Health tech policy Q2 recap—HHS overhauls ONC, Congress dabbles in telehealth

By Emma Beavins - The 118th Congress and the Biden administration were hard at work in the last quarter to push their health technology policy priorities forward before their terms come to an end this December. Read Full Article…

HVBA Article Summary

1. Legislative Developments and Delays: Throughout 2024, Congress has considered significant health technology policies, including a two-year extension of Medicare telehealth policies, comprehensive health data privacy legislation, and the creation of a roadmap for healthcare AI. Despite these efforts, no major legislation has been enacted, leaving many such programs to be potentially settled in the post-election lame duck session.

2. Executive Actions and Regulatory Changes: The Department of Health and Human Services (HHS) has been active, finalizing several important regulations and making organizational changes. This includes updates to HIPAA’s Health Breach Notification Rule, the Affordable Care Act’s nondiscrimination rule, and the information blocking rule by the Office of the National Coordinator for Health IT. HHS has also revamped its technology leadership, opening positions for key roles including a chief technology officer and a chief AI officer to drive forward its tech initiatives.

3. Supreme Court Decisions Impacting Healthcare: The Supreme Court's 2024 term concluded with several significant rulings affecting healthcare. Notably, it overturned the Chevron doctrine, reducing agencies' power to interpret laws, and made critical decisions regarding abortion rights in Idaho and the ongoing availability of the abortion medication mifepristone. These decisions are poised to have substantial effects on healthcare policy and access.

New pricing data fuel employer lawsuits against Aetna

By Lauren Berryman - Employers plagued by escalating healthcare spending are suing the health insurance companies that manage their benefits in a trend that could disrupt the group health plan market. Read Full Article…

HVBA Article Summary

1. Increased Transparency and Employer Actions: The Consolidated Appropriations Act of 2021 and recent healthcare price transparency regulations have provided employers with enhanced visibility into how insurers, like Aetna, manage self-funded health plans. Empowered by access to detailed broker payments, vendor comparisons, and hospital reimbursement rates, several large corporations including Kraft Heinz and Aramark have initiated lawsuits against Aetna. These lawsuits allege that Aetna has failed to fulfill its fiduciary duties under ERISA by improperly managing health benefit costs, resulting in overpayments for services and undisclosed fees.

2. Financial Implications and Corporate Lawsuits: Employers, who bear the cost of health benefits through self-insured plans, have identified discrepancies in payments that suggest mismanagement by insurers serving as third-party administrators. For instance, companies like W.W. Grainger have cited specific instances where Aetna approved payments for non-covered procedures, leading to significant financial losses. These allegations form the basis of the lawsuits, highlighting a breach of fiduciary duty that could have widespread implications for all insurers operating under similar models.

3. Future Trends and Industry Response: As more employers scrutinize their health plan expenditures, experts anticipate an increase in legal actions aimed at recouping costs and ensuring fiduciary responsibilities are met. This scrutiny could drive substantial changes in how third-party administrators manage health plans, potentially leading to slower growth in healthcare costs for employers and plan members. Despite potential industry pushback, these legal challenges signal a significant shift towards greater accountability and transparency in health plan management.

Why Will Healthcare be the Industry that Benefits the Most from AI?

By Julie Yoo - The healthcare industry has been a severe laggard in the adoption of tech (software in particular): it has consistently spent less than half on IT/software spend as a percentage of revenue versus peer industries, and workflows are primarily dominated by manual processes and legacy tools like faxes and phone calls. You don’t see anything close to the equivalent of the likes of Salesforce, Slack, JIRA, Notion dominating the app layer in the way workers do their jobs, as you do in other industries. Read Full Article…

HVBA Article Summary

1. Asset vs. Liability in Adoption: The article highlights a paradigm shift in how the low adoption of software in healthcare is now viewed as an asset rather than a liability. Unlike other industries burdened with the sunk costs of outdated enterprise software, healthcare can leapfrog directly to cutting-edge AI solutions without the encumbrance of last-generation technologies. This presents a unique opportunity for rapid integration and utilization of AI tools in healthcare operations and decision-making processes.

2. Scaling Clinical Judgment: The healthcare industry is currently facing a significant staffing crisis, with a shortage of over 100,000 doctors and nurses amidst growing demand for medical services. The complexity of medical care is increasing, requiring new tools that can synthesize complex data sets in real-time to support critical clinical decisions. The article discusses the potential of AI in expanding the reach and efficiency of clinical judgment, thus addressing both the shortage of healthcare professionals and the escalating complexity of patient care.

3. Regulatory Environment and Market Opportunity: Well-established regulatory frameworks, such as those by the FDA for clinical AI products, position healthcare uniquely to leverage AI advancements. The regulatory vetting process ensures that only the most rigorously developed AI products reach the market, creating a high barrier to entry but also a significant competitive advantage for those who succeed. Furthermore, the potential market for AI in healthcare is vast, far exceeding traditional tech expenditures within the industry, indicating a substantial opportunity for disruptive innovation in healthcare services and operations.

US uninsured rate rises to 8.2%

By Maia Anderson - The number of people in the US without health insurance has been steadily rising since the official end of the Covid-19 public health emergency was declared in May 2023. Read Full Article…

HVBA Article Summary

1. Reversal of Medicaid Policy Impact: The uninsured rate in the U.S. increased to 8.2% in the first quarter of 2024, rising from a record low of 7.2% in the second quarter of 2023. This increase follows the cessation of the Medicaid continuous enrollment policy, which expired in May 2023. The policy had previously allowed all beneficiaries to retain coverage without interruption, leading to a significant reduction in uninsured rates.

2. Implications for Healthcare Providers and Patients: Despite the rise in uninsured rates, health economist Daniel Polsky suggests that this should not yet affect the financial well-being of healthcare providers who are committed to treating all patients. However, the increase in uninsured individuals could lead to more instances of medical debt and delayed care among patients, potentially resulting in severe long-term health consequences.

3. Future Projections and Comparisons: Although the current uninsured rate of 8.2% marks an increase, it remains significantly lower than the pre-pandemic rate of 10.3%. The Congressional Budget Office anticipates that the uninsured rate will further climb to 8.9% by 2034, largely as a result of the termination of additional Covid-era policies that had temporarily boosted coverage rates.

Majority of weight loss drug prescriptions going to commercially insured patients 

By Jakob Emerson - In 2023, more than 61% of Ozempic prescriptions went to patients with commercial health insurance, and less than 10% of all semaglutide prescriptions went to Medicaid enrollees, according to a study published Aug. 2 in JAMA Health Forum. Read Full Article…

HVBA Article Summary

1. Prescription Fill Increase: The study found that the number of semaglutide prescriptions, covering brands like Ozempic, Wegovy, and Rybelsus, surged by 442% from January 2021 to December 2023. This substantial increase highlights a growing utilization of semaglutide-based treatments in the U.S. retail pharmacy sector.

2. Brand Dominance and Payment Distribution: Ozempic emerged as the most prescribed semaglutide brand, comprising over 70% of the total prescriptions. In terms of payment methods for 2023, commercial insurance was the predominant payer for Ozempic and Wegovy, covering 61.4% and 89.5% of the prescriptions, respectively. Meanwhile, Medicare Part D significantly contributed to Ozempic and Rybelsus fills at 28.5% and 32.9%, whereas Wegovy only saw 1.2% of fills through Medicare.

3. Lesser Role of Medicaid: Across all three semaglutide brands, Medicaid accounted for less than 10% of the prescription fills in 2023, indicating a relatively minor role in the financing of these medications compared to commercial insurance and Medicare Part D. This data could point to demographic and access disparities in medication usage within the Medicaid population.

The future of Medicare Advantage

By Cara Repasky, Anna Buchholtz, Ava Clarke, Sonja Pedersen-Green, and Will Lyle - As Medicare Advantage (MA) payers continue to be buffeted by regulatory and market changes that could dampen margins, payer leaders should not lose sight of the importance of investing now to stabilize their businesses for the long run. A critical area of focus for leaders should be the Medicare Advantage Star Ratings program. While 4+ star performance is becoming table stakes, plans that emphasize achieving better Star-program performance tend to have an advantage. Read Full Article…

HVBA Article Summary

1. Evolving Complexity and Importance of Star Ratings: Since its inception in 2007, the CMS Star Ratings system has undergone numerous refinements to push Medicare Advantage (MA) plans towards improving quality of care. Despite complexities and frequent updates that challenge implementation, these ratings significantly influence plan selection by members. MA payers must align with the evolving metrics of the Star Ratings to secure a 4+ rating, crucial for maintaining profitable operations and securing payments and rebates from the Quality Bonus Program.

2. Impact on Health Outcomes and Plan Choices: The Star Ratings program has demonstrably enhanced health outcomes, including increased cancer screenings, better medication adherence, and expanded coverage of preventative measures like flu shots and diabetic eye exams. Over the years, the majority of the program’s raw scores have improved, reflecting heightened competition and formulary complexities. Additionally, the ratings have increasingly influenced member decisions, with a significant shift in the percentage of MA members choosing plans rated 4+ stars based on perceived quality.

3. Strategic Adjustments and Future Directions: MA payers face the challenge of adapting to the removal of COVID-19 era provisions and other regulatory changes that affect their performance in the Star Ratings system. To sustain and improve their ratings, payers need to focus on integrating Star Ratings strategies into their broader MA operations. This involves enhancing provider relationships, increasing member engagement, and addressing social risk factors among beneficiaries. These efforts will be vital in navigating future challenges and ensuring the long-term sustainability and quality of MA plans.

How to manage employee benefits compliance post-Chevron

By Brooke Salazar - The Supreme Court overturned the Chevron deference framework less than two months ago, fundamentally reshaping the relationship between federal agencies and the judiciary. Read Full Article…

HVBA Article Summary

1. Impact of Chevron Overturn on Legal Interpretations: The recent overturn of the Chevron deference shifts the burden of interpreting ambiguous statutes from administrative agencies to the courts. This change compels benefits professionals to closely follow legislative texts and judicial decisions, which may now override previous agency guidelines. It's critical for these professionals to understand the evolving landscape to ensure their compliance strategies remain effective and lawful.

2. Challenges for Employee Benefits Brokers: With the Chevron deference overturned, agencies like the Department of Labor and the Internal Revenue Service will likely face more rigorous judicial review of their rules and enforcement actions. This can lead to challenges in established interpretations of compliance rules, potentially affecting how benefits are managed and necessitating updates to compliance practices to avoid legal pitfalls.

3. Strategies for Proactive Compliance: Benefits professionals should adopt a proactive compliance strategy that includes continuous monitoring of legal developments, maintaining thorough documentation, and engaging with compliance experts. These measures will help adjust compliance strategies promptly in response to new judicial interpretations and ensure that organizational policies align with the latest regulatory requirements, thereby safeguarding against potential legal challenges.

This Marine Corps veteran and CEO has a strong message for employers

By Lee Hafner - A young military veteran walks into a job interview for an entry-level management position at his local pharmacy. He presents well, makes good eye contact and answers the interviewer's questions politely. He does not get an offer. Read Full Article…

HVBA Article Summary

1. Invisible Competencies: The scenario described captures a common challenge for veterans transitioning to civilian jobs: their resumes often miss the specific keywords that hiring managers are looking for, and their full skill sets are not adequately portrayed. This issue is compounded when interviewers fail to ask the right questions that could uncover the depth of experience and capability veterans bring from their military service.

2. Valuable Transfers of Skill: As highlighted by Jim Rowley, a Marine Corps veteran and CEO, the skills acquired in the military—such as leadership, courage, responsibility, and strategic planning—are immensely transferable to civilian roles. However, these are frequently overlooked due to narrow perceptions of veterans' capabilities. This underestimation can prevent businesses from tapping into a highly skilled and adaptable workforce.

3. Cultural and Structural Enhancements: Employers can significantly benefit from integrating more inclusive hiring practices and veteran-friendly policies. By collaborating with organizations like the Department of Labor and the Wounded Warrior Project, companies can better recognize and utilize the diverse skills of veterans. Furthermore, fostering an inclusive environment with comprehensive support systems not only aids in the smooth transition of veterans but also enhances the overall workplace culture, promoting a high return on investment in employee potential.

How Targeting 'Zombie Cells' Could Help Extend Healthspan

By Christina Szalinski - What if a drug could help you live a longer, healthier life? Scientists at the University of Connecticut are working on it. In a new study in Cell Metabolism, researchers described how to target specific cells to extend the lifespan and improve the health of mice late in life. Read Full Article…

HVBA Article Summary

1. Research Focus and Implications: The study by Ming Xu and colleagues at the UConn Center on Aging centers on combating cellular senescence—specifically targeting cells marked by high levels of p21, known as p21high cells. By genetically modifying mice to eliminate these cells via an inducible "suicide gene," the research demonstrated extended lifespans and reduced age-related ailments. This approach could potentially delay aging and onset of diseases in humans, with human trials possibly beginning within 2-5 years.

2. Methodology and Results: Xu's team employed genetic engineering to introduce a "suicide gene" into mice, which was activated by administering tamoxifen, leading to the targeted death of p21high cells. This treatment, applied monthly from an older age, significantly improved the health and longevity of the mice, exemplified by their enhanced walking speed and grip strength. These promising results suggest a novel method for extending healthspan and possibly preventing age-related diseases like diabetes and Alzheimer’s.

3. Broader Context and Potential Drawbacks: While the study offers hope for aging interventions, Douglas Vaughan, MD, underscores the dual nature of cellular senescence. Although targeting senescent cells might reduce aging symptoms and prolong life, it could also increase the risk of cancer due to the loss of the protective role of senescence against cell proliferation. Furthermore, Vaughan emphasizes the effectiveness of non-pharmacological interventions like caloric restriction and maintaining a healthy lifestyle, which have proven benefits in extending healthspan without the risks associated with new drugs.