Senators Warren, Hawley introduce bipartisan bill that would force insurers, pharmacies to sell off PBMs

By Allison Bell - Hell has not frozen over, and death and taxes still exist, but Sen. Elizabeth Warren, D-Mass., and Sen. Josh Hawley, R-Mo., have joined to introduce a pharmacy benefit manager control legislation, the Patients Before Monopolies Act bill. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Key Provisions of the Bill: The proposed legislation aims to address conflicts of interest in the pharmacy and insurance sectors by prohibiting any entity from simultaneously owning a pharmacy and an insurance company or a pharmacy benefit manager (PBM) and a pharmacy. Targeted companies include Cigna's Express Scripts, CVS Health's Caremark, and UnitedHealth's OptumRx. Companies currently operating under these models would have three years to divest their pharmacy assets, with federal and state regulators empowered to enforce compliance through legal action.

2. Arguments For and Against the Bill: Supporters, including independent pharmacies and lawmakers like Sen. Elizabeth Warren, argue that vertically integrated PBMs inflate drug costs, harm small pharmacies, and exploit market power to benefit their subsidiaries. Critics, represented by PBM trade group CEO JC Scott, counter that PBMs provide significant savings to patients and employers, reduce drug costs, and offer valuable pharmacy options, including mail-order services. Scott warns that the bill could limit access to affordable medicines and raise prescription costs.

3. Legislative Challenges and Prospects: While the bill enjoys bipartisan support and aligns with widespread concerns about PBM practices, its passage is uncertain. The sponsors may attempt to attach the bill to "must-pass" legislation, such as defense or government funding packages, to ensure progress. However, Senate procedural rules and potential opposition could delay its adoption, requiring reintroduction in the next Congress if not enacted before the current session ends in January 2025.

Employers face higher healthcare costs in 2025, and may adopt new approaches

By Ron Southwick - Large employers are looking at higher healthcare costs in the coming year, and they will face growing pressure to consider new strategies to control costs. The Business Group on Health, a trade group which represents large employers on health policy issues, said those higher costs top their trends to watch in the coming year. The organization released a report outlining its 2025 projections earlier this week. Read Full Article… 

HVBA Article Summary

1. Increased Scrutiny on Healthcare Costs and Vendors: With healthcare cost increases expected to hit a decade-high, businesses are anticipated to reassess their health benefit plans and vendor partnerships. Companies may consider disruptive strategies and alternative providers, such as agile health plans and pharmacy benefit managers (PBMs), to achieve better value and predictable costs. This shift could include disengaging from long-standing partners and adopting innovative plan designs.

2. Addressing High Pharmacy Costs and Weight Loss Drug Coverage: Employers are prioritizing pharmacy cost management as a critical factor in curbing overall healthcare expenses. A significant number plan to reassess PBM contracts, explore new partnerships, or negotiate better terms. Additionally, companies are weighing coverage for expensive GLP-1 weight loss medications, balancing immediate costs against the potential long-term savings from improved employee health outcomes.

3. Mental Health Benefits and Workplace Policies: Mental health is now among the top five conditions driving corporate healthcare costs. Employers are not only expanding mental health services but also reevaluating workplace policies to support employee well-being better. Comprehensive mental health programs are expected to play a crucial role in addressing the rising costs and improving workforce health.

Poll: Majority back government health care, ACA approval soars

By Alan Goforth - Access to health care – and how to pay for it – was a key issue in this fall’s presidential and congressional elections. More than 6 in 10 Americans (62%) now say it is the responsibility of the federal government to ensure that all Americans have health care coverage, according to a Gallup poll conducted in early to mid-November.  Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Shifting Public Opinion on Government's Role in Health Care: Public sentiment on whether the government should ensure health coverage for all Americans has fluctuated significantly over the past two decades. While majorities consistently supported this idea between 2000 and 2008, opposition grew during the Affordable Care Act's (ACA) passage under President Obama, dividing Americans on the issue. Support rebounded in the latter years of Obama’s presidency, with notable increases among independents and even Republicans in recent years.

2. Partisan Divides on Government-Run vs. Private Health Care Systems: Americans are evenly split on the preference for a government-run healthcare system versus one based on private insurance. Democrats overwhelmingly favor a government-run system (71%), while most Republicans (75%) support private insurance. Independents are divided, with 49% favoring a private system and 47% supporting a government-run model. Republican support for a government-run system has reached its highest level to date at 21%, reflecting a broader shift in attitudes.

3. ACA Approval and Implications for Policy: Approval of the Affordable Care Act is at a near-record high of 54%, with broad support among Democrats (94%) and rising approval among independents (53%). While those who approve of the ACA are evenly split on whether to retain it as-is or make significant changes, most opponents (66%) advocate for its repeal and replacement. These trends could influence future healthcare strategies as public opinion aligns increasingly with the ACA's core principle of ensuring universal health coverage.

4 Cybersecurity Trends CEOs Followed in 2024

By Jay Asser - Shoring up cybersecurity became a necessity for healthcare organizations this year as several attacks highlighted vulnerabilities. While other pain points such as the workforce continue to keep CEOs up at night, cybersecurity has come to the fore and forced leaders to rethink the number of resources they're putting into keeping their and their patients' data safe. Read Full Article…

HVBA Article Summary

1. Cybersecurity Needs Immediate Attention: The Change Healthcare attack underscored the critical vulnerabilities in healthcare systems, with 94% of hospitals experiencing financial impacts and many CEOs, like Aspirus Health's Matt Heywood, dubbing 2024 "the year of chaos." This has amplified the urgency for health organizations to prioritize cybersecurity measures to mitigate risks.

2. Preparedness and Response Plans Are Essential: Despite the rise in cyberattacks, only 63% of healthcare organizations have response plans in place. Comprehensive plans with defined roles, communication protocols, and prioritized tasks are essential to reduce downtime and financial losses when breaches occur.

3. Investments and Recovery Efforts Are Increasing: A growing number of healthcare organizations are ramping up IT and cybersecurity investments, with 75% of surveyed providers and payers increasing spending in 2024. However, longer recovery times from ransomware attacks—now taking more than a month for 37% of organizations—highlight the need for further resource allocation and strategic planning.

Eli Lilly to test weight loss drugs as addiction treatments

By Alexander Murphy - Eli Lilly will launch studies to investigate whether its weight loss medications can help control addictive behaviors such as smoking and alcohol and drug abuse, CEO Dave Ricks revealed in a Dec. 10 interview, Bloomberg reported. Read Full Article…

HVBA Article Summary

1. "Anti-Hedonics" and Addiction Treatment: Eli Lilly's CEO, Mr. Ricks, introduced the concept of "anti-hedonics," describing how their drugs may alleviate addiction by curbing cravings, potentially offering groundbreaking solutions for patients struggling with dependence.

2. Upcoming Clinical Trials: Eli Lilly plans to initiate large-scale clinical trials next year, targeting alcohol and nicotine use and potentially drug abuse. This marks an expansion of the company's focus on broader therapeutic applications for its weight loss treatments.

3. Competition in the Field: Rival drugmaker Novo Nordisk has signaled similar ambitions, announcing plans earlier this year to study the effects of its weight loss medications on alcohol consumption, highlighting a competitive and promising new frontier in addiction therapy.

Vermont faces nation’s steepest health insurance hike for 2025

By Daniel Duric - Vermont residents will face the country’s highest health insurance costs in 2025, with premiums jumping 27% to reach $13,884 annually, according to a new ValuePenguin.com report. The increase will push Vermont’s rates 86% above the national average, with residents paying approximately $1,157 per month for private health insurance coverage. Read Full Article… 

HVBA Article Summary

1. Rising Premiums in 2025: Private health insurance premiums will increase by 7% nationally in 2025, averaging $621 per month or $7,452 annually. This marks the fourth consecutive year of rising premiums, driven by escalating healthcare costs passed on to policyholders.

2. Subsidies Provide Relief: Over 90% of enrollees qualify for subsidies, which can reduce costs by over $800 annually. In fact, four in five eligible individuals may pay less than $10 per month for their health insurance.

3. Future Uncertainty of Subsidies: The enhanced health insurance subsidies program is set to expire in 2025. If Congress does not act to extend it, millions of Americans could face significant increases in their health insurance costs starting in 2026.

Common ACA reporting pitalls (and why they matter)

By David Saltzman - This marks the tenth year of reporting under the Affordable Care Act (ACA). For employers with 50 or more full-time employees or equivalents, self-insured employers (regardless of size), or health insurance providers, ACA reporting might seem like old hat by now. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. The Hidden Complexity of ACA Reporting: While ACA reporting may appear straightforward at first glance, its nuances—such as tracking eligibility for variable-hour employees or managing multiple EINs—often trip up non-experts. Mistakes in classification, affordability calculations, or compliance tracking can result in significant penalties, up to $330 per employee per month.

2. Pitfalls of Relying on Generalists: Many businesses turn to payroll companies or non-specialized service providers for ACA reporting, believing it to be a routine task. However, these providers often lack the specialized knowledge required to navigate intricacies like classed employee contributions or transitions in employee status, which can lead to costly errors.

3. The Value of Expert Guidance: Engaging an ACA specialist ensures compliance with IRS guidelines and reduces the risk of penalties. From seasonal workforce management to collectively bargained employee reporting, experts bring the meticulous attention to detail necessary for avoiding high-stakes mistakes and achieving peace of mind.