Employers May Follow Medicare Coverage Of GLP-1 Weight Loss Drugs

By Bruce Japsen - News of the Biden administration plan to require Medicare and Medicaid government health insurance to cover weight loss drugs could trigger private employers to do the same for their obese employees. Read Full Article…

HVBA Article Summary

1. Rising Costs for Employers and Employees: Employers are facing significant cost pressures from the increased use of GLP-1 drugs like Ozempic and Wegovy for weight loss, which are the leading drivers of higher healthcare premiums. Employer-sponsored health insurance costs are projected to rise by 9% in 2025, surpassing $16,000 per employee annually. This financial burden is partly passed on to employees through higher co-payments, deductibles, and paycheck deductions.

2. Medicare and Medicaid Expansion: The Biden administration proposes expanding Medicare Part D and Medicaid coverage to include anti-obesity medications, aligning with the medical consensus that obesity is a disease. While the move aims to improve health outcomes for millions, it is expected to significantly raise healthcare expenditures for state Medicaid programs, Medicare, and private Medicare Advantage plans.

3. Balancing Health Equity and Financial Sustainability: Employers and policymakers must navigate the tension between expanding access to life-saving weight loss drugs and managing soaring healthcare costs. Analysts highlight the need to consider prevalence, cost, equity, and system inefficiencies when making coverage decisions, as the increasing adoption of these medications adds to broader healthcare inflation.

Medicare Pays Wildly Different Prices for the Same Drug

By Jared S. Hopkins and Josh Ulick - The cost of prescription drugs in the U.S. isn’t like the tabs for other products. The price for a single medicine can range by thousands of dollars depending on the drug plan. Read Full Article…

HVBA Article Summary

1. Wide Variations in Drug Prices Across Medicare Plans: Medicare beneficiaries face significant disparities in drug prices depending on their location and chosen plan. Generic medications like Zytiga can have price discrepancies exceeding $3,000 per month in different regions, reflecting a fragmented pricing structure shaped by middlemen, known as Pharmacy Benefit Managers (PBMs).

2. Cost Burden and Confusion for Seniors: Many seniors bear substantial out-of-pocket costs due to the inconsistent pricing. For example, Paula Kirk, a Medicare beneficiary, experienced a $2,500 annual savings by switching plans. However, navigating these choices often requires switching plans annually, adding stress and financial strain, particularly for those on fixed incomes.

3. Systemic Issues in Drug Pricing: The involvement of PBMs has created a complex and costly system that leads to inefficiencies and inflated costs for both Medicare and patients. Critics argue this model benefits PBMs at the expense of transparency and affordability, with Medicare paying tens of millions more due to the patchwork pricing negotiated by these intermediaries.

Employers Must Attest to Removal of Gag Clauses by End of Year

By Remy Samuels - New health care regulations should give plan sponsors more clarity related to the cost and quality of provider services—but some of the onus will remain on plan sponsors to ensure access to the relevant data. Read Full Article… 

HVBA Article Summary

1. Compliance Deadlines: Employers must ensure service providers remove gag clauses from health care contracts and attest to compliance annually, with the next deadline on December 31, 2024. Attestations, submitted electronically via the Gag Clause Prohibition Compliance Attestation form, are enforced under CAA ’21, with potential penalties of $100 per day per affected individual for non-compliance.

2. Gag Clause Restrictions: The CAA ’21 bans agreements restricting access to provider-specific cost and quality data to help employers better evaluate health plans. Despite this, many employers struggle to obtain necessary data from third-party administrators and service providers.

3. Updated Rules and Fiduciary Risk: 2024 attestations require new details like the attestation year, period, and plan type. Employers are leveraging CAA ’21 to demand better access to claims data, addressing fiduciary risks such as overpayments, and amending contracts to explicitly prohibit gag clauses.

Health coverage gap making some Americans sicker

By Kristen Beckman - Despite progress made to ensure Americans have access to health insurance through the Affordable Care Act, a coverage gap remains, and health plans do not always guarantee affordable or timely access to care. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Insurance Gaps and Financial Barriers: The survey reveals that 20% of respondents experienced a lapse in insurance coverage in the past year, while nearly 25% were underinsured, with high out-of-pocket costs that made care unaffordable. These gaps lead to significant financial challenges, especially for those with employer-based coverage (two-thirds of the underinsured) and other insurance types.

2. Impact of Cost on Health Outcomes: Over 50% of respondents skipped recommended care due to cost, with up to one-third of those with chronic conditions, like diabetes, forgoing necessary medications. Additionally, 44% delayed essential care because of medical debt, exacerbating health issues for 41% of those who skipped or delayed care.

3. Policy Recommendations to Close Coverage Gaps: The Commonwealth Fund emphasizes the need for policy actions such as expanding Medicaid, reducing marketplace plan costs, and eliminating medical debt from credit reports. Extending COVID-era premium tax credits beyond 2025 and creating a federal fallback insurance option could prevent millions from losing coverage and promote access to essential care.

Compliance and coverage: A look at the finalized mental health parity rule

By Deanna Cuadra - Healthcare compliance is rarely an employer's favorite topic of conversation — but it's a conversation they won't be able to avoid over the next few years. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Enhanced Employer Responsibilities: The Biden administration's finalized rule under the Mental Health Parity and Addiction Act requires employers to strengthen their mental health care networks, document coverage limitations more rigorously, and ensure non-discriminatory practices in their plans. Compliance will be challenging both administratively and financially but is expected to address long-standing disparities in mental health access.

2. Workplace Impact and Leadership Role: Employers are encouraged to not only expand coverage but also foster a culture that reduces stigma around mental health. Leaders can play a key role by normalizing mental health discussions and prioritizing holistic support, ensuring employees feel safe utilizing their benefits.

3. Anticipated Benefits and Uncertainty: While the rule aims to create a healthier, more productive workforce, compliance costs and potential legal challenges may complicate implementation. However, the long-term goal of equitable mental health care aligns with broader efforts to support employee well-being and satisfaction.

Survey: Most American workers satisfied with employer-provided health coverage

By Michael Popke - A new nationwide poll finds that a strong majority of Americans receiving health care coverage through work — about 180 million people — are satisfied with their current employer-provided plans (75%) and prefer to get their coverage through an employer rather than through the federal or state government (74%). Read Full Article…

HVBA Article Summary

1. Key Drivers of Satisfaction: The survey revealed that employees value their employer-provided health coverage primarily for its comprehensive coverage (49%), affordability (48%), and choice of providers (45%), highlighting these factors as critical to satisfaction with workplace health plans.

2. Impact on Employment Decisions: Employer-provided health coverage plays a pivotal role in workforce dynamics, influencing job acceptance (61%) and retention (80%). Employees also express high confidence in their plans, with 76% believing their coverage would protect them during a major medical emergency.

3. Advocacy for Employer-Provided Coverage: Industry leaders emphasize the significance of employer-provided health benefits as a cornerstone of workforce strategy and healthcare affordability. Policymakers are urged to safeguard and enhance these programs to support the diverse health needs of employees and their families.

Most hospitals falling short on price transparency: Report

By Ron Southwick - Despite regulations aimed to make it easier for patients to understand hospital billing practices, most hospitals aren’t meeting their obligations, according to a new report from an advocacy group. Read Full Article… 

HVBA Article Summary

1. Decline in Hospital Compliance: PatientRightsAdvocate.org's latest report reveals that only 21.1% of hospitals are fully compliant with federal price transparency rules, a significant drop from the 34.5% compliance reported earlier this year. The report highlights the persistent failure of hospitals to publish their discounted cash prices and negotiated rates, undermining consumer rights to price transparency.

2. Non-Compliance Despite Consumer-Friendly Displays: While most hospitals have met requirements to list 300 shoppable services in a consumer-friendly format or via price estimator tools, 78% were still non-compliant due to incomplete machine-readable files. Only a few hospital systems, such as Prime Healthcare (90%), Baylor Scott & White (68%), and Sanford Health (59%), excelled in providing sufficient pricing data.

3. Calls for Stronger Enforcement: Cynthia Fisher and other advocates are urging the federal government to strengthen oversight and enforce penalties more rigorously. Despite the regulations in place since January 2021 and over $4 million in fines issued, enforcement remains limited, with only 15 hospitals fined to date, prompting criticism of the Biden administration's handling of transparency laws.