Daily Industry Report - February 21

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)

Employers' waning hesitancy over weight loss drugs

By Erica Carbajal - While a majority of corporate health insurance plans cover glucagon-like peptide-1 receptor agonist drugs for diabetes, less than a third said they cover the class of drugs for weight loss. However, experts say it's only a matter of time before more employers move to cover obesity treatments, CNBC reported Feb. 16. Read Full Article…

VBA Article Summary

  1. Survey on GLP-1 Coverage: A survey of 205 companies revealed a discrepancy in health coverage for GLP-1 medications, with 76% providing coverage for diabetes treatment but only 27% offering it for weight loss purposes. Additionally, 13% of these companies are considering expanding their coverage to include GLP-1s approved for obesity treatment, such as Wegovy and Zepbound.

  2. Anticipated Expansion Despite Concerns: Despite concerns over the high costs of GLP-1 drugs and questions about their long-term financial benefits, many experts predict an increase in employer coverage for weight loss uses. This expectation is based on strong employee interest in these treatments. Companies that currently cover GLP-1 medications, like those represented by Accolade, express intentions to continue doing so, citing benefits such as higher employee engagement and improved health outcomes.

  3. Costs and Employer Considerations: The cost for monthly supplies of GLP-1 medications for weight loss, including Wegovy and Zepbound, ranges between $1,000 and $1,500, potentially leading to an annual expense of $18,000 per employee. Employers face the challenge of balancing the desire to offer comprehensive benefits, which aids in recruitment and retention, against the need to manage these benefits' costs effectively.

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!

KFF Health Tracking Poll February 2024: Voters on Two Key Health Care Issues: Affordability and ACA

By Audrey Kearney, Alex Montero, Isabelle Valdes, Ashley Kirzinger, and Liz Hamel - With inflation and health care affordability remaining among the most important issues voters want to hear the presidential candidates talk about heading into the 2024 election, two-thirds of voters (67%) describe the national economy as either “not so good” or “poor.” Republican voters are more than twice as likely as Democrats to rate the economy negatively (88% v. 37%) and seven in ten independent voters (72%) rate the economy negatively. Read Full Article…

VBA Article Summary

  1. Voters' Economic Concerns and Health Care Costs: Most voters perceive the national economy negatively, attributing their views to the cost of everyday expenses, inflation, and the cost of housing and health care. Despite reports of an improving economy, 67% of voters rate it as "not so good" or "poor," highlighting inflation and health care affordability as critical issues for the 2024 presidential candidates to address. Voters are divided along party lines regarding the future of the Affordable Care Act (ACA), with large disparities in importance placed on the issue between Democrats and Republicans.

  2. Health Care Affordability and Financial Worries: Health care costs, including unexpected medical bills and monthly insurance premiums, top the list of financial concerns for Americans, with a substantial majority worried about affording health care services. This concern cuts across partisan lines, indicating a universal anxiety over health care affordability. The debate over the ACA's future intensifies, with differing views on its expansion or repeal, reflecting the deep partisan divide on health care policy.

  3. Partisan Perspectives on Health Care Policy: The article illustrates a stark partisan divide in opinions on health care costs and the ACA's future. While Democratic voters tend to support President Biden's approach to health care and favor the ACA's expansion, Republican voters are more critical of the ACA and express dissatisfaction with current health care policies. Despite these differences, there is widespread agreement on the importance of protections for pre-existing conditions, demonstrating a common ground in health care concerns among the American public.

Telehealth Advocates: HHS Has Done Its Bit on Expanding OUD Treatment; DEA Needs to Step Up

By Marissa Plescia - This month, the U.S. Department of Health and Human Services (HHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) took steps to expand access to opioid use disorder treatment through its new final rule, which includes a provision that permanently allows for the initiation of treatment (methadone and buprenorphine) via telehealth. Read Full Article…

VBA Article Summary

  1. Limited Scope of Final Rule: The final rule issued by HHS specifically applies to practitioners working in Opioid Treatment Programs (OTPs) but does not extend to other healthcare providers like primary care physicians or addiction medicine specialists. This rule allows for the initiation of medication-assisted treatment (MAT) such as methadone and buprenorphine via telehealth under certain conditions, aiming to ease access to treatment for opioid use disorder. Despite these advancements, the rule does not cover the virtual prescribing of a broader range of controlled substances nor does it apply to a wider range of healthcare providers, highlighting a need for further action by the DEA.

  2. Advocacy for DEA Action: Telehealth advocates commend the advancements made through HHS's final rule but emphasize the necessity for the DEA to broaden telehealth access for treatment by allowing a wider range of medical professionals to prescribe controlled substances virtually. The advocates argue that while the rule is a significant step forward, its impact is limited without concurrent DEA action to expand the scope of providers eligible to offer care via telehealth and to make these changes permanent. This call to action reflects a broader desire within the healthcare community to sustain and enhance the accessibility of treatment for substance use disorders facilitated by telehealth innovations.

  3. Potential for DEA to Expand Access: The DEA is encouraged to adopt and possibly expand upon HHS’s regulatory changes by creating a special registration process for medical professionals to prescribe controlled substances virtually, a mandate from Congress that has been pending since 2008. Advocates argue that such a move is critical for maintaining continuity of care and expanding access to treatment for vulnerable populations. The final rule by HHS, coupled with potential action from the DEA, represents a pivotal moment in the ongoing effort to leverage telehealth in addressing the opioid crisis by ensuring broader and more inclusive access to essential treatment services.

With the Rise of AI, What IP Disputes in Healthcare Are Likely to Emerge?

By Stephanie Baum - Intellectual property can be a thorny issue in health tech and medtech. The intersection of healthcare data and AI is setting up some complex patent showdowns and interesting ethical discussions. What are the implications for how we think about personal health data and innovation based on that data? Read Full Article…

VBA Article Summary

  1. Data Ownership and Privacy Concerns: Howison emphasizes the complexity of data ownership, especially when derived from connected medical devices. He highlights the valuable nature of this data, not just for clinical trials but also as a significant asset for companies training diagnostic models. The legal challenges revolve around navigating HIPAA and privacy laws, determining who owns the data (especially when it pertains to an individual), and how it can be legally utilized without infringing on privacy rights or HIPAA regulations.

  2. Intellectual Property Use Cases: In the realm of IP, Howison delineates three primary categories relevant to his clients: patents, trademarks, and data. He illustrates how businesses leverage these categories differently, depending on whether their focus is on using IP as a tool for development (e.g., in diagnostics and drug research) or creating IP as a source of value (e.g., through patents on new medical devices or data collection). The importance of clear agreements on data ownership and usage rights, particularly in relation to medical devices and the accompanying data, is underscored.

  3. Regulatory and Ethical Challenges: Looking forward, Howison predicts increased use of AI, like ChatGPT, in the medical field, particularly for self-diagnosis and enhancing telehealth. He anticipates the significant impact of wearables and connected devices on patient care and medical research. However, he also points out the regulatory and ethical challenges that will arise, especially concerning FDA approval processes for AI models used in medical devices and the ongoing debate over the patentability of AI algorithms and the proprietary nature of data used in training AI models.

Southern Lawmakers Rethink Long-Standing Opposition to Medicaid Expansion

By Daniel Chang and Andy Miller - As a part-time customer service representative, Jolene Dybas earns less than $15,000 a year, which is below the federal poverty level and too low for her to be eligible for subsidized health insurance on the Obamacare marketplace. Read Full Article…

VBA Article Summary

  1. Coverage Gaps and Health Care Challenges in Non-expansion States: In Alabama, like several other states that have not adopted the Affordable Care Act's Medicaid expansion, individuals such as the 53-year-old resident face significant out-of-pocket health care costs due to falling into coverage gaps. These gaps exist because they earn too much to qualify for Medicaid but not enough to afford private insurance, leading to hundreds of dollars a month in out-of-pocket payments to manage chronic health conditions. This situation highlights the acute challenges faced by low-income, uninsured individuals in non-expansion states.

  2. Shifting Political Landscape for Medicaid Expansion: The article discusses a changing political climate in traditionally conservative states like Alabama, Georgia, and Mississippi, where lawmakers are reconsidering their stance on Medicaid expansion. This shift is driven by strong public support, the economic pressures on hospitals, especially in rural areas, and the success of Medicaid expansion in other states. Republican leaders in these states are now exploring options for expanding coverage, including public-private partnership models, influenced by the potential to cover more than 600,000 uninsured individuals and the financial incentives offered by the federal government under the American Rescue Plan Act.

  3. Obstacles and Momentum Towards Expansion: Despite the growing momentum and reconsideration of Medicaid expansion in some Southern states, significant obstacles remain. Political opposition, the search for fiscally responsible models, and the specifics of legislative proposals continue to shape the debate. However, the article points out the potential benefits of expansion, such as reducing uninsured rates, improving access to care, and supporting hospitals financially. The discussion around Medicaid expansion reflects broader concerns about health care accessibility, the economic implications for states, and the health outcomes of low-income populations.

Some health systems ditch their health plans

By Rylee Wilson - Some health systems are getting out of the insurance business. In the first weeks of 2024, two health systems announced plans to sell their health insurance subsidiaries. In February, Springfield, Mass.-based Baystate Health reached a deal to sell Health New England to Point32Health. Read Full Article…

VBA Article Summary

  1. Acquisitions and Divestitures in the Health Insurance Sector: In recent developments within the health insurance industry, several notable transactions are taking place, reflecting a trend towards consolidation. ProMedica, based in Toledo, Ohio, announced its plan to sell its insurance subsidiary, Paramount Health, to Medical Mutual of Ohio, aiming to refocus on its core health system operations. Similarly, Point32Health's acquisition of Health New England is aimed at enhancing its product offerings and expanding its network, highlighting the movement of larger nonprofit insurers to acquire smaller entities to broaden their service offerings and member base.

  2. Impact on Healthcare and Strategic Focus: These acquisitions signify a strategic shift for both acquiring and divested entities. For instance, ProMedica's decision to sell Paramount Health is part of a broader strategy to concentrate on its primary health system operations, as articulated by ProMedica CEO Arturo Polizzi. On the other hand, acquisitions like that of Health New England by Point32Health are expected to improve product diversity and network reach, with Point32Health's president Cain Hayes emphasizing the importance of preserving strong, not-for-profit health plans for the healthcare ecosystem in Massachusetts.

  3. Industry Response and Future Directions: The ongoing consolidation and strategic realignments in the health insurance sector have elicited diverse responses from healthcare executives. Kevin Mahoney, CEO of the University of Pennsylvania Health System, advocates for partnerships between health systems and insurance companies rather than adopting a "payvider" model, suggesting a collaborative approach to population health management and patient care. This perspective underscores a critical discourse on the evolving relationships between healthcare providers and insurers, highlighting the potential benefits of collaboration over competition in enhancing patient care outcomes.

Pharmacists confront AMA's 'scope creep' stance

By Tina Reed - The American Medical Association has long been advocating against what it calls "scope creep," or nonphysicians gaining expanded scopes of practice. On Feb. 16, two pharmacist associations fired back. Read Full Article…

VBA Article Summary

  1. AMA's Stance on Pharmacists Diagnosing Patients: The American Medical Association (AMA) published an article early in February expressing concerns over proposed bills that would enable pharmacists to diagnose patients based on test results. AMA argued that pharmacists lack the extensive clinical training and education in diagnosis and patient care across life cycles that physicians undergo, highlighting a significant difference in training duration—physicians train more than six times longer than pharmacists in clinical settings.

  2. Counterarguments by Pharmacy Leaders: Michael Hogue, PharmD, and Lee Vermeulen, leaders of the American Pharmacists Association and the American Association of Colleges of Pharmacy, respectively, criticized the AMA's position as "out of touch," demanding a retraction. They defended the competency of pharmacists in patient assessment and care across all ages, noting that a substantial number of pharmacists have undergone postgraduate residency and many are board certified in various clinical specialties. Their response underscores the belief in the capability of pharmacists to provide essential healthcare services, especially in the face of primary care physician shortages.

  3. Broader Context of Scope of Practice Debates: The AMA's position on pharmacists diagnosing patients is part of a larger debate on the scope of practice for various healthcare professionals. AMA opposes broadening the scope of practice for not only pharmacists but also advanced practice registered nurses, nurse anesthetists, nurse practitioners, optometrists, physician assistants, and psychologists, citing concerns about patient care quality. Conversely, leaders from the pharmacy sector argue that expanding pharmacists' roles could alleviate some of the strain on the healthcare system by addressing access issues, especially in underserved areas.

Will Wearable Health Device Data Bring Woe Or Wealth To Providers?

By Michael L. Millenson - The exploding use of activity trackers, smartwatches and other consumer health wearables prompted three business school professors to pose a bottom-line question: from a competitive viewpoint, will incorporating patient-generated health data into the clinical workflow boost or bring down providers’ profits? Read Full Article…

VBA Article Summary

  1. Game Theory Application in Healthcare: The study leverages game theory to explore how the integration of patient-generated health data impacts the competitive dynamics among healthcare providers, consumers, and technology firms. This mathematical approach goes beyond simple logic, aiming to predict complex interactions and outcomes in a sector where traditional fee-for-service payment models still dominate and a significant majority of consumers (91% as per a 2023 survey) are willing to share their health data with physicians.

  2. Economic Implications of Data Integration: The research outlines various scenarios to illustrate the economic forces at play. In one baseline scenario, healthcare providers avoid integrating patient-generated data to maintain the status quo, preventing any single provider from gaining a competitive edge and avoiding integration costs. Another scenario shows larger health systems potentially benefiting from such integration due to their ability to spread costs across a larger patient base, thus enhancing their attractiveness to patients. However, this prompts smaller systems to follow suit, increasing costs without gaining new patients, benefiting consumers ultimately.

  3. Impact of Third-Party Platforms and Privacy Concerns: The involvement of third-party platforms introduces complexity, especially concerning consumer privacy and the ease of switching healthcare providers. While consumers may lose some welfare gains due to privacy concerns, the ease of data portability could favor smaller providers and consumers by facilitating provider switching. The study highlights the potential for monopolistic practices and the need for regulatory oversight to protect privacy and security, underscoring the inevitable push towards integrating patient-generated data driven by technology advancements and changing consumer expectations.

Insight: What happens when a $2 million gene therapy is not enough

By Deena Beasley - Baby Ben Kutschke was diagnosed at three months with spinal muscular atrophy, a rare inherited disorder which is the leading genetic cause of death in infancy globally. It leaves children too weak to walk, talk, swallow or even breathe. Read Full Article…

VBA Article Summary

  1. High Expectations and Mixed Outcomes with Zolgensma: Zolgensma, introduced by Novartis as a revolutionary gene therapy for spinal muscular atrophy (SMA), was launched with hopes of being a one-time cure. Costing $2.25 million, it promised to replace genes crucial for muscle control. However, outcomes have varied; while some patients have shown significant improvement, others, like Ben Kutschke, have seen limited progress, necessitating additional treatments. This raises questions about the efficacy and value of high-cost gene therapies, especially those approved through accelerated processes.

  2. Financial and Ethical Implications: With Zolgensma's sales reaching $1.4 billion in 2022 and being responsible for 91% of worldwide gene therapy sales, its financial success contrasts with the ongoing debates about its pricing and long-term efficacy. Critics argue that the therapy's price, set with expectations of a complete cure, may not be justifiable if additional treatments are needed, challenging the economic model of charging upfront for potentially curative therapies. This scenario underscores the complexities of pricing and reimbursement in the era of gene therapies, with implications for patients, payers, and healthcare systems.

  3. The Path Forward and Real-World Challenges: The experience of families and the evolving scientific understanding of Zolgensma's impact highlight the nuanced reality of living with SMA post-treatment. Despite initial hopes, the journey for many involves additional therapies and navigating insurance challenges, as seen with Ben's need for another drug, Spinraza. Novartis has adjusted its messaging around Zolgensma, focusing on it being a one-time treatment rather than a cure. This shift reflects a broader industry and healthcare system grappling with the promises and limitations of gene therapy, emphasizing the importance of tailored treatments and ongoing support for patients with complex conditions.