Daily Industry Report - February 20

Your summary of the Voluntary and Healthcare Industry’s most relevant and breaking news; brought to you by the Health & Voluntary Benefits Association®

Jake Velie, CPT
Vice Chairman, President & COO
Health & Voluntary Benefits Association® (HVBA)
Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF
Chairman & CEO
Health & Voluntary Benefits Association® (HVBA)
Daily Industry Report (DIR)

After Promising to Make Government Health Care Data More Accessible, the Biden Administration Now Wants to Clamp Down

By T. Christian Miller - In January, the Biden administration pledged to increase public access to a wide array of Medicare information to improve health care for America's most sick and vulnerable. Read Full Article…

VBA Article Summary

  1. Increased Fees and Restricted Access to Data: The Centers for Medicare and Medicaid Services (CMS) proposed changes that would significantly increase the fees and limit access to critical claims data. This data has historically informed thousands of health care studies and supported major public health reforms. The proposal has sparked widespread concern among over 300 leading health economics researchers, who fear a "catastrophic impact" on health care research. This data is crucial for evaluating patient care trends, developing public policy, and improving health equality for the nearly half of all Americans covered by Medicare, Medicaid, and the Children's Health Insurance Program.

  2. Justification and Impact of Proposed Changes: CMS justifies the proposed changes as a measure to better protect health care records, citing an increase in data breaches. However, the move to a CMS-controlled computer platform for data analysis, which would cost researchers starting at $35,000 per year for single-user access, is criticized for potentially shutting out less-funded researchers, including Ph.D. students and junior faculty. Critics argue that this will limit critical research on public health care initiatives and the effectiveness of treatments, such as gene therapy for sickle cell disease, and investigations into abuse and fraud within Medicare and Medicaid.

  3. Concerns Over Research Freedom and Feasibility: The requirement for researchers to use a government-controlled system raises concerns about the freedom to conduct research critical of CMS policies, particularly in light of increasing scrutiny over programs like Medicare Advantage. Additionally, the feasibility of accommodating the computational needs of thousands of researchers accustomed to conducting complex analyses on their own systems is questioned. Critics, including professors and public health experts, argue that the administration's steps make conducting essential health care research more difficult, potentially impacting the quality of health care research and public health policies.

HVBA Poll Question - Please share your insights

What do you believe is the primary factor contributing to the average 20% increase in pharmacy costs as a percentage of total medical spending for businesses:

Login or Subscribe to participate in polls.

Our last poll results are in!


of Daily Industry Report readers who responded to our last polling question “absolutely believe and would engage in the legal importation of specialty medications” when asked if they would advise clients to import speciality or high cost brand drugs like Ozempic, Mounjaro, Wegovy from abroad to save 35-50% off U.S. prices of $850, $1,070, $1,670 per month respectively.

26.83% of respondents have no opinion on the matter or are neutral, neutral or uncertain, 25.25% would consider it, but not too familiar with the process, while 20.41% do not believe or have trust in medications being sourced outside of the U.S. pharmacies.

Have a poll question you’d like to suggest? Let us know!

ANALYSIS: Drug Price Fights Still Have Shot After One Suit Axed

By Alexis Kramer - Drugmakers still have a chance to unravel the Biden administration’s drug price negotiation program despite a blow to one legal challenge. Read Full Article…

VBA Article Summary

  1. Jurisdictional Dismissal of NICA Lawsuit: A federal district court in Texas dismissed a lawsuit by the National Infusion Center Association (NICA) and other industry groups on February 12, citing lack of jurisdiction. The lawsuit challenged Medicare reimbursement policies under the Inflation Reduction Act, arguing it would lead to significantly lower reimbursement rates for provider-administered drugs. The court decided that since NICA's claims were rooted in the Medicare Act, they were required to exhaust administrative remedies before seeking judicial intervention.

  2. Distinct Nature of Ongoing Lawsuits: Unlike NICA's lawsuit, the eight other legal challenges currently progressing through the courts are primarily filed by drug manufacturers and do not center on provider reimbursements. These lawsuits allege violations of the U.S. Constitution but are distinguished from the NICA case in their focus, which might lead to different judicial considerations and outcomes.

  3. Implications for Medicare Reimbursement and Drug Price Negotiation: The court's decision underscores a significant provision of the Inflation Reduction Act that enables direct negotiation between the federal government and drug manufacturers for lower drug prices. This ruling highlights the procedural requirement for plaintiffs, like NICA, to first seek resolution through administrative channels before proceeding to court, based on a precedent that emphasizes the exhaustion of administrative remedies in disputes arising under the Medicare Act. This decision could influence the strategies of both provider groups and drug manufacturers in challenging aspects of the Inflation Reduction Act related to Medicare reimbursements and drug pricing negotiations.

Disputes over surprise billing continue to soar, new CMS data shows

By Rebecca Pifer - The No Surprises Act, passed in 2021, is viewed as the most comprehensive consumer health legislation since the Affordable Care Act. But implementation of the law, which is meant to hold patients blameless for unexpected out-of-network medical bills, has been less than perfect. Read Full Article…

VBA Article Summary

  1. Surge in Disputes and Operational Challenges: In the first half of 2023, the federal government experienced an unexpected surge in surprise billing disputes, receiving 13 times more cases than anticipated for an entire year. This increase not only contributed to a backlog but also strained the arbitration system's capacity, which was designed to resolve financial disagreements between healthcare providers and insurers. Despite the high volume of disputes, fewer than half were resolved in this period, with arbiters making payment decisions in less than a third of cases.

  2. Dominance of Providers in Arbitration Wins and Systemic Issues: Providers won a significant majority (77%) of payment determinations in the arbitration process, a notable statistic given their arguments that the system is biased towards insurers. However, a few large physician staffing firms, responsible for 58% of all disputes, have been accused of exploiting the process for profit, raising concerns about the integrity of the independent dispute resolution (IDR) system. Additionally, the IDR has faced operational hurdles, including multiple restarts due to legal challenges and the complexity of assessing dispute eligibility.

  3. Impact on Healthcare Costs and Insurance Premiums: The No Surprises Act, aimed at protecting patients from unexpected medical bills, successfully prevented over 10 million surprise bills in its first nine months of 2023. However, there are concerns that the act could inadvertently raise healthcare costs, particularly insurance premiums, as arbitration decisions often result in payments higher than the qualifying payment amount (QPA). While this suggests a potential increase in premiums, it's also argued that the QPAs might be lower than pre-act out-of-network payments, possibly mitigating the impact on overall healthcare expenses.

Some virtual care companies putting patient data at risk, new study finds

By Amina Zafar - If you visit a doctor virtually through a commercial app, the information you submit in the app could be used to promote a particular drug or service, says the leader of a new Canadian study involving industry insiders. Read Full Article…

VBA Article Summary

  1. Industry Concerns and Data Privacy: The article highlights concerns among industry insiders, including Dr. Sheryl Spithoff, about the potential for virtual care to prioritize pharmaceutical company objectives over patient care. It also raises issues regarding the protection of patients' private health information, with fears that some virtual care companies may not prevent the misuse of this data by drug companies and third parties for marketing purposes.

  2. Commercialization and Patient Care: The study, published in BMJ Open, based on interviews and analysis of privacy documents from Canadian virtual care companies, suggests a commercialization of patient data, with instances of A/B testing for drug uptake. This commercial aspect raises questions about the conflict of interest between patient care and the financial gains of shareholders, as noted by Lorian Hardcastle, an associate professor of law and medicine.

  3. Regulatory and Industry Response: The article discusses the need for better legislation, regulation, and funding for primary care to address these concerns. While some virtual care companies claim to take privacy seriously and do not exploit patient data, the overall industry response suggests a gap in ensuring data privacy and ethical use. Calls for an opt-out option for commercial use of data and a review of policies by self-regulatory bodies are among the solutions proposed to safeguard patient interests.

Older Americans skipping surgeries over cost, missed work worries

By Kristen Beckman - Older Americans may forego elective surgeries because they are worried about out-of-pocket expenses and time away from work, along with potential exposure to COVID-19. Read Full Article…

VBA Article Summary

  1. Financial and Work-Related Concerns Over Medical Concerns: The University of Michigan Institute for Healthcare Policy and Innovation found that older Americans are more deterred by the cost of surgery and the necessity to take time off work than by concerns related to the pain or recovery process from the surgery itself. Nearly half of the respondents very concerned about cost and over half of those worried about taking time off work refrained from undergoing surgeries they considered, while pain concerns did not significantly impact the decision to proceed with surgery.

  2. Changing Demographics and Insurance Dynamics: Over the last two decades, there has been a notable increase in the employment rate among people over 60, as well as growth in enrollment in Medicare Advantage plans with limited networks and high deductible health plans. These changes, coupled with the types of surgeries considered (e.g., hip/knee replacements, cataract surgery), highlight the evolving landscape of healthcare and insurance that influences decision-making regarding elective surgeries.

  3. Policy Gaps and Additional Concerns: Despite attempts to make surgery costs more transparent, current policies do not fully address the financial implications of losing wages or the specific costs associated with an individual's health insurance structure. Moreover, concerns related to COVID-19 and caregiving responsibilities during recovery also significantly influence older Americans' decisions on whether to proceed with elective surgeries, indicating a complex web of factors beyond just the medical aspects of surgery.

Payers ranked by total membership | Q4 2023

By Rylee Wilson - UnitedHealthcare ended 2023 with the largest total membership of large payers across Medicare, Medicaid, military, commercial and individual business. Read Full Article…

VBA Article Summary

  1. Significant Membership Growth in 2023: The company experienced notable membership growth in 2023, adding around 1 million members to its base according to the fourth-quarter earnings report. This indicates a strong performance and potential market expansion during the year.

  2. Comparison Among Leading Healthcare Payers: At the end of 2023, UnitedHealthcare led the pack with a total medical membership of 52,750,000, followed by Elevance Health with 46,961,000 members. Centene, CVS Health, Cigna, and Humana also showed significant membership numbers, highlighting the competitive landscape among the largest healthcare payers.

  3. Market Positioning and Strategic Implications: The membership numbers reflect the strategic positioning of these companies within the healthcare sector. UnitedHealthcare’s leading position with over 52 million members underscores its dominance. Meanwhile, Elevance Health, Centene, CVS Health, Cigna, and Humana's substantial memberships demonstrate their significant roles in the healthcare ecosystem, impacting competitive strategies, market share distribution, and future growth opportunities.

States clamping down on coverage of weight-loss drugs

By Tina Reed - States are tightening access to blockbuster weight-loss and diabetes drugs to protect against the pricey treatments from blowing up their budgets. Read Full Article…

VBA Article Summary

  1. Surge in Costs Due to GLP-1 Agonists: State employee health benefits and Medicaid programs are facing a significant rise in expenses attributed to a class of drugs known as GLP-1 agonists, used primarily for diabetes and weight loss. This surge has led to financial constraints, prompting some state officials to impose restrictions on these drugs, including higher copays, limited patient access, or outright discontinuation of coverage for weight loss purposes.

  2. State Responses to Escalating Expenses: In response to the escalating costs, states like North Carolina have taken drastic measures by discontinuing GLP-1 coverage for weight loss among state employees, citing potential budget overruns. Other states, such as Delaware and Connecticut, are exploring or implementing alternative strategies like mandatory participation in clinical lifestyle management programs to manage these costs more effectively.

  3. Impact on Medicaid and Potential Backlash: The cost increase for GLP-1 drugs is also a concern for state Medicaid programs, with only a limited number of states providing coverage for weight-loss medications under strict conditions. This approach may lead to budget savings but risks backlash from patients who view these restrictions as unfair barriers to accessing treatment for obesity, as seen in Washington where a state employee has already filed a lawsuit challenging the state's coverage ban.

By Todd Bevington and Kim Cochrane - In the modern workplace, the call for employers to take an active role in supporting employee financial wellness is louder than ever. Surveys reveal that a significant 76% of employees believe their employers should play a part in their financial wellbeing. Read Full Article…

VBA Article Summary

  1. Expanding Financial Wellness Beyond Retirement: The article highlights a significant gap in employer offerings concerning financial wellness programs, with only 2 in 5 employers currently providing such support. It stresses the importance of moving beyond traditional retirement-focused benefits to include a more holistic approach that addresses all aspects of an employee's financial wellbeing. This could include integrating services from personal insurance brokers alongside financial advisors to help employees navigate the complexities of personal insurance, which has become a major household expense due to rising premiums and other factors.

  2. The Impact of Financial Stress on Workplaces: Research cited from PwC indicates that financial stress significantly affects employees, with 56% of those financially stressed spending three or more hours weekly at work dealing with personal finance issues. This stress not only detracts from productivity but also increases turnover rates, with financially stressed employees more likely to seek new job opportunities. The article suggests that by addressing financial wellness comprehensively, employers can improve both employee retention and productivity.

  3. Meeting Employee Wellness Needs Holistically: There's a growing awareness among HR leaders of the need to address not just the physical and mental wellness of employees but their financial wellness too. The evolving expectations of employees regarding their benefits packages call for a comprehensive approach that includes support for managing debt, home buying, and navigating personal insurance. By offering access to independent insurance brokers within financial wellness benefits, employers can provide critical support, helping employees to manage risks, prepare for emergencies, and achieve financial peace of mind, thereby fostering a workplace culture of wellbeing and prosperity.

New Guidance on Pension-Linked Emergency Savings Accounts

By Elizabeth Thomas Dold, Michael Kreps, Eboni Onuoha, Thomas Roberts, and J. Rose Zaklad - Over the past several years, there has been a growing interest in enhancing employee benefit programs to help employees save for emergencies. Employers and service providers have developed a number of different types of emergency savings programs with some being “in plan” (i.e., established within a qualified retirement plan) and others being offered as standalone saving options. Read Full Article…

VBA Article Summary

  1. Introduction of Pension-Linked Emergency Savings Accounts (PLESAs): The SECURE 2.0 Act of 2022 introduces the concept of Pension-Linked Emergency Savings Accounts (PLESAs), allowing employers to offer these accounts as part of their defined contribution plans starting from plan years after December 31, 2023. PLESAs enable participants, excluding highly compensated employees, to contribute on an after-tax basis with a cap of $2,500. These contributions are eligible for employer matching within certain constraints, and withdrawals can be made tax-free for any purpose. The Act encourages voluntary participation and allows for automatic enrollment by employers.

  2. IRS and DOL Guidance on PLESAs: Recent guidance from the IRS and DOL clarifies several aspects of PLESAs to prevent abuse and ensure compliance with existing tax and labor laws. The IRS Notice addresses anti-abuse rules, including provisions to prevent manipulation of employer matching contributions, and outlines what constitutes unreasonable anti-abuse procedures. Meanwhile, DOL FAQs provide clarifications on the design and operation of PLESAs, including account size limitations, contribution timing, withdrawal policies, recordkeeping requirements, and fee restrictions. These clarifications aim to balance the interests of participants and plan sponsors while maintaining the integrity of the savings program.

  3. Unresolved Questions and Future Considerations: Despite the guidance provided, several key questions about the operation and regulation of PLESAs remain unanswered, particularly regarding involuntary distributions, applicability to governmental plans, and investment options like stable value funds. The guidance also opens discussions on the prudence of selecting investment products with liquidity constraints, suggesting that stable value products without such constraints may be more appropriate for PLESAs. The DOL and IRS continue to evaluate additional issues, including reporting requirements and model participant notices, indicating that further clarification and regulation may be forthcoming.