Connecting Payers to Patients with Rare Diseases
Patients with rare diseases often require complex, expensive medications that may or may not be on their payer’s formulary. In a recently published paper in Future Medicine, Siva Narayanan put forward a payer-patient engagement framework (PPEF) intended to connect rare disease patients with payers to make informed reimbursement decisions based on the individual's needs.
Employer Plan Beneficiaries Still Struggling to Pay for Healthcare
Despite employer health insurance coverage, a newly published study in JAMA finds that many employers are still having difficulties affording healthcare. The results come from the National Health Interview Survey, which was conducted between 2000 and 2020 and contains responses from 238,000 adults with employer sponsored health insurance.
Top 5 Managed Care Executive Tuning in to the C-Suite Podcast Episodes of 2022
Managed Healthcare Executive (MHE) has published its top 5 most-listened episodes of its Tuning in to the C-Suite podcast. The episodes feature host Jim Graham’s interviewed with executives in pharma and healthcare, as well as a member of the MHE advisory board, Ateev Mehrotra. At number 5 is an interview with Tim Ashe of Wellsky
Humana and TriWest Nets $136 Billion in Tricare Contracts
Humana Military and Triwest have been awarded two Tricare managed care contracts totalling $136 billion. The contract for the East Region went to Humana to the tune of $70.9 billion, while TriWest nabbed the West Region contract for $65.1 billion.
Becker’s Payers Issues: Humana in 2022
A newly released article in Becker’s Payers Issues revisits their biggest stories of 2022 about the payer giant Humana. In May, they covered the partnership they made with the Welsh, Carson, Anderson, & Stowe to expand its value-based primary care clinic offerings. In July, Humana announced it would split, with the company divided into an insurance provider and Centerwell.
Report Finds Medicare Part B Lab Test Spending Jumped $1.3 Billion in 2021
A newly released report by the Office of the Inspector General (OIG) found that Medicare Part B spending on lab testing jumped by $1.3 billion in 2021 from 2020. This 17% increase brought the total spending on laboratory tests to $9.3 billion. A key driver of the spike comes from mass utilization of COVID-19 testing.
Democrats Cautiously Optimistic About Drug Pricing Reform in 2023
Despite a split Congress beginning next year, US Democrats are cautiously hopeful about their drug pricing efforts in the coming years. This is because of the provision in the Inflation Reduction Act that will give Medicare the ability to negotiate some drug prices over the next ten years. If negotiations with Medicare go well, some Democrats expect this might act as a useful slippery slope to give private payers the power to negotiate too.
Bettering Health Outcomes for Older People Through Real-World Data
Older adults account for a sizeable portion of Medicare Advantage (MA) beneficiaries, but healthcare is only one determinant of health. Non-medical benefits could help address other lifestyle and social determinants of health (SDoH). However, more data is needed to identify and address these factors. Real-world data (RWD) may be an avenue to do just that.
AJMC Staffs 2022 Favorite American Journal of Accountable Care Papers
The AJMC staff have just published their top 5 favorite articles published in The Journal of Accountable Care (AJMC) this past year. These papers covered the cost-effectiveness of virtual healthcare, how employers can get the most from high-deductible health plans, value-based care at the end of life, and more.
US Department of Defense Announces TRICARE Managed Care Contracts Totaling $136 Billion
The US Department of Defense (DoD) has awarded $136 billion in TRICARE managed care support contracts. These T-5 contracts are scheduled to initiate in 2024 and will shift 6 states from the East region to the West Region. The transfer will move around 1.5 million patients, although it is not expected to have a major immediate impact on patients’ existing care plans.
Managed Healthcare Executive: Top Predictions for 2023
As 2023 nears, industry leaders look toward the new year. In a new Managed Healthcare Executive article, industry leaders offer up their top 10 predictions for healthcare in 2023. Brandon Clark, chief strategy officer of Equality Health, says that 2023 is going to be a watershed year for value-based care.
High Deductibles Discourage Follow-Up Testing After Abnormal Mammogram Results
A recent study found that 20% of women who receive abnormal results from a mammogram will not seek additional screening if their deductible is too high. 932 patients who received mammograms at Boston Medical Center were surveyed. The results showed that ~60% of respondents who had to pay a deductible would still go in for testing, while another 20% were undecided. Social determinants of health (SDoH) like low income, Hispanic ethnicity, and uninsured status were associated with decreased follow-up testing
Entering the Dual Eligible Market? 5 Things for Payers to Consider
Changes in the US dual eligible landscape, patients who qualify for both Medicare and Medicaid, have complicated things for payers looking to crack into the market. In a new article on Health Payer Intelligence, Kelsey Waddill discusses 5 important things for payers interested in the dual eligible market to consider beforehand to ensure market success. The first is the increasingly picky dual eligible special need plan enrollment process.
Pharma and Payers Gear Up for 2023
Coming off the heels of an upset in the US mid-term elections, drugmakers and payers are preparing for what is set to be a tumultuous upcoming year. A major upcoming event on the minds of stakeholders is the beginning of Medicare negotiations with pharma to lower drug prices, a key provision of the Inflation Reduction Act. This only applies to a few drugs and with Medicare, but some fear it may portend future, more comprehensive legislation.
Improving Medication Access by Addressing Price Instability
US citizens and residents pay more for prescription medication than those living in any other country, causing many to forgo life-saving medication. This problem is worsened by seemingly random fluctuations in price due to shifting rebates, discounts, and formulary inclusion on the part of drugmakers, payers, and pharmacy benefit managers (PBMs). Tackling price instability by considering national drug acquisition costs may be the first step to addressing high drug prices.
Employers Reaping Benefits from Patient Assistance Programs
An increasing number of employers are leveraging patient assistance programs intended for patients to help cut spending on employee health plans. These programs, long objected to by many employers, are offered by drugmakers to help cover expensive treatments when a plan deems the treatment nonessential due to cheaper alternatives. This has led to employer plans changing essential status to capitalize on these programs.
Moody’s Report Finds Risk Rising in the Healthcare Industry
A new report from Moody’s Investors Service finds that healthcare companies are facing increasing financial and social risk. The report, which looked at 193 healthcare companies in North America, shows that the number of companies rated B3 negative or lower has jumped from 9 in 2015 to 34 today.
ED Coding Leaves Payers and Providers at Odds
Recent increases in high-intensity emergency department (ED) billing in the US have put payers and providers at odds. A recently published study in Health Affairs investigates the underlying causes of this growth, looking at data from the Nationwide Emergency Department Sample. Almost half the increases come down to administrative changes and higher utilization by older adults. Another reason for the recent increase in high-intensity billing, the authors argue, comes down to coding changes.
Will Global Drug Price Transparency Improve Access for Patients?
With conversation building worldwide about growing drug prices, many have recommended efforts to increase global drug price transparency. This allows countries to make comparisons when negotiating prices with drug manufacturers. However, easy comparisons are not always possible, and the problem of high drug prices goes far beyond manufacturers.
Pharmacy or Medical Benefit? Specialty Pharmacy Weighs In
The reimbursement and dispensing of specialty pharmacy drugs is made complicated by inconsistencies in coverage, wherein different plans will categorize the same treatment as a pharmacy benefit or a medical benefit. This can determine coverage and therefore where patients will go for medications. In a recent article in Pharmacy Times, Bill Bolgar discusses a comprehensive pharmacy services approach that lets specialty pharmacies categorize drugs into medical or pharmacy benefits.
New CMS Rule Proposal to Improve Access to Health Information and Streamline Prior Authorization
The US Centers for Medicare & Medicaid Services (CMS) has announced a rule proposal to streamline the prior authorization process and increase access to health information for patients and providers. The rule would require payers to share data with other payers when patients change plans. In addition, it would mandate that payers establish systems and policies that would expedite the prior authorization process.
More Providers Looking to Bill for Patient Messaging
After a recent health system implemented a plan to bill patients for patient-provider messaging, what was before a free service, some providers and care systems are eyeing similar moves. The Cleveland Clinic started charging patients $50 dollars for messages that require medical expertise. Many patient groups worry that more care providers will adopt the practice, as several already have.
Senate Committee Unveil Draft Legislation to Make Medicare Advantage Directories for Mental Healthcare Accurate
The US Senate Finance Committee has released a draft of new legislation intended to make Medicare Advantage plans update and make available certain information to patients. This information includes provider contact details and availability for new patient intake. In addition, the draft would help target pay parity in mental healthcare.
Eisai and Biogen’s Alzheimer’s Drug Surrounded by Cost and Safety Worries
As Eisai and Biogen’s novel Alzheimer's drug lecanemab inches closer to the finish line, many worry that the high price of the antibody-based therapeutic may lower patient access. A primary concern is whether payers will cover lecanemab, especially after the aduhelm controversy over the past few years. In addition, recent adverse events, including a second patient death, have engendered worry for many.
Insurance Coverage Reduces Cigarette Use in People Living with Mental Illness and Substance Use Disorders
An article recently published in Addiction found that insurance coverage is associated with reduced cigarette use in people living with mental illness or substance use disorder. People within this demographic are at increased risk of cigarette use, especially when they are under- or uninsured. The study examined data from nearly 450,000 respondents of the US National Survey of Drug Use and Health Surveys from 2009-2019.
