Alright, first off, let me calm down any attorneys right outta the gate here. We will not be talking about—at all—the legal activity that is currently ongoing that my guest today, Ann Lewandowski, is involved with.
The suit mostly on our radar today is the one where an EBC (employee benefit consultant) allegedly had 61% of their revenue coming from pocketing their clients’ pharma rebates and using said clients’ pharma rebates to fund their executive bonus pool. Doing all this, not transparently (ie, none of their clients were aware that this was going on), it was not disclosed as per the Consolidated Appropriations Act of 2021.
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So, these EBCs’ clients were (one would assume) plan sponsors, like self-insured employers, of course. This pocketing of the rebates amounted to allegedly $27 million. Nice executive bonus poll they got there, I guess, would be one comment.
Anyway, allegedly when the whistleblower—who happened to be, at the time, this employee benefit consultant’s compliance officer—when he, you know, did his thing and sounded the alarm and said, “Hey, gang. Consolidated Appropriations Act. We gotta disclose this compensation we are earning from, you know, pocketing our clients’ pharma rebates and all that. It’s the law of the land.”
Well, a couple things went down at that point, but yeah … EBC executive team winds up ultimately firing their compliance officer (ie, the whistleblower). We gotta be opaque as hell, I believe is the alleged quote. So, this case has all the things. It’s a violation allegedly of the CAA (Consolidated Appropriations Act) legislation. It’s got retaliation. It’s got self-dealing. It’s got a lot of WTHs per mile, as they say … allegedly.
Right about now, I am going to mention that Peter Hayes last week on this podcast (EP475) talked about how regulations like the CAA are a major force colliding with two other major forces: transparency and public outrage.
So, three major forces combining to shake up the status quo. And maybe this whole pharma rebates getting disappeared case is a great example of this actually allegedly happening. We got all three of these forces—outrage, transparency, and regulations—revealing (allegedly) one giant swirl cone of cluster f’ery that could certainly inspire even the most uninspired plan sponsor to take a serious look into their brokers or PBMs (pharmacy benefit managers) or TPAs (third-party administrators) or other vendors. At least do some level of auditing there.
So, there’s that.
But also, to me, the big takeaway circles back once again to this trust touchstone that, again, keeps coming up in lots of Relentless Health Value episodes lately.
And it’s just a really big reminder that trust isn’t just for patients and their doctors, and it’s not just for clinicians and their administrators or leadership. It’s also for plan sponsors and their advisors.
Although distrust is the problem with everybody else I just mentioned, in this particular instance, the problem isn’t a lack of trust. It’s often too much of it. Plan sponsors often really trust their longtime EBCs or TPAs, and yeah … sometimes it’s warranted. Sometimes it’s not. Brutally not.
Kimberly Carleson the other day, she wrote, “$14.5 million is being returned to self-funded health plans after the Department of Labor found that … the TPA had been pocketing undisclosed markups.”
She continues, “But your premiums are still rising today because behavior like this hasn’t stopped. This isn’t just about one TPA [or one EBC]. It’s a warning shot.”
So, yeah, this whole goings-on with this pharma rebates disappearing lawsuit is a warning shot on several levels. One is just how many millions of dollars can go missing on its way from point A to members’ wallets.
But another level of warning shot is more personally self-interested in nature because the thing about whistleblowing is that it’s only possible when there is a scent of illegal activity wafting in the air.
And if that bad smell turns out to be verifiable by the DOJ or DOL or courts of law, at that point, personally, you can either be the whistleblower or be on the other side of the table. And being on the other side of the table could mean millions of dollars in fines or even jail time.
We talk about that generic drug manufacturer collusion whistleblower case a little bit later on in the show today, where the CEOs are facing possible prison and there’s millions of dollars in fines also, just BTW.
So, all of this and more comes up today in my conversation with Ann Lewandowski.
I mean, if you had the chance to talk about whistleblowing with a whistleblower, you would’ve done the same thing in my shoes, right? Talk about whistleblowing with someone who has made the decision to be one herself.
And it is a truly difficult choice. It takes just such firm conviction and commitment to doing the right thing. As Ann has written, she wrote, “Whenever someone sees [what appears to be illegal] actions without saying something, it means people are protecting the status quo.”
“The problem,” as Ann wrote, “… that the penalty [that can arise for whistleblowing] is real. So we need more voices so that those speaking up cannot be silenced.” In other words (this is me paraphrasing), it’s hard as heck to be a whistleblower, which we discuss. And we also get into how to make the choice to whistle blow, how to do it safely. Basically, you know, what to consider there but also not to get into a “damned if you do, damned if you don’t” territory, because the risk of choosing not to whistle blow if you see illegal activity is also real.
There are plenty of cases, again, referring back to that generic collusion case is just one of them. There are plenty of cases where a whistle got blown by someone, and others on the team face the penalties of that.
Alright, let me land this plane by saying, in sum, don’t forget, there’s upsides to whistleblowing. Like, you get a percentage of the dollars recouped. Also, you’re in the clear because no one else is gonna blow the whistle first, and then you find yourself on the wrong side of the table. But, for sure, there’s downsides.
Today, as aforementioned, I am speaking with Ann Lewandowski. Ann Lewandowski is a nationally recognized award-winning healthcare executive with extensive experience. Most listeners probably know her last name, at the very least, from the Lewandowski v. Johnson and Johnson case that came out last year.
Ann does a lot of work with plan sponsors and others.
There will be another show. It’s gonna be a Summer Short with Ann Lewandowski, where we’re gonna dig in on pharma rebates. More kind of, I’d say, the less intuitive ins and outs afoot there.
Also mentioned in this episode are Peter Hayes; Kimberly Carleson; James Gelfand, JD; AJ Loiacono; Paul Holmes; Matt Ohrt; Eric Bricker, MD; Michelle Bernabe, RN, KAT; Jennifer Stanley; John Lee, MD; and Vivian Ho, PhD.
You can learn more at patientvalueinsights.com and by emailing ann@patientvalueinsights.com. You can also follow Ann on LinkedIn.
Ann Lewandowski is a nationally recognized healthcare executive and trusted advisor to health plan sponsors, known for helping employers strike the balance between cost control and benefit quality. With deep experience in health policy, compliance, and benefit design, Ann empowers plan sponsors to adopt a participant-first mindset—ensuring health benefits work for employees while protecting the organization’s fiduciary and financial responsibilities.
Ann’s dual perspective as a healthcare administration professional and a patient sets her apart. This gives her unmatched insight into the real-world challenges employees face when navigating care while addressing the economic pressures plan sponsors face in a volatile healthcare market. Her experience in health plans, providers, and the pharmaceutical industry gives her unrivaled insights into the complex purchasing environment healthcare purchasers face.
Ann’s approach leads to measurable outcomes: cost savings, stronger compliance, more competitive benefits, and better employee satisfaction and retention. Her work has been recognized with numerous national awards, including honors from HRSA (Health Resources and Services Administration), the Pharmacy Society of Wisconsin, and the Healthcare Advocate Summit. In 2024, she was named a MarketWatch Top 50 Maven for her leadership in pharmacy policy and pricing reform.
She recently completed a Master of Legal Studies at Arizona State University, with dual emphasis in Health Law and Healthcare Compliance.
08:10 What does it mean to be a whistleblower?
09:05 What’s happening in the current whistleblower case about pharma rebates?
14:24 What are the disclosure requirements, and how does this affect contracts in healthcare?
16:46 Why having a “defensive health plan” is important.
17:31 Matt Ohrt’s post about healthcare’s soul.
17:42 Michelle Bernabe’s post about how healthcare has lost its heart.
18:15 Why “trust and verify” is important when building contracts and relationships in healthcare.
18:42 Quote by W. Edwards Deming.
21:35 How has this case moved from state to federal court?
23:30 Whistleblower case on generic drug collusion.
24:01 What is a qui tam lawsuit?
28:08 What is an Upjohn warning and the issue of corporate Miranda rights?
30:01 What is Ann’s advice to employees who might be whistleblowers?
31:41 EP438 with John Lee, MD.
33:31 What are some red flags that employees should look for to understand what kind of company they work for?
Recent past interviews:
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Peter Hayes, Yashaswini Singh, Dr Kenny Cole, Dr Eric Bricker, Dr Christine Hale, Nikki King, James Gelfand (Part 2), James Gelfand (Part 1), Matt McQuide, Stacey Richter (EP467), Vivian Ho