Banking on Rx Alternative Funding

By Bruce Shutan - Specialty drugs, along with cell and gene therapy, have made a growing number of scripts unattainable for many working Americans. However, self-insured health plans have several avenues of alternative funding and patient advocacy at their fingertips to help defray enormous price tags. Read Full Article…

HVBA Article Summary

1. Decline of Patient Assistance Programs (PAPs): Pharmaceutical manufacturers have historically offered Patient Assistance Programs (PAPs) to provide medications at reduced costs, earning public goodwill and tax benefits. However, rising prescription drug costs, decreasing margins, and federal crackdowns on high prices have led to a reduction in the number of PAPs, with some industry insiders predicting their potential disappearance.

2. Challenges and Importance of the 340B Program: The 340B federal subsidy program, established in 1992 to aid those in need of charitable care, has become the second-largest federal prescription drug program after Medicare Part D. It mandates significant discounts on outpatient drugs for hospitals serving low-income patients. Despite its crucial role, 340B faces congressional investigations, federal lawsuits, and a Supreme Court ruling. The program's future is contentious, with a struggle between pharmaceutical companies seeking to protect profits and hospitals fighting to maintain essential funding.

3. Complexities of Rx Alternative Funding and Fraud Risks: The Rx alternative funding market offers various opportunities to reduce out-of-pocket costs for needy patients through grants and patient foundations. However, this market is plagued by fraudulent activities and questionable practices among service providers, PBMs, and brokers. Misrepresentation of patient income and other eligibility factors compromises the integrity of these programs, highlighting the need for self-insured employers to scrutinize shared savings arrangements and ensure transparent, pass-through cost structures.

Some Surprises in the No Surprises Act

By T. Christian Miller - In 2020, Congress passed the No Surprises Act to protect patients from exorbitant medical bills that had burdened Americans with tens of thousands of dollars in debt. The law was designed to decrease the charges for patients treated by an out-of-network doctor during medical emergencies. Such ER visits often left people vulnerable to so-called surprise bills, in which their insurer would only pay a portion of the expensive treatment. Read Full Article…

HVBA Article Summary

1. Successes of the No Surprises Act:

   • The No Surprises Act has significantly reduced the number of unexpected and financially crippling medical bills for patients.

   • An insurance industry survey estimated that approximately 10 million surprise bills were avoided in the first nine months of 2023.

   • Reports suggest that costs for emergency room care and air ambulance trips have decreased for consumers covered under the law.

2. Challenges and Unintended Consequences:

   • The government system to resolve payment disputes between doctors and insurers is proving cumbersome, leading to potential negative outcomes such as higher insurance premiums and fewer available physicians in rural areas.

   • Disputes have surged far beyond initial estimates, with almost 680,000 cases filed in 2023, causing significant backlogs and delayed payments.

3. Ongoing Debates and Legal Issues:

   • There is significant contention between doctors and insurers, each accusing the other of abusing the arbitration process for financial gain.

   • Legal challenges and adjustments to the arbitration process have contributed to delays and uncertainty, with courts overturning initial CMS guidelines and requiring continuous adjustments.

   • Despite intentions to lower healthcare costs, arbitration outcomes have sometimes resulted in higher payments to providers, potentially driving up overall insurance premiums.

Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated

By Christopher Weaver, Tom McGinty, Anna Wilde Mathews and Mark Maremont - Gloria Lee was perplexed when the phone calls started coming in from a representative of her Medicare insurer. Could a nurse stop by her Boston home to give her a quick checkup? It was a helpful perk. No cost. In fact, she’d get a $50 gift card. Read Full Article…

HVBA Article Summary

1. Questionable Diagnoses and Increased Costs: Private insurers in the Medicare Advantage program have made numerous dubious diagnoses, including diabetic cataracts for non-diabetic patients, leading to significant taxpayer-funded payments. An analysis by the Wall Street Journal found that from 2018 to 2021, Medicare paid insurers about $50 billion for these added diagnoses, often without subsequent treatment for the conditions diagnosed.

2. Incentives and Diagnostic Practices: Medicare Advantage insurers have incentives to add diagnoses due to higher payments for certain conditions. Insurers use home visits and chart reviews, sometimes aided by AI, to identify additional conditions, rewarding patients and doctors for their participation. This practice has led to a high rate of diagnoses such as diabetic cataracts and HIV, often without appropriate follow-up care or treatment.

3. Impact on Patients and Oversight: The system has led to misdiagnoses that patients are often unaware of, resulting in unnecessary worry and potentially inappropriate treatment. Despite the intention to create a more economical healthcare system, Medicare Advantage has increased costs by tens of billions of dollars. Government efforts to audit and correct these practices are ongoing, with changes expected to take full effect by 2026. However, experts remain skeptical about the long-term efficacy of these measures in curbing systemic abuse.

What employers should know about the Hospital Price Transparency update

By Deanna Cuadra - Are Americans getting any closer to price transparency in their healthcare experience? The latest update from the Centers for Medicare and Medicaid Services (CMS) may have inched us toward that reality. Read Full Article…

HVBA Article Summary

1. Enhanced Compliance and Enforcement: With the new CMS requirement effective July 1, hospitals must use a standardized, machine-readable file format that includes prices, insurer-negotiated rates, reasoning behind negotiations, and an accuracy and completeness statement. This change significantly simplifies the process of checking and enforcing compliance, allowing CMS to easily identify hospitals that fail to meet the rule's requirements and take corrective actions as needed.

2. Empowering Employers and Consumers: The standardized data format will make price transparency data more accessible, enabling self-funded employers and consumers to compare costs effectively. Employers can now utilize this data alongside their claims data to determine if they are receiving the best rates. By comparing these rates to publicly available Medicare rates, employers can ensure they are not being overcharged, potentially leading to significant cost savings.

3. Potential Improvements in Hospital Pricing Practices: As transparency data becomes more widely used, hospitals may be incentivized to make their pricing more consistent and accessible to attract employers and consumers. This could lead to a shift in hospital pricing practices, making it easier for patients to understand their costs upfront and make informed decisions about their care. The ultimate goal is to empower patients and employers with clear, accurate pricing information, potentially transforming the healthcare pricing landscape.

Mounjaro bests Ozempic for weight loss in first head-to-head comparison of real-world use

By Karen Kaplan - In the first head-to-head comparison of two blockbuster drugs used in real-world conditions, people who took Mounjaro lost significantly more weight than their counterparts who took Ozempic — and the longer the patients kept taking the drugs, the wider the gap became. Read Full Article…

HVBA Article Summary

1. Significant Weight Loss Comparison: After three months, patients on Mounjaro lost 5.9% of their body weight on average, compared to 3.6% for those on Ozempic. At six months, the average weight loss was 10.1% for Mounjaro and 5.8% for Ozempic. After one year, Mounjaro patients had shed 15.3% of their weight on average, while Ozempic patients lost 8.3%.

2. Higher Likelihood of Meeting Weight Loss Milestones: The study found that patients on Mounjaro were 2.5 times more likely to lose at least 10% of their initial weight and more than three times as likely to lose at least 15% of their weight during the first year compared to those on Ozempic.

3. Broader Efficacy and Future Considerations: Despite the superior performance of Mounjaro, both medications resulted in substantial weight loss. Patients should consider factors such as side effects, insurance coverage, and drug availability before switching medications. Notably, Ozempic has shown additional cardiovascular benefits in clinical trials, whereas data on Mounjaro's secondary outcomes are still limited.

Keeping ACA premium tax credits high may cut 2025 group health use

By Allison Bell - Congress will have to decide soon whether to continue a big, temporary increase in premium tax credit subsidies for Affordable Care Act public exchange plan coverage. Read Full Article…

HVBA Article Summary

1. Impact on Employer-Sponsored Health Coverage Enrollment: According to an Urban Institute analysis, if Congress allows the subsidy increase to lapse, enrollment in employer-sponsored health coverage could rise by approximately 4 million, reaching a total of 151 million. This increase would be partly driven by small employers offering health coverage in response to ACA plan subsidy cuts.

2. Effect on Workers with Health Conditions: A significant portion of the enrollment increase would come from workers who previously found employer-sponsored health coverage unaffordable. These workers, potentially dealing with serious health conditions like diabetes, arthritis, or cancer, may abandon exchange plans and return to employer-sponsored plans as subsidies diminish.

3. Broader Insurance Coverage Implications: The lapse of increased subsidy levels could lead to a 2% drop in the total number of well-insured individuals, bringing the number to 249.5 million. Concurrently, the number of uninsured people and those with inadequate insurance might rise by 13%, reaching 31 million. This change reflects the critical role that richer premium tax credits have played in boosting exchange plan enrollment, which has surged from 12 million in 2021 to 21 million this year.

Plan Sponsors Reveal Optional SECURE 2.0 Provisions They Are Most Likely to Adopt

By Natalie Lin - The increase in catch-up contribution cap for participants aged 60 to 63 and the expanded in-service distribution choices made possible by the SECURE 2.0 Act of 2022 were among the top-ranked optional provisions for plan sponsors, according to respondents from a June survey by Fidelity Investments titled “SECURE 2.0 Optional Provisions Survey Insight.” Read Full Article…

HVBA Article Summary

1. Adoption of Catch-Up Contributions and Self-Certification Provisions: Among plan sponsors, 88% expressed a strong likelihood of adopting the catch-up contribution limit for participants aged 60 through 63 when it becomes available for plan years starting in 2025. Similarly, 88% are likely to adopt provisions for self-certification of hardships, unforeseeable emergency distributions, and withdrawals for federally declared disasters.

2. Anticipated Implementation Timeline and Adoption of Fidelity Solutions: Sixty percent of respondents anticipate that it will take six months or more to adopt the optional provisions they have chosen. Additionally, four in five respondents have considered utilizing at least one of Fidelity’s solutions—auto portability, self-certification, and/or student debt match—to facilitate the adoption of SECURE 2.0.

3. Interest in Optional Elements and Sector-Specific Preferences: Ninety percent of those surveyed showed interest in implementing some optional elements, with large and tax-exempt plans showing the greatest interest. Smaller plan sponsors are expected to have lower adoption rates. The top categories of interest included employer contributions as Roth and withdrawals for emergency needs. Auto-portability was favored by plan sponsors in manufacturing and finance, while professional, technical, and scientific services showed more interest in unenrolled member disclosures and emergency expense withdrawals.

Cracking the code on paying for cell and gene therapies

By Jennifer Levin Carter, M.D. - The future of healthcare is both daunting and promising for group health plans. Precision medicine will help employers raise the bar on managing some of their priciest medical claims, saving significant dollars – and lives – in the process. Read Full Article…

HVBA Article Summary

1. Rising Costs and Risks for Employers: The approval of cell and gene therapies, while promising for curing genetic diseases, has significantly increased specialty drug costs and financial risks for employers. Benefit brokers and advisers need to equip their clients with the right information to manage these challenges effectively. The FDA's approval of 37 such therapies, with many more in development, highlights the importance for group health plans to monitor and adapt to these rising costs driven by precision therapeutics.

2. Precision Medicine's Role in Cost Control: Precision medicine, leveraging patient biology, genetic, and genomic data, offers a novel approach to controlling excessive healthcare costs. This approach allows group health plans to develop tailored treatment strategies, including cell and gene therapies, based on individual patient data. The goal is to make more accurate treatment decisions to reduce costs and improve clinical outcomes. However, the high costs of these treatments, ranging from $350,000 to over $3 million, pose a significant challenge for employer-sponsored plans.

3. Innovative Financing Solutions: To address the financial burden of new specialty drugs, long-term financing solutions are essential. Collaborations between cell and gene therapy manufacturers and payers have led to managed access agreements, early access programs, and innovative payment models. These include significant discounts, annuity-based payments, loan-based pilot programs, and outcomes-based agreements. These strategies aim to make treatments more accessible and affordable, while also considering the need for robust outcome tracking and the challenges of an increasingly mobile workforce.

Eight Common Antidepressants Ranked by Weight Gain Potential

By Eve Bender - Eight commonly used antidepressants have been ranked by their weight gain potential. Results of a large observational study showed small differences in short- and long-term weight change in patients prescribed one of eight antidepressants, with bupropion associated with the lowest weight gain and escitalopram, paroxetine, and duloxetine associated with the greatest. Read Full Article…

HVBA Article Summary

1. Weight Gain Differences Among Antidepressants: The study found that users of escitalopram, paroxetine, and duloxetine were 10%-15% more likely to gain at least 5% of their baseline weight compared to those taking sertraline, which was used as a comparator. This suggests significant variability in weight gain potential across different antidepressants.

2. Importance of Informed Prescription Decisions: Lead author Joshua Petimar emphasized the importance of clinicians and patients being aware of the weight gain potential associated with different antidepressants. He highlighted that this real-world evidence can help in making better-informed decisions regarding which antidepressants to prescribe, considering weight gain as a factor.

3. Study Methodology and Limitations: The study analyzed electronic health records from 183,118 adults across eight healthcare systems in the U.S. between 2010 and 2019. Despite its large sample size and robust data, the study faced limitations such as missing weight information for many patients and low adherence rates, which complicated the attribution of weight changes to specific medications over time.

Initial Triple Therapy Shows Promise in Drug-Naive T2D

By Javed Choudhury - A triple combination therapy (TCT) of metformin, dapagliflozin, and saxagliptin is an effective and safe treatment option for drug-naive patients with type 2 diabetes (T2D) compared with stepwise add-on therapy. Read Full Article…

HVBA Article Summary

1. Study Design and Population: This randomized controlled open-label trial was conducted at nine sites in South Korea, involving 105 drug-naive patients with type 2 diabetes (T2D). The participants had a mean age of 49.5 years, with 32.4% being women. Patients were assigned to receive either triple therapy (metformin, dapagliflozin, and saxagliptin) or stepwise add-on therapy (starting with metformin, then adding glimepiride and sitagliptin based on baseline A1c levels).

2. Primary and Secondary Outcomes: The primary outcome measured was the proportion of patients achieving A1c levels < 6.5% without experiencing hypoglycemia, significant weight gain (≥ 5%), or discontinuation of drugs due to adverse events at week 104. Secondary outcomes included the proportion of patients reaching A1c levels < 7.0% at weeks 56 and 104, and < 6.5% at week 56, all without hypoglycemia, weight gain, or drug discontinuation due to adverse events.

3. Intervention Groups: The trial divided patients into two groups: those receiving triple therapy and those undergoing stepwise add-on therapy. The latter group started with metformin and added other drugs based on their initial A1c levels (< 9.0% or ≥ 9.0%). This methodology aimed to compare the effectiveness of an aggressive initial combination treatment with a more gradual, stepwise approach.