hour-long visits per week, up to 36 sessions.

Insured patients usually must make a per visit copay to participate. For regular Medicare members, that runs about $20 a session, although many have private supplemental insurance that covers that cost. For patients with job-based insurance —Ìý²¹²Ô»å enrollees in the alternative to traditional Medicare called Medicare Advantage — out-of-pocket costs can range from nothing per session to more than $60 a pop.

“Some insurers say a copay for a specialty visit is $50, whether that means going to a neurosurgeon once in their life or whether that’s three times a week for cardiac rehab,” said Pat Comoss, a consultant in Harrisburg, Pa., who trains nurses to work in these programs.

More than a year ago, federal Medicare officials met with insurers after advocates voiced their concern that higher copays were keeping patients from cardiac rehab, said Karen Lui, a legislative analyst for the American Association of Cardiovascular and Pulmonary Rehabilitation, the profession’s trade group.

“To their credit, they dug in and talked with plans that had much higher copays, such as $100 per session,” said Lui. Medicare officials told insurers that a $50 copay per session is the upper limit a plan should charge,” he added.

UnitedHealth, with nearly 3 million members in Medicare Advantage plans, said patient payments for cardiac rehab vary widely. About 12 percent of members pay nothing, while 23 percent pay $50 a session. Another large insurer, Humana, has a similar range, with copays running up to $60 a session.

Nationally, the weighted average payment now for Medicare members in private plans is just a bit more than the $20 that patients in traditional Medicare pay, said Dale Summers, director of the Center for Medicare & Medicaid Services’ division of finance and benefits.

Preventing The Next Heart Attack

Aside from cost, another big reasons so few patients participate is many are never referred to a program. Some hospitals are addressing this disconnect by building automatic referrals into their discharge system.

Patients may be reluctant to attend cardiac rehab, especially if they had not been physically active before their heart problem.

To counter that, Gary Balady, director of preventive cardiology at Boston Medical Center stresses its importance with his patients. He tells them that about 15 percent of heart attack patients may experience another one within a year.

“One of first things we say [in cardiac rehab] is we are here today to work together to prevent the next heart attack,” he said.

At the University of Virginia medical center, heart attack patients are given an appointment to come back to a special clinic within 10 days of discharge. Over the course of about an hour, patients meet with an exercise physiologist, a cardiologist, a nutritionist and a pharmacist — and all in the same exam room.

At the visit, the medical professionals answer questions, go over the patient’s medications, make diet tips and recommend cardiac rehab. Kathryn Ward, manager of UVA’s cardiology clinics, says up to 100 patients a month were referred to the clinic in its first year. Of those, 71 percent enroll, she said, well over the national average.

Other Barriers

Still, patients face other barriers to this kind of care, including time constraints, or having to travel long distances to the nearest program.

And existing programs aren’t enough to accommodate all patients who are eligible. A recent surveyed 812 existing cardiac rehab programs in the U.S., finding that even if they were expanded modestly and operated at capacity, they could still only serve 47 percent of qualifying patients.

“We have patients who are an hour away from any cardiac facility and they can’t afford the gas money or the time,” said UVA cardiologist Keeley.

Take Kathryn Shiflett of Culpeper, Va. At age 33, the last thing she expected was a heart attack.

But one night in late March, she felt pain in her arm — pain that spread to her jaw —Ìý²¹²Ô»å she felt nauseated. After tests at a local hospital, she was transferred by ambulance to UVA, where cardiologists opened a blocked artery in her heart.

Shiflett, a medical worker with two children, traveled back to UVA a week later for her clinic appointment, and was encouraged to participate in cardiac rehab.

Shiflett found the program appealing because she wants to be active and prevent a repeat of her heart attack. But she lives an hour away. In addition to the distance, she isn’t sure she can make any of the sessions. Cardiac rehab classes are during working hours. The latest starts at 3 p.m.

“I’m not sure I can get there by then,” Shiflett said.

One answer for patients like Shiflett could be a home-based program, which are less common, but drawing increased interest.

“There are a whole plethora of different ways to provide cardiac rehab outside traditional center model,” said Mark Vitcenda, senior clinical exercise physiologist at the University of Wisconsin Hospital and Clinics in Madison.

At his program, patients can start in a supervised program at a center for two or three sessions, then can choose whether to continue in a home-based model, with occasional visits to the center. About 30 to 40 percent of Wisconsin program patients choose the home-based option, he said, with most being younger, working patients with lower medical risk.

“If we can lower the barriers of transportation and cost, patients are able to be more involved,” he said.

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Hospitals provide observation care for patients who are not well enough to go home but not sick enough to be admitted. The care may seem just like what an admitted patient receives — they are in a hospital room, nurses check on them and doctors  order treatments.

But surprises can arise over billing because Medicare considers this outpatient care. So instead of Medicare picking up most of the bill, patients usually also have copayments for doctors’ fees and each hospital service, and they have to pay whatever the hospital charges for any routine drugs the hospital provides that they take at home for chronic conditions.

This video by Francis Ying and Thu Nguyen, narrated by Lynne Shallcross, explains what happens. For a transcript of the video, .

For more information, check out Medicare’s Ìý²¹²Ô»å .

KHN’s coverage related to aging & improving care of older adults is supported by .

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This is part of a about health care promises from presidential candidates that “sound like a good idea.” Julie Rovner and Francis Ying of Kaiser Health News explore why proposals to regulate drug prices may not be such a good idea after all.

For more information, see:

— Earlier KHN coverage:

— Kaiser Family Foundation/Peterson Center on Healthcare survey: .

The other “Sounds Like A Good Idea” videos examined Ìý²¹²Ô»å proposals to if lawmakers change the health law’s guarantee of insurance for people with pre-existing conditions.

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Presidential candidates like to propose solutions to long-standing problems. Health care is no exception.

But there’s a reason some problems are “long-standing.” They may have no easy solution. Or the solution is not politically feasible. Or there’s a solution that sounds good on the campaign trail but is not likely to actually work.

This is part of a series of videos about health policy promises that “sound like a good idea.” Here Julie Rovner and Francis Ying explore why increasing competition in health insurance by allowing sales of policies across state lines might not be such a good idea after all.

The other ±ð³æ²¹³¾¾±²Ô±ð»åÌý and and proposals to  if lawmakers change the health law’s guarantee of insurance for people with pre-existing conditions.

For more information on the interstate health insurance, see earlier KHN coverage: .

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