New Proposed Federal Legislation Takes Aim at Concerns Regarding Perceived “Looting” of Health Care Systems by Private Equity Investors

By Melissa L. Jampol and Kathleen M. Premo - On June 11, 2024, U.S. Senators Ed Markey and Elizabeth Warren from Massachusetts, introduced proposed legislation titled The Corporate Crimes Against Health Care Act (“CCAHCA”), aimed at addressing a perceived “looting” of health care systems by for profit private equity investors. Read Full Article…

HVBA Article Summary

1. Targeting Corporate Greed and Private Equity Abuse: The CCAHCA aims to combat corporate greed and abusive practices by private equity firms in the healthcare sector. It seeks to prevent exploitative practices and ensure accountability by addressing specific "triggering events" and targeting real estate investment trusts (REITs).

2. Imposing Penalties for Harmful Actions: The bill proposes significant criminal and civil penalties for executives of private equity firms and healthcare entities responsible for patient harm due to "triggering events" post-change of control transactions. This includes imprisonment, compensation clawbacks, and civil penalties up to five times the clawback amount.

3. Enhanced Reporting and Regulation: The CCAHCA mandates annual reporting for healthcare entities on transactions and financial details, with penalties for incomplete or false reports. It also restricts federal healthcare payments to entities engaging in certain financial practices with REITs, aiming to reduce tax incentives for REIT investments in healthcare properties.

Addressing Medical Debt Is Important. Addressing Its Root Causes Is Just As Essential.

By Wendell Potter - The huge and growing burden of medical debt undoubtedly will be a presidential campaign issue and one that Vice President Harris will highlight. It will be interesting to see what former President Trump will say about it. Read Full Article…

HVBA Article Summary

1. Address the Root Causes of Medical Debt: The article emphasizes the importance of not only addressing the immediate consequences of medical debt but also tackling its underlying causes. This includes scrutinizing the healthcare system's structure, particularly the shift towards high-deductible health plans, which has burdened insured individuals with significant out-of-pocket expenses.

2. Policy Interventions and Proposals: The article highlights recent and proposed policy measures aimed at mitigating the impact of medical debt. Notably, the White House's initiative to exclude medical bills from credit reports and the call for capping out-of-pocket expenses, especially for prescription drugs, are seen as crucial steps. These policies aim to provide relief and prevent families from losing their homes or declaring bankruptcy due to medical expenses.

3. Advocacy and Public Pressure: The article calls for sustained advocacy and public pressure on political leaders to address medical debt comprehensively. It encourages individuals and organizations to support measures that limit out-of-pocket costs and to hold candidates accountable for proposing effective solutions. The goal is to create a healthcare environment where unexpected medical costs do not devastate families financially.

Stuck in the Middle: Employers’ Challenges In Accessing Their Health Data

By Marissa Plescia - Self-funded employers are finding themselves in a difficult position of late. Employers have a fiduciary responsibility to make sure they’re offering employees the best medical benefits for the lowest price. And they need access to their medical claims data to do this. Read Full Article…

HVBA Article Summary

1. Data Access Challenges for Employers: Many employers are facing difficulties in accessing complete health data from third-party administrators (TPAs), essential for fulfilling their fiduciary duties. The Kraft Heinz/Aetna arbitration highlights the issue, where Aetna allegedly provided selective and edited medical claims data, preventing Kraft Heinz from effectively managing its employee health plans.

2. Rising Employee Litigation: In response to perceived mismanagement of health benefits, employees are increasingly suing their employers for breach of fiduciary duty. A notable example is the lawsuit filed by an employee against Johnson & Johnson, alleging overpayment for prescription drugs through pharmacy benefit manager Express Scripts, which supposedly led to increased costs for employees.

3. Steps for Employers to Protect Themselves: Experts suggest that employers need to scrutinize the relationships and agreements with TPAs and brokers to avoid conflicts of interest and ensure transparency. Employers are advised to establish fiduciary committees, invest in data analysis capabilities, and maintain thorough documentation of data requests to TPAs to safeguard against potential litigation and fulfill their legal responsibilities. Additionally, there is a push for legislative changes to hold TPAs and PBMs accountable as fiduciaries, ensuring they act in the best interest of the employers and employees they serve.

More on Braidwood: ACA Preventive Services Mandate Remains Mostly in Place (For the Time Being)

By Jesse T. Foley and Jennifer Rigterink - At the end of June, the U.S. Court of Appeals for the Fifth Circuit affirmed a district court order invalidating the Affordable Care Act preventive services mandate for “A” or “B” items and services recommended by the United States Preventive Services Task Force (USPSTF) on or after March 23, 2010, on the basis that the USPSTF members were not constitutionally appointed. Read Full Article…

HVBA Article Summary

1. Reversal and Remand by the Fifth Circuit: The Fifth Circuit Court reversed the district court’s nationwide injunction that previously enjoined the enforcement of the USPSTF preventive services mandate, citing procedural grounds. The case was remanded to the district court to evaluate the constitutionality of the preventive services mandate concerning ACIP recommendations on routine immunizations and HRSA recommendations on preventive care for women and children.

2. Implications for Health Plan Sponsors and Employers: Currently, the preventive services mandates recommended by USPSTF, ACIP, and HRSA remain in effect, except for the named plaintiffs concerning the USPSTF mandate. The district court’s future decision on the constitutionality of ACIP and HRSA recommendations is pending and may potentially be appealed back to the Fifth Circuit, creating a period of uncertainty for health plan sponsors and employers.

3. Geographic Impact and Future Uncertainties: While the USPSTF preventive services mandate is not expected to be enforced within the Fifth Circuit’s jurisdiction (Texas, Louisiana, and Mississippi), the practical implications for plan sponsors in these states remain unclear. Due to the ongoing litigation and potential for further appeals, plan sponsors might choose to hold off on making changes to preventive services coverage to avoid multiple adjustments in a short period.

Among pharma CEOs, the IRA now and the IRA later get very different reactions

By Max Bayer and Zachary Brennan - Pharma has a message to investors about the results of the first round of drug price negotiations under the Inflation Reduction Act: It’s fine. Over the last two weeks, many of the drugmakers subject to IRA pricing have, for the first time, said what they think of the prices they’ve ended up with after negotiations with the Centers for Medicare & Medicaid Services. Read Full Article…

HVBA Article Summary

1. Impact on Research & Development and Financial Planning: Pharmaceutical companies continue to challenge the pricing regulations stipulated in the IRA in court, citing potential long-term harm to research and development. Despite these concerns, companies like Novartis and Johnson & Johnson have already incorporated the anticipated impacts of these pricing changes into their financial forecasts, reflecting a degree of preparedness amidst uncertainty.

2. Negotiated Prices versus Current List Prices: According to Anna Kaltenboeck, while company executives may project confidence in public, the actual prices negotiated under the new law are expected to be much lower than current list prices. This shift aims to substantially reduce the cost burden on beneficiaries, who often pay more in cost-sharing than what plans pay for the drugs themselves.

3. Executive Perspectives on Pricing Under the New Law: Pharma executives from companies such as Novartis, Roche, and AbbVie have offered mixed views in their earnings calls regarding the pricing provisions of the IRA. While some acknowledge the near-term manageability of the pricing impacts, concerns remain about the long-term effects on drugs earlier in their lifecycle and the need for a reassessment of the law’s provisions to avoid stifling innovation and patient care.

Popular weight-loss and diabetes medications show promise for curbing smoking, study suggests

By Deidre McPhillips - A growing set of evidence suggests that using semaglutide could lead to decreased substance use, and a large new study shows a promising link between the medication and tobacco use. But experts emphasize that much more research is needed before using the medications off-label for smoking cessation. Read Full Article…

HVBA Article Summary

1. Medication Effects on Smoking Cessation in Diabetics: A recent study in the Annals of Internal Medicine found that type 2 diabetes patients beginning treatment with semaglutide—a medication under brands like Ozempic—showed fewer medical interventions related to smoking, such as counseling or cessation medication, compared to those treated with traditional drugs like insulin or metformin. This observation suggests a potential secondary benefit of semaglutide in reducing tobacco use or altering the approach to cessation among diabetics.

2. Potential Mechanisms and Future Research: The study highlights a possible interaction between semaglutide and the brain's reward pathways, which might influence cravings not just for food but for substances like nicotine. However, Dr. Nora Volkow from the National Institute on Drug Abuse emphasizes the necessity for further research to understand the drug's impact on smoking severity, cravings, and optimal dosages for treating tobacco use disorder.

3. Implications for Public Health: The findings hint at a promising new avenue for smoking cessation treatments, a critical area given the ongoing prevalence and health risks of tobacco use. With smoking being a leading cause of preventable disease and death, and successful cessation rates remaining low, semaglutide and similar medications could represent significant advancements in public health strategies.

What Increased Health Plan-Related Scrutiny Means for Plan Sponsors

By Remy Samuels - As the Federal Trade Commission is poised to file a complaint against the three largest pharmacy benefit managers, and with fiduciary litigation risk on the rise for employer-provided health plans, it is critical that plan sponsors ensure they are prudently managing their health plans. Read Full Article…

HVBA Article Summary

1. FTC Lawsuit as a Catalyst for Transparency: Jamie Greenleaf, co-founder of Fiduciary in a Box, highlights the FTC lawsuit against opaque healthcare practices as a positive move towards transparency. He likens the process to sunlight acting as a disinfectant, suggesting that these legal actions are crucial for exposing and correcting hidden and potentially unfair practices within the healthcare industry.

2. Impact of Fiduciary Standards on Healthcare Costs: Barbara Delaney, principal at SS/RBA, draws a parallel between the positive effects of fiduciary transparency in 401(k) plans and potential benefits in healthcare. She advocates for applying similar fiduciary standards to healthcare plans, which she believes could significantly lower costs and improve management, much as has been seen in retirement plan administration over the last decade.

3. Rising Fiduciary Litigation Risks: Recent webinars and legal actions, such as the case against Johnson and Johnson, underline an increase in fiduciary litigation risks concerning health plans. These cases point to a potential wave of claims alleging breaches of fiduciary duty due to mismanagement of plan costs and deceptive pricing methods, prompting a call for health plan sponsors to rigorously evaluate and enhance their fiduciary processes.

Alzheimer's Blood Test More Accurate Than Primary Care or Specialist Diagnoses

By Judy George - A blood test performed better than a standard evaluation by primary care doctors or dementia specialists in detecting Alzheimer's disease among people with cognitive symptoms. Read Full Article…

HVBA Article Summary

1. Enhanced Diagnostic Accuracy: The PrecivityAD2 blood test, featuring the amyloid probability score 2 (APS2), demonstrated a diagnostic accuracy of 91%, significantly higher than the 61% accuracy observed with standard clinical evaluations by primary care physicians and 73% by dementia specialists. APS2 uses ratios of specific biomarkers—plasma phosphorylated tau 217 and amyloid-beta—analyzed through mass spectrometry, providing a more reliable diagnosis of Alzheimer's disease.

2. Comparison and Implications in Clinical Practice: The blood test's accuracy was validated against traditional diagnostic methods such as clinical exams, cognitive tests, and CT scans. Not only does APS2 offer potential as a standalone diagnostic tool, especially in facilities lacking advanced diagnostic technologies like CSF or PET scans, but it could also replace these methods in many cases, streamlining and improving the diagnostic process in both primary and specialist care settings.

3. Study Findings and Broader Impacts: The study, involving 1,213 patients and presented by Oskar Hansson, MD, PhD, at the Alzheimer's Association International Conference, underscores the test's potential to reduce misdiagnoses—which occurs in 25% to 30% of cases in specialist settings when biomarkers are not used. The blood test not only enhances diagnostic precision but also opens up possibilities for its use in routine primary care, broadening the accessibility and early detection of Alzheimer's pathology.

Customization will unlock the full potential of invaluable resources

By Matthew Sydney and Cheryl Turner - Remember just a few years ago, when benefits for menopause weren't a thing? Or when we didn't discuss mental health in "polite" conversation? Now, employers not considering these benefits are behind the curve. Read Full Article…

HVBA Article Summary

1. Persistent Needs Meet Modern Solutions: Historically overlooked aspects of wellbeing, such as menopause management and mental health, have always been significant, yet only recently have they found robust support through innovative digital platforms and apps. This shift underscores the ongoing evolution of health solutions, aiming to meet enduring human needs with modern, accessible resources.

2. The Silent Struggles Within Workforces: Employees often face personal challenges—such as addiction recovery, caregiving for relatives with Alzheimer’s, or dealing with divorce—that remain invisible to employers. These struggles highlight the critical need for employers to offer flexible, comprehensive benefits that can be personalized. The data from various national surveys illustrate the widespread impact of these issues, driving home the point that traditional one-size-fits-all benefits may not adequately address the diverse needs of a modern workforce.

3. Empowering Employee Choice in Benefits: The rapid expansion of digital solutions for health, financial wellness, and mental wellbeing presents a new opportunity to revolutionize how benefits are chosen. Shifting from employer-selected to employee-selected benefits could enhance engagement, satisfaction, and overall effectiveness of these programs. By allowing employees to customize their benefits packages throughout the year, companies can ensure that these offerings are relevant and responsive to changing personal circumstances, thereby maximizing their impact and utility.