PBM executives threatened with fines and jail time for alleged perjury in House hearing

By Rebecca Pifer - The chair of the powerful House Committee on Oversight and Accountability is threatening the leaders of the three largest pharmacy benefit managers in the country with steep fines — or jail time — for allegedly lying in a recent congressional hearing. Read Full Article…

HVBA Article Summary

1. Chairman Comer's Accusations and Demands: Chairman James Comer of the House Oversight Committee accused executives from UnitedHealth's Optum Rx, Cigna's Express Scripts, and CVS' Caremark of providing false testimony during a July hearing. He argued that their claims of treating affiliated and unaffiliated pharmacies equally contradicted findings from both the committee and the Federal Trade Commission (FTC). Comer has requested these executives to correct their statements by September 11, threatening potential legal consequences including imprisonment and hefty fines.

2. Response from PBM Companies: Following Comer's accusations, Express Scripts openly denied the allegations, affirming their confidence in their previous testimony. CVS stated that it was reviewing the letter, while UnitedHealth has yet to respond. These responses highlight the differing approaches PBMs are taking in response to the increasing legislative and public scrutiny over their business practices.

3. Ongoing Congressional and FTC Scrutiny: The intense scrutiny from Congress and the FTC centers on the PBMs' significant market power and their role in high drug costs and restricted patient access to medications. With PBMs covering nearly 80% of U.S. prescriptions and their parent companies' vertical integration, there are concerns about preferential treatment towards owned pharmacies and the potential squeezing out of independent pharmacies. The ongoing investigations and the potential for legislative reform underscore the mounting pressures on PBMs to adapt their business practices in a more transparent and equitable manner.

The power of non-traditional benefits plans: A Q&A with Ali Payne

By Lily Peterson - As employers think of recruitment and retention strategies, they might think of competitive pay, a great office culture, or strong traditional benefits plans. One strategy that tends to be overlooked is the non-traditional benefits plan. Read Full Article…

HVBA Article Summary

1. Understanding Employee Needs Across Generations: Ali Payne emphasizes the importance of understanding the diverse needs of a multigenerational workforce. By engaging with and learning from their employees, employers can discover both the unique and common needs that exist within their workforce. This understanding helps in tailoring benefits that support all employees, ensuring they feel valued and supported both inside and outside the workplace.

2. Alignment of Brand and Culture: Payne highlights the critical need for alignment between an organization’s brand and its internal culture. Companies often focus on external branding but neglect the internal culture, which can lead to a disconnect and create distrust among employees. She suggests a holistic approach to employee experience, ensuring that every interaction reflects the company’s core values and promises, enhancing authenticity and trust.

3. Evolving Benefits with Employee Feedback: Payne advises on the best practices for evaluating and evolving employee benefits. She suggests that employers should frequently communicate and make existing benefits easily accessible to determine their relevance and value to the employees. Based on usage and feedback, employers can then decide which benefits to continue and which to replace, allowing for a dynamic benefits strategy that evolves with employee needs and preferences.

Cigna's Express Scripts unit moves away from AbbVie's Humira

By Allison Bell - Express Scripts is joining CVS Health in moving away from offering Humira as a standard prescription drug option for people with arthritis, Crohn's disease and other autoimmune disorders. Read Full Article…

HVBA Article Summary

1. Introduction of Competitors: Following the expiration of Humira's patent in early 2023, Express Scripts announced it will include several biosimilars on its main formularies, such as Boehringer Ingelheim's Cyltezo, Teva's Simlandi, and Sandoz' Adalimumab-adaz. These alternatives are part of a broader industry shift towards more affordable biosimilar drugs, aiming to reduce healthcare costs for employers and plan enrollees.

2. Market Impact of Biosimilars: Humira, a leading biologic medication for autoimmune conditions, was the most expensive drug for U.S. employers in 2023. With a significant $145 average spending per plan enrollee, the introduction of lower-cost biosimilars priced between $200 and over $1,000 could provide substantial savings and impact AbbVie’s market share.

3. Response from AbbVie and Other PBMs: While Express Scripts and CVS Health have taken steps to prioritize biosimilars over Humira, UnitedHealth's Optum Rx has adopted a more inclusive approach by adding biosimilars without removing Humira from its formulary. Despite these changes, AbbVie remains optimistic about Humira's market performance in the near term and is focusing on other patented drugs to sustain its revenue.

The 7 most dangerous trends facing payers

By Rylee Wilson - Cybersecurity threats and rising costs are some of the greatest challenges facing payers and accountable care organizations, according to executives. Read Full Article…

HVBA Article Summary

1. Preventive Care Post-Pandemic: Abdou Bah, from EmblemHealth, highlights a significant drop in preventive care and chronic disease management since the pandemic. This trend delays early disease detection and crucial interventions, which he addresses by enhancing partnerships with primary care physicians and focusing on social determinants of health.

2. Rising Healthcare Costs: Tenbit Emiru, of UCare, and Alessa Quane, from Oscar Health, both discuss the financial strain on healthcare systems due to escalating drug prices and overall rising healthcare costs. Emiru notes the impact of expensive new therapies like gene therapies on insurance premiums, while Quane calls for a shift in health insurance financing and delivery.

3. Cybersecurity Threats: Harlon Pickett from Eagle Care Health Solutions and Shelley Turk of Health Care Service Corp. emphasize the growing danger of cybersecurity breaches within healthcare. They note the increased frequency and complexity of attacks, such as ransomware, which pose significant risks to healthcare operations and patient data security.

Insurers can restrict mental health care. What laws protect patients in your state?

By Annie Waldman and Maya Miller - Accessing mental health care can be a harrowing ordeal. Even if a patient finds a therapist in their network, their insurance company can overrule that therapist and decide the prescribed treatment isn’t medically necessary. Read Full Article…

HVBA Article Summary

1. Challenges in Defining Medical Necessity: Insurers largely dictate their own standards for what constitutes medically necessary mental health care, often diverging from evidence-based guidelines recommended by professional medical societies. This flexibility allows insurers to create internal criteria that may prioritize cost-saving over patient needs, raising concerns about conflicts of interest and the potential for inadequate mental health coverage.

2. Impact of Utilization Reviews on Treatment Access: Insurers employ utilization reviews to manage how often and what type of mental health services are provided, requiring therapists to submit detailed treatment notes for review. This practice, intended to control costs, often serves as a barrier to continuous care, leading to disputes over the necessity of treatment and contributing to the shortage of accessible mental health services.

3. Transparency and Compliance Issues: Despite laws aimed at ensuring equal coverage for mental and physical health, enforcement is challenging and inconsistent across states. Many states require insurers to report their compliance with mental health parity laws, but discrepancies in reporting and lack of public transparency hinder accountability. This results in ongoing struggles to verify insurer adherence to the law, impacting patient access to necessary mental health care.

Americans confident in health care choices, but concerned about costs

By Henry Craver - Last week, HSA Bank, a division of Webster Bank, N.A., released its seventh annual HSA Bank Health & Wealth IndexSM. The study, which polled more than 2,000 randomly selected U.S. adults, gives important insights into consumers' desires, frustrations, and habits related to health care and financial matters. Read Full Article…

HVBA Article Summary

1. Consumer Confidence vs. Financial Concerns: While a significant majority of consumers (84%) feel confident in selecting the right health care plan, there are notable financial anxieties, with 35% worried about covering health care costs in the upcoming year and 36% uncertain about funding their health care after retirement. These concerns underscore the need for more robust financial planning and support mechanisms in health care.

2. Impact of Age on Health and Financial Stress: The data reveals a generational divide in how health and financial stresses are experienced and perceived. Younger generations, specifically Gen-Z and millennials, report higher rates of financial stress affecting their mental health and more workplace stress compared to older generations, highlighting a shift in challenges faced by different age groups within the workforce.

3. Trends in Health Management and Financial Decisions: A considerable portion of consumers are turning to alternative medicine, with 24% opting to research symptoms and treatments online, and 28% using natural or herbal remedies as a response to rising health care costs. Additionally, a majority (69%) have taken proactive steps to improve their financial situation through budgeting, debt repayment, and investments, indicating a growing consumer focus on comprehensive wellbeing.

Side Effects are Limiting GLP-1 Drug Efficacy: How Can Personalization Offer a Solution?

By Hakim Yadi - GLP-1 drugs have taken the industry by storm, but real-world evidence is showing that a significant proportion of patients are discontinuing treatment courses, many attributing this to intolerable side effects. By integrating digitization and machine learning, there is an opportunity to deliver personalized care to all patients and scale precision dosing with minimal physician involvement, maximizing the effectiveness and accessibility of these drugs. Read Full Article…

HVBA Article Summary

1. Impact and Challenges of GLP-1 Receptor Agonists: GLP-1 receptor agonist drugs, like Ozempic, Wegovy, and Mounjaro, initially approved for Type 2 diabetes, have dramatically transformed traditional weight loss approaches. Following the FDA's 2021 approval of Wegovy for weight management, the user base for such medications expanded over twentyfold by 2023, leading to significant drug shortages. This surge in demand underscores the necessity for new strategies to ensure continuous patient access and care, especially for those requiring these medications for both diabetes and obesity management.

2. Discrepancy Between Clinical Trial and Real-World Adherence: Clinical trials often report high persistence rates with GLP-1 treatments for obesity, sometimes over 85%, but real-world data presents a stark contrast, showing only about one-third of patients continue the therapy consistently after one year. The gap between controlled study environments and patient experiences in everyday settings highlights critical flaws in the current one-size-fits-all approach, leading to less effective and potentially unsafe outcomes due to unmanaged side effects.

3. Need for Personalized Treatment Approaches: The significant variation in drug efficacy and side effects observed among patients calls for a more personalized approach to GLP-1 treatment. Technological advances are facilitating the integration of digital healthcare solutions that allow for real-time monitoring and dose adjustments, promising improved treatment outcomes. Emphasizing patient-specific treatment plans could address the ongoing issues of drug efficacy and side effects, potentially reducing healthcare costs associated with drug wastage and mismanagement.

Alabama state health plan warns of funding shortfall

By Jakob Emerson - Alabama's state employee health plan is facing a projected loss of about $20 million in fiscal year 2025, the Alabama Reflector reported Aug. 22. Read Full Article…

HVBA Article Summary

1. Financial Challenges and Predictions: The board managing the health plan highlights significant financial strains due to an increasing number of retirees, a dwindling workforce, and escalating costs associated with Medicaid Advantage. They predict that while fiscal year 2025 can be managed using reserve funds, these reserves are expected to be exhausted by 2026, with projected losses reaching as high as $38 million.

2. State Responses to Healthcare Liabilities: The issue of unfunded healthcare benefits for retired public employees and their dependents is widespread, leading state legislators to explore new cost-saving measures. This situation is exemplified by recent developments in North Carolina, where officials have issued warnings about potential insolvency of the state health plan.

3. National Scale of Unfunded Liabilities: According to a report by the American Legislative Exchange Council, unfunded retiree healthcare liabilities across all states have exceeded $1 trillion as of 2019, highlighting a significant and widespread financial challenge that states are grappling with nationwide.

Cyber incident response planning – three "must-haves" brokers should know

By Gia Snape - As organizations continue to rely on technology to drive business operations, the risks associated with cyber incidents grow exponentially. The recent CrowdStrike outage has served as a stark reminder that even without the hand of malicious actors, cyber incidents can have far-reaching consequences, including financial loss, reputational damage, and legal liabilities. Read Full Article…

HVBA Article Summary

1. Essential Components of Cyber Incident Response: Gill Collins from Marsh McLennan emphasized the necessity of a comprehensive, regularly tested cyber incident response plan following the CrowdStrike outage. This plan must encompass proactive strategies like "out-of-band" communications for secure messaging when normal networks are compromised and a robust focus on third-party supply chain risks.

2. Challenges Highlighted by Recent Disruptions: The CrowdStrike incident significantly impacted businesses across various industries, revealing the critical need for organizational resilience against diverse types of cyber disruptions, not just malicious attacks. Over 500 clients were affected, underscoring the widespread vulnerability and the importance of being prepared for a variety of cyber events.

3. Recommendations for Enhancing Cyber Resilience: Experts recommend that organizations should conduct more frequent tests—suggesting three to four times a year—of their cyber incident plans across all operations to adapt to new threats effectively. Additionally, the plan should include a detailed command structure, quick-response communication processes, and continuity plans that focus on virtual operations rather than just physical locations.