Insurer stock prices fall after Trump pledges to 'knock out middlemen'

By Erica Carbajal - Shares of the three largest pharmacy benefit managers' parent companies took a hit Dec. 16, after President-elect Donald Trump vowed that his administration would work to "knock out the middlemen." Read Full Article… 

HVBA Article Summary

1. Trump Administration's Focus on PBM Reform: Former President Trump emphasized plans to "knock out the middlemen" in the pharmaceutical supply chain, targeting Pharmacy Benefit Managers (PBMs) as key contributors to high drug prices. His administration has signaled potential regulatory scrutiny, referencing discussions with Robert F. Kennedy Jr. and Dr. Mehmet Oz, his nominees for HHS and CMS leadership, respectively.

2. Market Impact and Industry Concentration: Following Mr. Trump's remarks, shares of major PBM operators — CVS Health, UnitedHealth Group, and Cigna — experienced significant declines. These companies, which dominate around 80% of the U.S. prescription claims market through CVS Caremark, Optum RX, and Express Scripts, have come under bipartisan scrutiny for their market practices and business models.

3. Legislative Push Against Vertical Integration: Bipartisan efforts, including the proposed Patients Before Monopolies Act, aim to address perceived conflicts of interest in PBM operations. This legislation would require insurers and PBMs to separate from their pharmacy businesses, a move intended to support independent pharmacies and mitigate concerns over monopolistic practices. PBMs argue these changes could disrupt their ability to negotiate lower drug prices, potentially increasing medication costs.

2-year extension of telehealth, plus hospital-at-home program boost likely as negotiations crest in Congress

By Emma Beavins - Lawmakers reached a deal Saturday evening to extend expiring healthcare programs, lobbyists close to the issue said. The package, floated Friday, is more robust than lobbyists expected. Read Full Article… 

HVBA Article Summary

1. Key Provisions in the Healthcare Package: The healthcare package includes significant measures such as a 2.5% Medicare physician payment increase for one year, a two-year extension of Medicare telehealth flexibilities, and a five-year extension of the hospital-at-home waiver program. Additionally, it provides a one-year extension of pre-deductible telehealth coverage for high-deductible health plans linked to health savings accounts, countering the recent Medicare physician fee cut.

2. Legislative Uncertainty and Deadline Pressure: With government funding set to expire on December 20, Congress is under intense pressure to finalize the healthcare package and a short-term continuing resolution (C.R.) to avoid a shutdown. Lobbyists and stakeholders are grappling with conflicting updates as lawmakers work to solidify the deal before the weekend.

3. Impact on Healthcare Stakeholders: The proposed package addresses various healthcare priorities, including funding for community health centers, support for opioid treatment programs, and extensions for pandemic preparedness. However, transparency measures for health plans remain under discussion, with hospital-related transparency excluded from the deal. The final package is seen as unlikely to change significantly, but last-minute negotiations could still impact its provisions.

Cap on employer health tax exclusion? New House bill coming soon

By Allison Bell - A House bill that's due to show up in the next few days will include about 75 proposals for changing U.S. health care finance and delivery rules and programs — and a provision that would cap the current federal income tax exclusion for employer-sponsored health benefits.  Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Key Provisions of the Fair Care Act of 2024: The bill proposes capping employer health benefits tax exclusions at $10,200 for individual coverage and $27,500 for family coverage, adjusted for inflation. It also aims to repeal the ACA employer mandate, enable employees with employer-sponsored coverage to access ACA subsidies, and require transparent billing practices from healthcare providers.

2. Potential Fiscal Impact: According to Congressional Budget Office (CBO) projections, implementing a cap similar to the one in the bill could generate $709 billion in tax revenue from 2025 to 2034, potentially reducing federal debt accumulation by 3.5%. However, critics like Garrett Hohimer of the Business Group on Health warn that altering the tax treatment of health benefits could lead to permanent changes in the system.

3. Legislative Challenges and Opportunities: With no cosponsors and oversight by nine House committees, the bill faces hurdles in advance. However, it may influence must-pass legislation like disaster relief or government funding measures. Even if it doesn't progress this term, it could resurface in the 119th Congress beginning January 2025.

The government agency that oversees HIPAA ‘not effective’ at improving cybersecurity, report finds

By Maia Anderson - Cyberattacks against healthcare systems have skyrocketed in recent years, but reports show that those who oversee the industry’s cybersecurity measures aren’t always doing their jobs as intended. Read Full Article…

HVBA Article Summary

1. Inadequate Enforcement and Resource Constraints: The Office for Civil Rights (OCR), responsible for enforcing HIPAA compliance, has not conducted comprehensive compliance audits since 2017, according to an OIG report. OCR's audits have assessed only a small fraction (8 of 180) of HIPAA requirements, hampered by a stagnant $39 million budget and a 30% reduction in investigative staff since 2010, despite a sharp rise in complaints and data breach reports.

2. Self-Audit Tools and Industry Responsibility: In light of resource limitations, OCR collaborated with the National Institute of Standards and Technology to develop a self-audit tool for healthcare facilities to evaluate their cybersecurity measures. Experts suggest that while this tool empowers organizations to take proactive steps, criticism of OCR's limited audits overlooks the agency's financial and staffing constraints.

3. Growing Threats and Legislative Intervention: The healthcare sector faces escalating cybersecurity threats, with ransomware attacks targeting valuable patient data. A separate Government Accountability Office report highlights broader challenges faced by HHS in improving cybersecurity. In response, a bipartisan Senate bill proposes enhanced coordination between HHS and the Cybersecurity and Infrastructure Security Agency to bolster the sector's defenses.

Biden's last effort to boost ACA enrollment

By Maya Goldman - President Biden is making a final push to build on the Affordable Care Act, extending the enrollment period for marketplace coverage that kicks in Jan. 1 as sign-ups lag. Read Full Article…

HVBA Article Summary

1. Record ACA Enrollment Under Pressure: Under the Biden administration, ACA marketplace enrollment has surged to historic highs, reaching 21.3 million for 2024, bolstered by enhanced subsidies and expanded insurer participation. However, these gains face uncertainty as the incoming Trump administration signals potential rollbacks in ACA support, including cuts to navigator funding and subsidies.

2. Critical Enrollment Deadlines Extended: To sustain momentum, the federal government extended the open enrollment deadline for 2025 coverage to Dec. 18, with additional enrollment for February-start plans running through Jan. 15. This extension aims to maximize sign-ups, especially in the final days when enrollment typically peaks.

3. Challenges Ahead for Continued Growth: New ACA enrollments are lagging compared to last year, influenced by fewer external motivators like pandemic-related coverage shifts and intensified competition for public attention during the election season. Potential policy shifts under a Republican-led administration, such as reduced subsidies or alternative coverage options, could further challenge enrollment gains.

HHS releases slimmed-down HTI-2 interoperability rule, with more regulations on the horizon

By Heather Landi - The Department of Health and Human Services this week finalized a pared-down version of a final rule aimed at advancing health data interoperability and implementing provisions related to the Trusted Exchange Framework and Common Agreement (TEFCA). Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Final Rule Focus on TEFCA: The finalized HTI-2 rule, significantly streamlined from its draft version, centers primarily on advancing the Trusted Exchange Framework and Common Agreement (TEFCA). It establishes minimum qualifications for health information networks to become Qualified Health Information Networks (QHINs) and sets procedures for their designation, governance, and compliance. By codifying TEFCA into regulation, the rule aims to secure its permanence and enhance interoperability nationwide.

2. Deferred Provisions of HTI-2: Many ambitious components from the original HTI-2 proposed rule, such as payer certification pathways, public health IT software certifications, and expanded interoperability requirements, were left out of the final rule. These deferred elements are expected to be addressed in future regulations, although their fate may be uncertain due to potential shifts in regulatory priorities with the incoming administration.

3. Industry Implications and Future Regulations: The focus on TEFCA in the final rule reflects ASTP/ONC's efforts to solidify its legacy. However, industry experts emphasize the importance of addressing technical corrections and unresolved components of HTI-2 in subsequent rules. The health IT sector anticipates additional regulations, including a related rule currently under review, which may encompass public health data exchange, payer API standards, and electronic prior authorization provisions.

McKinsey agrees to pay $650 million for its role in the opioid crisis

By Deborah Becker - The management consulting firm McKinsey and Company will pay $650 million over work it did for Purdue Pharma that federal prosecutors say helped fuel the opioid crisis. Read Full Article…

HVBA Article Summary

1. Historic Accountability for Consulting Firms: The settlement marks the first instance of a consulting firm being held accountable for its role in the opioid crisis. McKinsey agreed to a compliance program, forfeiture of Purdue-related fees, and acceptance of responsibility for its actions, underscoring the growing scrutiny of professional services firms in public health crises.

2. Acknowledgment of Missteps and Profound Regret: McKinsey admitted it failed to recognize the societal harm caused by opioids and expressed deep regret for its involvement in Purdue Pharma’s sales and marketing efforts. This public acknowledgment highlights the broader implications of corporate accountability in addressing public health emergencies.

3. Legal Repercussions for Individual Actions: Alongside the corporate penalties, a former senior McKinsey partner, Martin Elling, agreed to plead guilty to obstruction of justice for destroying records related to the company’s work with Purdue. This underscores the importance of individual accountability in legal and ethical investigations.

America: No. 1 for Being 'Burdened by Disease'

By Steven Ross Johnson and Jaclyn Jeffrey-Wilensky - While people around much of the world generally have been living longer, they’ve also been living more years burdened by disease or disability. Read Full Article…

HVBA Article Summary

1. Global Life Expectancy vs. Healthspan Growth: Between 2000 and 2019, global life expectancy increased by 6.5 years, reaching 72.5 years on average, while the disease- and disability-free years (healthspan) rose by only 5.4 years to 63.3 years. This discrepancy reflects a growing global gap between lifespan and healthspan, which widened by 13% during this period, highlighting the persistent burden of disease despite longer lives.

2. The U.S. Healthspan-Lifespan Gap: In the U.S., life expectancy grew modestly from 2000 to 2019, but the disparity between lifespan and healthspan expanded significantly. The "healthspan-lifespan gap" rose from 10.9 to 12.4 years, 29% higher than the global average. Chronic diseases, particularly musculoskeletal issues, mental health conditions, and substance use disorders, were identified as key contributors to this widening gap.

3. Gender and Mental Health Disparities: U.S. women faced a larger healthspan-lifespan gap than men, with an increase from 12.2 to 13.7 years, exceeding the global average for women by 32%. Additionally, mental health challenges were prominent, as 23% of U.S. adults reported a mental health diagnosis such as anxiety or depression, and 26% reported emotional distress, underscoring a critical area for health intervention.

An employer’s guide to offering the right voluntary benefits

By Tate Hackert - With open enrollment season around the corner, many organizations are revamping their benefits packages to maximize their appeal. But in the search for a competitive edge, employers may overlook a key factor — employee needs. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Employee-Centric Benefit Design: Employers must prioritize understanding and aligning benefit offerings with employee preferences. Conducting thorough surveys and leveraging feedback ensures that benefits reflect employees' diverse priorities, fostering greater satisfaction and engagement.

2. Pilot and Educate for Impact: Testing benefits through pilot programs and educating employees on how to access and utilize them effectively ensures resources are both relevant and well-used. Proactive communication and hands-on learning sessions maximize engagement and value.

3. Continuous Evaluation and Feedback: Maintaining open communication and utilizing data to track benefit usage and satisfaction ensures offerings evolve with employees’ changing needs. This adaptive approach strengthens trust, reduces attrition, and positions benefits as a strategic investment.