GOP bill fails, leaving key healthcare provisions in limbo

By Alan Condon - Republican lawmakers on Dec. 19 failed to pass a pared-down government funding bill backed by President-elect Donald Trump after dropping a broader package he opposed. Read Full Article… 

HVBA Article Summary

1. Key Healthcare Provisions Excluded: The revised bill omitted critical healthcare provisions, including the long-term extensions for Medicare telehealth reimbursement and hospital-at-home programs, which were shortened to March 31, 2024. Additionally, it excluded measures to address physician pay cuts, delay $8 billion in Medicaid disproportionate share hospital cuts, and impose new regulations on pharmacy benefit managers.

2. Debt Limit Suspension Added: A significant addition to the bill was the suspension of the debt limit through 2027, a provision backed by Mr. Trump but seen as a departure from the bipartisan agreement reached in December.

3. Implications of Government Shutdown: As lawmakers work against a Dec. 20 deadline to avoid a government shutdown, essential programs like Medicare and Medicaid are expected to continue due to mandatory funding. However, prolonged delays could create uncertainty and disrupt other critical areas of government operations.

Employers Press Congress To Cement Health Price Transparency Before Trump’s Return

By Julie Appleby - It seems simple: Require hospitals and insurers to post their negotiated prices for most health care services and — bingo — competition follows, yielding lower costs for consumers. Read Full Article… 

HVBA Article Summary

1. Impact of Transparency Regulations Remains Unclear: Despite regulations from the Trump and Biden administrations requiring hospitals to post pricing information online, the tangible effect on reducing patient costs remains uncertain. The bipartisan agreement on price transparency adds complexity to the debate, especially with the possibility of future policy changes under a returning Trump administration.

2. Legislative Efforts to Cement Price Transparency Fail: Advocates pushed for Congress to enshrine hospital and insurer price transparency rules into law to shield them from future regulatory changes or legal challenges. However, this effort was unsuccessful, leaving the regulations vulnerable to potential rollback or legal scrutiny, especially after a Supreme Court ruling limiting regulatory agency authority.

3. Employers and Regulators Push for Compliance: Large employers, represented by groups like the ERISA Industry Committee, are leveraging transparency data to manage health care costs and are calling for stronger legislative support. Meanwhile, federal regulators have issued thousands of warnings to non-compliant hospitals, though fines have been limited to just over a dozen institutions.

NJ would ban health insurers from pre-approval demands

By Brenda Flanagan - “I was denied a relatively inexpensive scan that could’ve caught my cancer when it was still curable. I want to make sure nobody else has to go through that,” says Brad Schnure. He is battling terminal lung cancer — a disease he believes progressed undiagnosed to Stage IV, partly because his health insurance denied coverage for a CT scan in 2022, before his cancer had spread. Read Full Article… 

HVBA Article Summary

1. Legislative Push for Reform: Public outrage over insurance pre-authorization practices, intensified by recent events such as the assassination of United Healthcare's CEO, has prompted a renewed push for reform. State Sen. Jon Bramnick's proposed bill (S2257) seeks to eliminate pre-approval requirements for medical tests, procedures, and prescription drugs, shifting decision-making power from insurers to doctors and patients. Bramnick acknowledges the uphill battle against the powerful insurance lobby but emphasizes the importance of prioritizing patient care over bureaucratic processes.

2. Impact on Healthcare Delays and Costs: Critics of pre-authorization argue that it exacerbates healthcare delays and increases overall medical costs. Despite insurance industry claims that the process ensures appropriate care and resource allocation, healthcare advocates and physicians report that the system often results in significant treatment delays and administrative burdens, negatively affecting patient outcomes.

3. Incremental Improvements vs. Comprehensive Solutions: A new state law set to take effect Jan. 1 will require insurers to respond to urgent pre-authorization requests within 24 hours, addressing some delays. However, Bramnick and Senate President Nick Scutari continue to advocate for a more comprehensive ban on pre-authorization requirements, arguing that incremental measures fail to address the root issues of inefficiency and patient dissatisfaction.

Lilly's US weight-loss drug shortage ends, curtailing copies

By Ike Swetlitz - Eli Lilly diabetes and weight-loss drugs Mounjaro and Zepbound are no longer in short supply in the U.S., which means compounding pharmacies must stop making less expensive copycat versions in the coming months.  Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. FDA Declares Shortage Resolved: The FDA reaffirmed its decision that the shortage of Lilly's drugs is over, requiring compounders to stop producing copies of the medications within 60 to 90 days. This move comes despite legal challenges from compounding industry groups, which argue that pharmacies still face supply constraints and that the decision jeopardizes patient access.

2. Impact on Compounding and Telehealth Markets: The booming market for compounded weight-loss drugs, estimated to generate up to $1 billion annually, faces disruption as compounders must halt production. Telehealth companies, like Hims & Hers Health, which provide similar services, saw significant market reactions, highlighting the industry's reliance on compounded medications during brand-name shortages.

3. Legal and Safety Disputes Intensify: Lilly and Novo Nordisk continue to challenge the sale of compounded versions of their drugs through legal and public relations campaigns, citing safety and quality concerns. Meanwhile, compounders defend their practices, claiming they meet patient needs with quality medicines, as the ongoing lawsuit against the FDA underscores broader tensions between pharmaceutical companies, regulators, and compounders.

Big Health Care is ending a terrible year. Is anyone happy with this business?

By Maria Aspan - Health care companies are ending 2024 in the hot seat. Yet some of the pressures they're facing have been mounting all year — or longer. Read Full Article…

HVBA Article Summary

1. The Industry Under Fire: The murder of UnitedHealthcare CEO Brian Thompson has intensified scrutiny on the U.S. healthcare industry, already grappling with skyrocketing costs, declining profits, and significant investor dissatisfaction. This high-profile incident underscores the systemic frustrations of consumers and stakeholders alike, particularly around denied claims and the rising expense of care.

2. Regulatory and Political Challenges: Lawmakers from both parties, including Senators Elizabeth Warren and Josh Hawley, have proposed legislation aimed at breaking up large healthcare conglomerates like UnitedHealth Group. Additionally, President-elect Donald Trump has targeted pharmacy benefit managers (PBMs) for their role in prescription drug pricing, signaling an era of heightened regulatory focus on Big Health Care.

3. Investor and Public Discontent: Despite their vast profits and influence, healthcare conglomerates face growing criticism from investors, who are disappointed with stagnant profit growth, and from the public, frustrated by unaffordable and inaccessible care. This widespread discontent highlights the challenges of balancing shareholder interests with the urgent need to address systemic inefficiencies in the healthcare system.

J&J sues Cigna units, accusing them of exploiting patient assistance funds

By Lucy Peterson - According to a recently unsealed lawsuit filed in New Jersey federal court – Johnson & Johnson has sued two divisions of health insurer, Cigna. The lawsuit alleges that Cigna worked with a drug-benefit middleman to drain J&J financial-assistance funds that were put aside for patients taking their more costly drugs, the Wall Street Journal reported. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Expansion of Legal Action by J&J: In its latest lawsuit, Johnson & Johnson expanded its legal efforts against SaveOnSP LLC by naming Cigna's Express Scripts and specialty pharmacy Accredo as defendants. The company alleges that these entities collaborated on a program that increased J&J's drug copay assistance costs by over $100 million.

2. Accusations of Collusion and Profit Sharing: J&J claims that since 2016, Express Scripts and Accredo have worked closely with SaveOnSP, promoting its program and receiving a share of the fees it charged. Accredo was also alleged to be the exclusive pharmacy for most patients enrolled in the program, strengthening the integration between the entities.

3. Protecting Patient Assistance Programs: J&J asserts that the actions of SaveOnSP and its partners undermine patient assistance programs by diverting funds for financial gain, harming patients' access to necessary medicines. The company is seeking monetary damages and a court order to halt the program's practices.

4 benefit trends employers should watch in 2025

By Deanna Cuadra - A new year means a fresh start, but for many employers, it's also an opportunity to tackle old problems. From healthcare costs to AI training and development, 2025 will likely be defined by the benefits and policy challenges leaders have struggled to make headway on in the last few years. Add in the political and economic uncertainty Trump's incoming presidency brings, and it's clear HR teams will continue to have a lot on their plates. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Prioritize Employee-Centered Decision-Making: Leaders must actively listen to employees to address their concerns effectively, especially in areas like healthcare, flexibility, and mental health. Decision-making in isolation risks missing critical insights into what drives employee satisfaction and retention. Engaging employees in conversations about benefits, policies, and workplace improvements fosters trust and alignment with their needs.

2. Adapt Benefits to Evolving Needs: With rising healthcare costs and increasing demands for mental health support, HR teams must redesign benefit offerings. Employers should evaluate high-utilization healthcare plans and invest in tools that improve access to quality care. Additionally, mental health benefits need to go beyond traditional employee assistance programs, addressing holistic wellness to improve productivity and reduce burnout.

3. Embrace Flexibility and Emerging Technologies: Employers should balance operational goals with employee preferences, especially regarding return-to-office policies and AI integration. Flexibility remains crucial for retention, as rigid mandates can undermine trust. Similarly, providing AI training and inviting employees to identify its practical applications in their roles can drive innovation and create a more engaged workforce.

4 key barriers holding biosimilars back (and how to remove them)

By Mark Campbell - Spending on prescription drugs rose 9.9% in 2023 alone, while pharmacy benefits remained the fastest growing component of health care in 2024. With prescription benefits costs expected to continue rising – estimated to increase more than 8% next year – solutions that can lower costs for patients and plan sponsors are needed more than ever. Read Full Article…

HVBA Article Summary

1. Challenges to Biosimilar Adoption: Despite the promise of cost savings and increased access, the adoption of biosimilars has been hampered by complex formulary structures, entrenched market advantages of branded biologics, high initial pricing, and low prescriber and patient awareness. These barriers have left significant potential savings untapped.

2. Opportunities for Reform: Addressing these challenges requires action across multiple fronts: reforming rebate structures and formulary policies, implementing competitive pricing strategies, and investing in education for both prescribers and patients to build confidence in biosimilars. Early success stories, like the shift in CVS Caremark and Express Scripts formularies, highlight the potential for impactful change.

3. The Path Forward: With more biosimilars entering the market, particularly for high-cost treatments, there is a crucial window to foster a competitive and transparent environment. Coordinated efforts by PBMs, policymakers, and healthcare providers can help unlock billions in savings while expanding patient access to essential treatments.