Impact of Supreme Court Chevron Decision on Health Policy

By Marci Nielsen, PhD, MPH - The Supreme Court has overturned longstanding precedent by striking down the “Chevron doctrine,” a 40-year-old standard that required courts to defer to regulatory agencies to interpret ambiguous laws. Read Full Article…

HVBA Article Summary

1. Increased Legal Challenges to Regulations: Experts predict a surge in lawsuits challenging existing regulations by key health agencies, including CMS. These challenges may target reimbursement policies, Medicaid standards, and state waiver approvals, leading to potential delays and inconsistencies in healthcare policy enforcement.

2. Slower Rulemaking and Policy Implementation: The necessity for courts to independently interpret statutory authority will likely slow down the rulemaking process. This could result in backlogs and inconsistent decisions, causing delays in providing clear guidance for federal agencies and impacting state Medicaid programs.

3. Reduction in New Programs and Innovations: With courts taking a more active role in statutory interpretation, federal agencies may become more hesitant to introduce new programs or innovations without explicit Congressional approval. This shift could stifle proactive responses to emerging healthcare needs and reduce the development of new initiatives by agencies like the Centers for Medicare and Medicaid Innovation.

Vermont latest state to sue PBMs for allegedly driving up drug prices

By Brendan Pierson - Vermont's attorney general on Wednesday sued two of the largest U.S. pharmacy benefit managers, accusing them of driving up prescription drug prices for patients in order to enrich themselves, joining other states that have brought similar claims against the drug industry middlemen. Read Full Article…

HVBA Article Summary

1. Allegations of Unlawful Practices: Attorney General Charity Clark of Vermont filed a complaint in Washington County Superior Court, alleging that CVS Health's Caremark, Cigna Group's Express Scripts, and their affiliates pushed patients toward more expensive drugs instead of cheaper alternatives. This practice, according to Clark, violated Vermont's consumer protection law by pocketing the extra costs through a non-transparent fee system.

2. Defense and Industry Dynamics: CVS spokesperson Mike DeAngelis countered the allegations, stating that Pharmacy Benefit Managers (PBMs) like Caremark and Express Scripts help lower drug prices through negotiations with drug manufacturers. He emphasized that PBMs do not set drug prices, which are determined by the manufacturers, and vowed that CVS would vigorously defend against what he termed a baseless lawsuit. Collectively, Caremark, Express Scripts, and OptumRx control about 80% of the PBM market.

3. Broader Scrutiny and Legal Actions: The case in Vermont is part of a broader trend of increased scrutiny on PBMs. The U.S. Federal Trade Commission is expected to sue the three major PBMs for their role in negotiating insulin prices. Additionally, several other states, including Hawaii, California, Ohio, and Kentucky, have initiated lawsuits over PBMs' business practices. The Vermont case is filed under the title State of Vermont v. Evernorth Health Inc in the Superior Court, Washington Unit.

Nearly half of U.S. adults struggle to afford healthcare, research shows

By Eleanor Laise - American consumers are cutting back on food and utilities to pay for medical care. Nearly half of U.S. adults are struggling to cover the cost of prescription drugs and doctor visits, new research shows, marking a new low for healthcare affordability. Read Full Article…

HVBA Article Summary

1. Sharp Decline in Healthcare Affordability: The West Health-Gallup Healthcare Affordability Index reveals a troubling trend in healthcare affordability, with the percentage of U.S. adults able to afford quality care dropping by 6 percentage points since 2022. Adults aged 50 and older experienced the steepest decline, with affordability dropping by about 8 percentage points for those aged 50 to 64 and 65 and older.

2. Worsening Financial Strain: A significant portion of the U.S. population is struggling to cover medical expenses, with over 72 million Americans skipping needed care in the last three months due to cost concerns. The financial burden is particularly severe for younger adults aged 18 to 49, with 10% considered "cost desperate" compared to 3% of those aged 65 and older. Many in this desperate category have had to cut back on essentials like food and utilities to afford healthcare.

3. Inequality in Healthcare Affordability: The index highlights widening racial and gender disparities in healthcare affordability. Black and Hispanic adults are more likely to be "cost desperate" than white adults, and women are nearly twice as likely as men to fall into this category. Despite these challenges, the perception of value in healthcare has improved, with fewer adults feeling they are overpaying for the quality of care they receive compared to three years ago.

Healthcare costs set to rise by as much as 8% in 2025: PwC

By Paige Minemyer - Healthcare costs are set to rise between 7% and 8% in 2025, according to a new report from PwC. The analysis comes from PwC's Health Research Institute and projects that costs will rise 8% year-over-year in the group market and 7.5% in the individual market. That spending growth is likely to reach a 13-year high, according to the analysis. Read Full Article…

HVBA Article Summary

1. Inflationary Pressures and Prescription Drug Costs: Ongoing inflationary pressures on hospitals and innovative prescription drug products are significant factors driving the increase in medical costs. Hospitals are increasingly relying on higher payouts from the commercial sector to offset rising operating costs due to reduced federal payments in public plans. Prescription drugs, especially GLP-1s and those treating central nervous system conditions, are notable contributors to rising healthcare expenses.

2. Increased Utilization for Behavioral Health: The report highlights a rise in utilization for behavioral health services as a contributing factor to increasing healthcare costs. This trend reflects a growing recognition of the importance of mental health, but also adds to the overall spending burden on the healthcare system.

3. Health Plans' Evolving Strategies: Health plans are adapting their strategies to manage rising costs more effectively by addressing interconnected factors driving expenses. Modern initiatives focus on reducing over-utilization, improving operational efficiency, and enhancing medical management. Despite these efforts, the analysts emphasize that these strategies must be more comprehensive to tackle the broader challenge of healthcare affordability.

FTC Scrutinizes Pharmacy Managers for Opaque Practices, Inflating Drug Costs

By Remy Samuels - After a two-year investigation into pharmacy benefit managers, the Federal Trade Commission has released an interim report, which argues that these “powerful middlemen” are inflating costs and “squeezing Main Street pharmacies.” Read Full Article…

HVBA Article Summary

1. Fiduciary Responsibility in Health Plan Evaluation: Plan sponsors must ensure that the fees they pay for health care plans are fair and reasonable as required by the Consolidated Appropriations Act of 2021. This necessitates applying a fiduciary process to evaluate their health plans thoroughly and staying informed about pending litigation, such as the FTC's potential lawsuit against major PBMs for allegedly pushing patients toward more expensive brand-name drugs.

2. FTC's Investigation into PBMs: The FTC is investigating the practices of the three largest PBMs—OptumRx, Caremark, and Express Scripts—accusing them of driving patients to costly brand-name drugs, including insulin. The FTC's report highlights that these PBMs control nearly 80% of all prescriptions in the U.S., wield significant influence over drug prices and access, and have opaque and complex business practices that obscure true pharmacy reimbursements and complicate the prescription reimbursement system.

3. Impact of PBM Practices on Drug Costs and Access: The FTC has found that PBMs and branded medication manufacturers negotiate rebates that can limit access to lower-cost generic drugs, impacting patients' ability to afford medications. The FTC's scrutiny of PBM practices aims to ensure transparency and fair pricing, especially given the significant role PBMs play in the drug supply chain and their impact on the costs borne by the federal and state governments, the largest purchasers of health care in the U.S.

AI-generated messages to patients on par with clinicians, and can even be more empathetic, study finds

By Dave Muoio - Electronic health record messages to patients drafted by generative AI were of similar quality and accuracy to those written by healthcare professionals, according to a newly published study conducted using queries from NYU Langone Health patients. Read Full Article…

HVBA Article Summary

1. Evaluation of AI vs. Human Drafts: Researchers from NYU Grossman School of Medicine conducted an analysis where 16 primary care physicians evaluated 334 AI-drafted messages and 169 messages from human professionals. The study found that both AI and human drafts were comparable in terms of informational content, completeness, and usability. Notably, AI drafts were rated more empathetic, understandable, and positively toned compared to human drafts, though they were also longer and more linguistically complex.

2. Implications for Healthcare Providers: The findings suggest that chatbots, specifically AI like OpenAI’s Chat GPT-4, could significantly reduce the workload of healthcare providers by generating efficient and empathetic responses to patient concerns. This potential reduction in workload is crucial given the 30% annual increase in patient messages observed at NYU Langone, which has contributed to financial inefficiency, stress, and burnout among physicians.

3. Areas for Improvement and Future Directions: The study highlighted the need for AI improvements in drafting less complex, more accessible language to avoid exacerbating health inequities, particularly for those with low health or English literacy. Additionally, the performance of AI in specific message types, such as lab results, requires further refinement. The researchers also noted that using generative AI for categorizing and directing patient messages, as explored by Kaiser Permanente, could further optimize healthcare workflows and ensure appropriate expertise levels handle patient queries.

Proposed CY 2025 Physician Fee Schedule – A Drilldown on the Telehealth Proposals

By CCHP - On July 10, 2024, the Centers for Medicare and Medicaid Services (CMS) released their proposed Physician Fee Schedule (PFS) for CY 2025. Each year the PFS contains new or updated policies which CMS will be adopting for Medicare in the following year. Read Full Article…

HVBA Article Summary

1. CMS Proposes Permanent Policy for Audio-Only Telehealth Services: One of the key proposals from CMS is to redefine "interactive communication system" to allow audio-only communication for any telehealth service. This proposal, if finalized, would permanently expand the scope beyond the 2022 definition that limited audio-only communication to mental and behavioral health services. The new definition would enable any eligible telehealth service to be delivered via two-way, real-time audio-only communication, provided the patient cannot or does not consent to using video technology.

2. Comments and Potential Changes: The public has until 5:00 pm on September 9, 2024, to submit comments on these proposed policies. CMS's proposals reflect an attempt to mitigate the impact of the December 31, 2024, deadline for the COVID-19 telehealth waivers. CMS acknowledges the potential adverse effects on Medicare enrollees if these waivers expire and has proposed several actions to address these issues, such as maintaining certain temporary waivers and soliciting public input on redefining telehealth services.

3. Limitations and Legislative Requirements: Certain telehealth policies, such as the eligibility of providers and patient locations, remain bound by federal statutes, requiring Congressional action to change. For instance, after December 31, 2024, Medicare enrollees receiving telehealth services from physical therapists in their homes would be impacted due to existing statutory limitations. CMS is aware of these constraints and highlights the importance of legislative changes to prevent disruptions in telehealth services.

How this platform is providing healthcare price transparency

By Deanna Cuadra- As employers scramble to mitigate healthcare costs, employees are left to pay for increasingly alarming medical bills. But unlike any other big purchase, Americans often don't know what their care will cost them. Read Full Article…

HVBA Article Summary

1. Enhanced Price Transparency: Certainly Health provides a user-friendly search engine for NYC consumers insured by major companies like Blue Cross Blue Shield, UnitedHealth Group, Cigna, and Aetna. The platform allows users to see the cost of medical and cosmetic services across various providers, offering clarity on out-of-pocket expenses and remaining deductibles by integrating insurers' negotiated rates. This transparency aims to reduce the prevalence of surprise medical bills and instill greater trust in healthcare pricing.

2. Consumer Protection and Cost Coverage: One of Certainly Health's key features is its commitment to covering any cost discrepancies. If the platform underestimates the expense of a service, it takes responsibility for the difference, ensuring that consumers are not caught off guard by higher charges. This approach not only enhances trust but also provides a financial safety net for patients, addressing a significant pain point in the U.S. healthcare system.

3. Free Access and Provider Incentives: Certainly Health operates at no cost to consumers, making it an accessible tool for price comparison and decision-making. Instead, the platform charges providers a fee for each patient who visits them through the site. This model incentivizes providers to be transparent about their pricing, ultimately benefiting consumers with more accurate and comprehensive cost information. By fostering transparency and accountability, Certainly Health aims to create a win-win scenario for both patients and healthcare providers.

A first look at outcomes under the No Surprises Act arbitration process

By Matthew Fiedlerand Loren Adler - The No Surprises Act (NSA) was enacted in 2022 to protect patients from “surprise” bills for out-of-network care. Under the law, the amount a patient owes for out-of-network emergency care and non-emergency services delivered at in-network facilities cannot exceed the cost-sharing the patient would owe for similar in-network care. Read Full Article…

HVBA Article Summary

1. IDR Process Overview: The independent dispute resolution (IDR) process, established under the NSA, involves a final-offer arbitration where an IDR entity selects between the payment offers made by insurers and providers for out-of-network services. This binding process aims to adjudicate payment disputes effectively and has been instrumental in resolving disagreements.

2. CMS Data Release and Findings: On February 15, 2023, CMS released data on IDR disputes decided in the first half of 2023. Analysis of this data reveals that median IDR decisions are significantly higher than Medicare rates, often aligning more closely with historical out-of-network allowed amounts rather than prior in-network commercial prices. Providers frequently submit higher offers, and IDR entities tend to favor these offers over insurers' proposals.

3. Implications for Prices and Premiums: The outcomes from the IDR process suggest a potential increase in in-network prices and insurance premiums, contrary to Congressional Budget Office (CBO) projections. The higher-than-expected IDR decisions could influence future negotiations between providers and insurers, possibly leading to increased overall healthcare costs, which was not the intention of the law's architects.