Oliver Wyman: 5 ACA Trends To Watch Over the Next Decade

By Marissa Plescia - The Affordable Care Act is entering its second decade of existence. Over the last decade, coverage has doubled, consulting firm Oliver Wyman stated in a recent report. ACA enrollment continues to increase, with the Biden Administration expecting 2024 Marketplace enrollment to reach 19 million people. Read Full Article…

VBA Article Summary

1. Scale and Market Leadership: The article discusses how success in the ACA marketplace will be driven by scale. Oliver Wyman predicts that large carriers with the ability to adapt to changing regulations and the capacity for risk in new markets will dominate. The example of Centene is highlighted, showing how its significant national presence and strategic practices like pricing discipline and risk adjustment have led to a 75% year-over-year growth in membership. The future may see one or two major insurers dominating the ACA Marketplace, similar to the Medicare Advantage market.

2. ICHRA Impact: Individual Coverage Health Reimbursement Arrangement (ICHRA) is expected to significantly disrupt the industry by increasing consumer movement to ACA coverage. Since its inception in 2020, ICHRA membership has grown about 350%, with projections reaching 2 million people by 2032. Factors contributing to this growth include state-specific tax breaks, increased adoption by small employers, and technological advancements facilitating easier integration of ICHRAs into benefits platforms.

3. Network and Exchange Evolution: The article highlights that about 72% of ACA Exchange plans in 2019 were narrow networks, indicating a trend towards such networks due to cost-saving preferences. Insurers are creating differentiated networks, often in partnership with health systems, to attract more enrollees. Additionally, more states are expected to move to State-based Exchanges, which could lead to extended open enrollment periods and better coordination with Medicaid, among other benefits. Furthermore, the demand for seamless digital experiences and transparent pricing in health insurance is emphasized, particularly among younger, subsidy-receiving, cost-conscious consumers.

Exclusive: Drugmakers set to raise US prices on at least 500 drugs in January

By Michael Erman and Patrick Wingrove - Drugmakers including Pfizer (PFE.N), Sanofi (SASY.PA) and Takeda Pharmaceutical (4502.T) plan to raise prices in the United States on more than 500 drugs in early January, according to data analyzed by healthcare research firm 3 Axis Advisors. Read Full Article…

VBA Article Summary

1. Significant Drug Price Increases Expected: More than 140 brands of drugs are set to experience price hikes next month. These increases come as the pharmaceutical industry prepares for the Biden Administration to release discounted prices for 10 high-cost drugs in September. The industry is also dealing with challenges like higher inflation and manufacturing costs. Simultaneously, there's growing concern about supply chain disruptions due to the ongoing Middle East conflict, potentially affecting shipping routes.

2. Legislative Impact on Drug Pricing: The Inflation Reduction Act (IRA) under President Biden allows Medicare to negotiate drug prices directly from 2026. Additionally, the American Rescue Plan Act mandates rebates from drug companies to the Medicaid program if drug price increases exceed inflation rates. Some companies, including GlaxoSmithKline, have announced price cuts on certain drugs for 2024 to avoid potential penalties. Despite this, drugmakers have largely maintained price increases at 10% or below, following industry practices established in response to criticism in the last decade.

3. Trends and Predictions in Drug Pricing: Pfizer leads in the number of planned price increases for January, with hikes on 124 drugs. Other companies like Takeda-owned Baxalta and UCB Pharma are also planning significant price rises. On the other hand, companies like Sanofi are reducing prices on some products, like insulin, but raising them on others, like vaccines. The overall trend shows that while established drug prices are seeing moderated increases, the prices for newly launched drugs are reaching record highs, with an average price increase of over 20% in recent years, significantly impacting the healthcare cost landscape.

White House announces plan to scrutinize private equity ownership in healthcare

By Marty Stempniak - The White House recently announced its intent to scrutinize corporate ownership of healthcare entities. Read Full Article…

VBA Article Summary

1. Launch of Public Inquiry into Healthcare Corporate Greed: The Biden-Harris administration announced a cross-government public inquiry into "corporate greed in healthcare," focusing on how hospital mergers in concentrated markets have led to significant price increases and the rapid growth of private equity ownership in healthcare. This inquiry, involving the Department of Justice, Federal Trade Commission, and Health and Human Services, aims to address concerns about healthcare being excessively financialized, prioritizing corporate profits over patient welfare.

2. Focus on Anticompetitive Business Practices: The inquiry will target "roll-up" acquisitions, a strategy used by private equity firms and health insurers to consolidate markets through small acquisitions that often evade antitrust review. The administration is concerned these practices lead to worse patient outcomes and higher healthcare costs. The inquiry will involve collecting public input on the impact of such corporate control on the healthcare system and prioritizing enforcement against anticompetitive practices, exemplified by the FTC's lawsuit against Welsh, Carson, Anderson & Stowe for consolidating the anesthesiology market.

3. Increasing Private Equity Influence in Specialties: A 2020 JAMA analysis indicated a growing trend of radiologists and other specialists moving under private equity ownership, with a notable increase in the number of imaging physicians in multispecialty groups joining investor-backed firms. Specialties like anesthesiology, emergency medicine, family practice, and dermatology have seen significant private equity activity. Well-known private equity-supported groups in radiology include Premier Radiology Services, LucidHealth, Radiology Partners, and others, highlighting the widespread nature of this trend.

Employers seek to navigate rising expenses for health care workers

By Alan Goforth - Employers face rising health care costs and persistent inflation as they attempt to provide competitive benefits in the coming year. Their workers also are experiencing many of the same financial pressures. Read Full Article…

VBA Article Summary

1. Impact of Inflation on Health Plan Costs and Employee Financial Stress: The survey highlights the need for plan sponsors to prepare for the impact of inflation on health plan costs. Inflation is creating financial stress for employees at all income levels, making it difficult for low earners to meet monthly expenses and medical bills. The tight labor market across various industries necessitates HR departments to leverage health benefits as a tool to attract and retain employees.

2. Enhancing Benefits Thoughtfully: Employers are focused on enhancing benefits, not just by adding features, but by seeking opportunities to add real value. This includes filling gaps in current benefits with more inclusive options, revising time-off policies for greater flexibility, and paying close attention to the growing need for better support in mental health, as indicated by employee surveys.

3. Managing Cost Growth Without Burdening Employees: Despite a modest increase in the per-employee cost of employer-sponsored health insurance in 2022 (3.2%), which was lower than the general inflation rate, employers are cautious of potential cost increases in the future. This is due to expected wage hikes and higher supply costs in the healthcare sector, leading to anticipated higher prices as provider contracts are renewed. Employers are preparing for a projected average cost increase of 5.4% in 2023 and continued accelerated cost growth in the subsequent years.

Report: Nearly Half of Patients Miss Medical Bills Due to Communication Problems

By Marissa Plescia - Issues in provider communication methods may be leading to patients missing medical bills, a new survey showed. About 45% of patients have missed or forgotten to pay medical bills because of challenges they experienced in communicating with their provider, the survey from Artera found. Another 43% of patients said that these communication issues negatively affected their health. Read Full Article…

VBA Article Summary

1. Patient Communication Challenges: Artera's survey of over 2,000 patients revealed significant issues in healthcare communications. Notably, 59% of patients would consider changing doctors due to poor communication, while 77% find automated text exchanges with providers valuable. However, the current approach to these exchanges is overly simplistic, with 75% of patients indicating that most texts from healthcare providers only allow for "yes" or "no" responses. This simplicity contributes to frustration among 69% of patients who desire more conversational text interactions and 66% who find text messaging experiences often incomplete.

2. Desire for Humanized Communication: Meg Aranow, Senior Vice President at Artera, emphasizes the need for more humanized communication in healthcare. Patients seek more than just robotic, transactional text exchanges; they want meaningful conversations, especially in vulnerable situations like healthcare. The survey supports this, with patients expressing dissatisfaction with non-conversational text communication methods. Many patients, 81% of those who couldn’t achieve their goals through text, had to resort to phone calls to complete their conversations.

3. Recommendations for Improvement: To enhance patient experience, Artera suggests moving away from robotic text solutions and focusing on documenting who delivers communication to patients. Aranow advises gaining visibility into the breadth of communication within organizations and considering the formation of a cross-functional governance committee. This committee could document and oversee communications, thereby measuring impact and making necessary adjustments. The survey also found that 62% of respondents experienced issues like error messages or lack of response, 68% received repetitive messages, and 65% got messages out of order, highlighting the need for these improvements.

Subscription-based care moves beyond peddling birth control and helping with hair loss

By Tom Murphy - Need help losing weight or handling depression? How about a pill that lowers cholesterol and treats erectile dysfunction? Read Full Article…

VBA Article Summary

1. Expansion of Online Health Subscription Services: Companies like Hims & Hers, Ro, and Lemonaid Health have evolved from focusing mainly on hair loss, acne, or birth control to offering a wider range of health services. These include weight loss programs, seasonal affective disorder treatment, and more. Hims, for example, has launched a weight-loss program at $79 per month, while Lemonaid began treating seasonal affective disorder at $95 a month.

2. Concerns and Benefits of the Netflix-like Healthcare Model: This model, offering easy access to specialists and regular prescription deliveries, addresses two significant issues in U.S. healthcare: access and prescription refills. However, it raises concerns about the quality of care provided. Critics argue that the focus might be more on selling drugs than on comprehensive healthcare, while proponents highlight careful patient screening and the convenience of the service.

3. Broader Implications and Future Directions: Subscription-based health care is growing, with companies expanding their services to include treatments for a variety of conditions. There is a concern about the focus on specific conditions rather than comprehensive care. Companies like Lemonaid and Hims emphasize the importance of follow-ups and comprehensive care, but the model still presents challenges in ensuring quality and maintaining patient health over time.

Senators concerned Medicare Advantage plans deny long-term care

By Rylee Wilson - A pair of senators are asking CMS to require Medicare Advantage plans to cover stays in long-term care facilities at the same rate as traditional Medicare. Read Full Article…

VBA Article Summary

1. Concerns Raised by Senators Murphy and Tillis: Senators Chris Murphy and Thom Tillis have expressed concerns regarding Medicare Advantage (MA) plans. They've observed that these plans often use different standards than traditional Medicare to approve long-term care, leading to frequent denials of care in long-term care hospitals.

2. Request for Clarification from CMS: In their letter to CMS Administrator Chiquita Brooks-LaSure, the senators highlight the necessity for clear guidance. They reference the final rule issued by CMS in April, which states that MA plans should not have more stringent prior authorization criteria than traditional Medicare, especially concerning long-term care hospitals.

3. Ensuring Equal Treatment in Medicare Advantage Plans: The senators urge CMS to publicly clarify that the same rules apply to long-term care hospitals as to other post-acute care providers under Medicare Advantage regulations. This clarification aims to eliminate confusion and ensure that patients in long-term care hospitals receive the care they need without undue barriers.

Is Private Equity Acquisition of Hospitals a Sentinel Event?

By Owen Scott Muir, M.D. - I recently wrote an article about death by suicide after treatment in an acute care setting as a new sentinel event up to one week later. Sentinel Events are defined like this. Read Full Article…

VBA Article Summary

1. Sentinel Events and Their Consequences: The article begins by defining a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. It emphasizes that sentinel events are significant as they necessitate immediate investigation and response. The article specifically highlights falls with serious injuries as a common sentinel event, noting that since 2009, The Joint Commission’s Sentinel Event database has recorded 465 reports of such falls, primarily in hospitals, with about 63% resulting in death.

2. Impact of Private Equity Acquisition on Hospital Safety: The article raises concerns about the safety implications of hospitals being acquired by private equity firms. It references a study published in JAMA, which found that private equity acquisition of hospitals was associated with a 25.4% increase in hospital-acquired conditions, including falls and bloodstream infections. The increase in falls, a recognized sentinel event, was particularly notable at 27.3%. This suggests a correlation between private equity takeovers and a decline in hospital safety and patient outcomes.

3. Healthcare Workforce Attrition and its Implications: The article also discusses the alarming rate of healthcare workforce attrition, particularly among physicians, citing a report from Definitive Healthcare that indicates over 145,000 healthcare providers left the workforce between 2021 and 2022. This rate of attrition is nearly double the number of new doctors entering the workforce annually. The article suggests that this trend, along with the increased risks associated with private equity hospital takeovers, contributes to a decline in hospital safety and effectiveness, ultimately impacting patient care and outcomes.

New weight loss drugs are out of reach for millions of older Americans because Medicare won’t pay

By Amanda Seitz - New obesity drugs are showing promising results in helping some people shed pounds but the injections will remain out of reach for millions of older Americans because Medicare is forbidden to cover such medications. Read Full Article…

VBA Article Summary

1. Debate Over Medicare Coverage for Obesity Drugs: There's a growing bipartisan push in Congress, supported by drugmakers, to allow Medicare to cover new weight loss drugs like Wegovy and Zepbound. This comes as obesity rates among older adults rise, prompting a reevaluation of the longstanding prohibition on Medicare funding for such medications. The debate is fueled by concerns over the high cost of these drugs, which could significantly impact Medicare's finances.

2. Changing Perceptions of Obesity and Legislative Efforts: The conversation around obesity has evolved, recognizing it not just as a cosmetic issue but as a significant health problem. New studies suggest these drugs offer more than just weight loss; they could reduce risks of serious health issues like heart attacks. Representatives Brad Wenstrup and Raul Ruiz have introduced legislation to allow Medicare coverage for these drugs, reflecting a shift in how obesity is viewed and treated in healthcare policy.

3. Economic Implications and Growing Support: The cost of covering these obesity drugs under Medicare is a major concern, with estimates of potentially massive expenditure. However, other research indicates long-term savings due to reduced obesity-related health issues. The push for Medicare to cover these drugs has garnered increasing support from a wide range of lawmakers and interest from pharmaceutical companies, suggesting a significant shift in policy may be on the horizon.

Pharma giants are hiking prices on over 500 drugs for 2024, report says

By Rebecca Roman - Pharmaceutical giants Pfizer, Sanofi, and Takeda Pharmaceutical are due to raise prices on more than 500 drugs in the US from January, according to the Reuters news agency. Read Full Article…

VBA Article Summary

1. Pfizer, Sanofi, and Takeda Pharmaceutical, major players in the pharmaceutical industry, are set to increase prices on over 500 drugs in the United States from January. This information comes from a Reuters news agency report, which is based on data analyzed by the healthcare research firm 3 Axis Advisors.

2. The report highlights that these price hikes will impact approximately 140 different drug brands. This pricing strategy aligns with the pharmaceutical sector's anticipation of the Biden Administration's plan to release discounted prices for 10 high-cost drugs in September. Moreover, looking ahead, the Biden administration's Inflation Reduction Act, starting in 2026, will introduce measures allowing Medicaid to negotiate directly with drug manufacturers over prices.

3. Contrary to this trend of rising prices at the start of 2024, the Reuters report notes that not all pharmaceutical companies are increasing their prices. Specifically, three companies, including GlaxoSmithKline, are set to lower the prices of at least 15 drugs in January.