Payers are missing major AI opportunities: McKinsey

By Jakob Emerson - Artificial intelligence has the potential to lower internal and member costs for insurers while also increasing profits, but the industry has largely not embraced these opportunities, according to a June 5 analysis from McKinsey. Read Full Article…

HVBA Article Summary

1. Significant Potential Savings: Fully implementing generative AI and automation technologies could result in substantial cost savings and revenue increases for payers. On average, these technologies could save 13-25% on administrative costs, 5-11% on medical costs, and boost revenues by 3-12%.

2. Focus Areas for AI Implementation: Divisions such as marketing and sales, utilization management, and IT hold the greatest potential for leveraging AI technologies to optimize processes and drive efficiencies within the payer industry.

3. Essential Components for AI Success: Payers aiming to harness AI effectively need to prioritize six key components: a strategic plan, appropriate talent, a supportive operating model, technological capabilities, accessible data, and strategies for ensuring widespread adoption and scalability. However, most payers currently lack the necessary capabilities to fully realize these opportunities, highlighting the need to bridge the gap between current and required capabilities.

Biden Plan to Save Medicare Patients Money on Drugs Risks Empty Shelves, Pharmacists Say

By Susan Jaffe - Months into a new Biden administration policy intended to lower drug costs for Medicare patients, independent pharmacists say they’re struggling to afford to keep some prescription drugs in stock. Read Full Article…

HVBA Article Summary

1. Immediate Impact on Pharmacies: Pharmacists, such as Clint Hopkins from Pucci’s Pharmacy in Sacramento, California, are facing financial strain due to a recent regulation altering prescription pricing for Medicare beneficiaries. Under the new system, adjustments to prices are made at the pharmacy counter before filling prescriptions, resulting in reduced overall costs for patients and the government. However, this change has led to decreased revenue for pharmacies, exacerbating existing challenges such as staff shortages, drug scarcities, and rising operational expenses.

2. Pharmacy Benefit Manager (PBM) Negotiations: The financial pressure on pharmacies is exacerbated by negotiations between Medicare insurance plans and PBMs, which dictate reimbursement rates. Despite concerns raised by independent pharmacists about the adverse effects of these negotiations, officials from the Centers for Medicare & Medicaid Services (CMS) have emphasized that such matters are the responsibility of the involved parties to resolve. This lack of intervention has prompted pharmacies to consider limiting medication availability and even discontinuing acceptance of certain Medicare drug plans.

3. Patient Impact and Regulatory Response: While the regulatory changes aim to lower costs for Medicare patients, they have inadvertently created financial hardships for both pharmacies and some patients. Pharmacies are experiencing cash-flow challenges due to immediate PBM clawbacks, impacting their ability to stock expensive medications. Despite warnings from industry groups like the National Community Pharmacists Association, CMS has not taken significant action to address these concerns, leaving pharmacies to navigate the financial implications independently.

Health and Employer Groups Push for Improved Health Pricing Transparency

By Paul Mulholland - The ERISA Industry Committee and other benefits and health industry groups have endorsed two bills that aim to improve transparency and lower costs in the administration of health care plans. Read Full Article…

HVBA Article Summary

1. Enhanced Pricing Transparency: The Lower Costs, More Transparency Act mandates hospitals and related facilities to disclose pricing details, encompassing negotiated charges and discounts, thereby enabling patients to make informed decisions regarding their healthcare expenses. This transparency extends to clinical labs, imaging services, and ambulatory surgical centers participating in Medicare, fostering greater clarity in healthcare pricing across various services.

2. Pharmacy Benefit Manager Accountability: Under both bills, pharmacy benefit managers (PBMs) face increased scrutiny and accountability measures. The legislation requires PBMs to furnish comprehensive reports to health plans, divulging crucial pricing information such as rebates, fees, and copayment assistance provided by drug manufacturers. Additionally, PBMs must disclose the list of covered drugs and total net spending by the health plan on prescription drugs, ensuring greater transparency in pharmaceutical pricing practices.

3. Combatting Exploitative Practices: Both bills aim to curb exploitative practices within the healthcare system. The Lower Costs, More Transparency Act specifically targets spread-pricing, prohibiting PBMs from charging payers more than what they pay pharmacies for Medicaid-related transactions. Similarly, the Pharmacy Benefit Manager Reform Act imposes stringent reporting requirements on PBMs, including disclosures of drugs purchased through pharmacies affiliated with the PBM, thereby fostering accountability and fairer practices within the pharmaceutical supply chain.

Maine woman files class-action lawsuit against Cigna over obesity drug coverage

By Patty Wight and Kaitlyn Budion - A Maine woman has filed a class-action lawsuit against insurance company Cigna for failing to cover drugs that treat obesity. Jamie Whittemore alleges that her doctor prescribed the drug Zepbound to treat her obesity, but Cigna denied coverage, in violation of the Affordable Care Act’s anti-discrimination law. Read Full Article…

HVBA Article Summary

1. Landmark Legal Action: Jeffrey Young, representing Whittemore, asserts that the lawsuit marks a groundbreaking legal challenge, being the first of its kind in the country. The suit aims to address discrimination against individuals with obesity by insurance providers, specifically targeting Cigna's denial of coverage for obesity-related treatments.

2. Representation Across States: Three law firms from Washington state, Minnesota, and Maine have jointly filed the lawsuit, representing a nationwide class of Cigna enrollees diagnosed with obesity. This collaboration underscores the widespread impact and significance of the legal action in challenging discriminatory insurance practices.

3. Legal Basis and Implications: Young emphasizes that the lawsuit is founded on provisions within the Affordable Care Act, which prohibit health insurers from discriminating against individuals based on disability. The case not only challenges Cigna's actions but also raises broader questions about the obligations of insurers under federal law. Additionally, Whittemore has pursued a separate claim against her employer, the University of Maine System, citing violations of the Americans with Disabilities Act and the Maine Human Rights Act due to inadequate insurance coverage for obesity treatment. This dual legal strategy highlights the multifaceted approach being taken to address systemic issues surrounding healthcare coverage for obesity.

Bigger and better mental health benefits are needed – and communication is key

By Amber Howe - Today, 50 million Americans struggle with their mental health, and more than half aren't receiving treatment for their condition. One of the issues is that many employees don't know if they have mental health benefits through their employer and/or don't know how to use them—if they're available at all. Read Full Article…

HVBA Article Summary

1. Enhancing Mental Health Benefits Communication: The Amwell survey highlights a significant gap in communicating mental health benefits to employees, with nearly half unaware of their company's offerings. Employers must adopt proactive strategies, such as town halls, regular communications, and feedback mechanisms, to ensure employees are informed about available resources and how to access them effectively. This approach fosters a culture of transparency and support, meeting employees where they are in their mental health journey.

2. Expanding Digital Mental Health Support: With a growing demand for online mental health services, employers should prioritize offering one-to-one support and digital resources. Nearly half of employees express a desire for online counseling, and a majority are open to utilizing digital mental health tools if provided. By diversifying access points and catering to varying preferences, employers can increase engagement and make mental health care more accessible to a broader workforce.

3. Cultivating a Mental Health-Friendly Culture: Employers can promote employee well-being by instituting mental health days, where individuals can request time off for self-care without facing stigma or interrogation. Additionally, investing in manager training to recognize and address behavioral health concerns demonstrates a commitment to fostering a supportive environment. By empowering employees to contribute ideas and initiatives, companies can instigate a cultural shift towards prioritizing mental wellness, ultimately enhancing employee satisfaction, retention, and overall organizational health.

Humana's Medicare Advantage clawback lawsuit to move forward, judge rules

By Rylee Wilson - Humana's challenge to a CMS rule implementing stricter auditing standards on Medicare Advantage plans can continue, a federal judge ruled. Read Full Article…

HVBA Article Summary

1. Legal Standing and Ripeness: U.S. District Judge Reed O'Connor denied HHS's motion to dismiss the case filed by Humana, stating that the insurer's compliance costs constituted substantial hardship. O'Connor deemed the issues fit for review, asserting that the case was ripe for adjudication despite CMS not having implemented audits based on the new risk-adjustment rules.

2. Jurisdictional Dispute: O'Connor also rejected HHS's request to transfer the case to the Dallas division of the Northern District of Texas court. Despite Humana's Texas subsidiary being headquartered in Dallas, the case was filed in the Fort Worth district, where O'Connor presides. This decision underscores O'Connor's pivotal role in several healthcare cases and his familiarity with the legal matters at hand.

3. Impact of Rule Change: CMS's decision in January 2023 to strike the fee-for-service adjuster from risk adjustment data validation audits stirred controversy, particularly with Humana challenging the rule. The insurer argued that the change would have unpredictable consequences for Medicare Advantage plans and alleged that CMS failed to meet legal obligations in the rulemaking process. Bloomberg's report highlighting Humana's potentially significant risk of clawbacks further emphasizes the financial stakes involved, with billions in overpayments at issue and substantial scrutiny on the insurer's earnings.

What Will New Weight-Loss Drugs Mean for Endometrial Cancer?

By Crystal Phend - Obesity has been recognized as an endometrial cancer risk factor since at least the 1960s and remains the single most impactful risk factor for the disease. Read Full Article…

HVBA Article Summary

1. Obesity's Impact on Endometrial Cancer Risk: Research indicates a significant correlation between obesity and endometrial cancer risk, with every 5 kg/m2 increase in BMI associated with a 60% greater risk. Additionally, women with obesity exhibit a 2.54-fold higher relative risk compared to those with normal weight, particularly affecting younger women.

2. Hope in Weight-loss Interventions: The emergence of effective weight-loss injectables like semaglutide and tirzepatide brings hope for mitigating the rising incidence of endometrial cancer. Bariatric surgery, often recommended for obese women with endometrial cancer, complements hormonal therapy, offering a potential solution to combat the disease.

3. Understanding Endometrial Cancer's Complex Factors: Recent insights reveal a complex interplay of factors driving endometrial cancer, including hyperestrogenism, inflammation, and insulin resistance induced by obesity. Studies like the Epidemiology of Endometrial Cancer Consortium (E2C2) aim to elucidate risk factors, including hypertension and diabetes, and address disparities across race and ethnicity, offering crucial insights for improved prevention and treatment strategies.

5 steps to improve employee satisfaction with benefits

By Keith Wilson - Employee benefits are crucial to the satisfaction and productivity of any workforce. Research has consistently shown a direct link between the perceived quality of benefits employers offer and overall employee job satisfaction. Read Full Article…

HVBA Article Summary

1. Align Benefits Strategy with Organizational Goals: Start by evaluating your current benefits strategy. Ensure it aligns with your company's talent strategy and caters to the diverse needs of your workforce. Assess the engagement levels of each benefit beyond mere cost analysis. Collaborate with providers to benchmark against industry standards, allowing for targeted improvements.

2. Personalize Benefits Experience: Move away from a one-size-fits-all approach. Embrace deep personalization to empower employees in choosing benefits that suit their unique circumstances. Provide ongoing education to ensure employees understand and maximize the value of their chosen benefits, leading to higher satisfaction and engagement.

3. Collect Real-Time Feedback: Foster a deeper connection between employees and benefits by soliciting feedback in real-time or shortly after benefits usage. This approach offers a more accurate understanding of employee needs, encourages behavior change, and enhances appreciation for the benefits offered. Aim for targeted and personalized feedback mechanisms to drive higher satisfaction and engagement.

4. Utilize Technology for Effective Communication: Leverage AI-powered tools to enhance benefits communication and education. Deliver personalized, jargon-free communications tailored to each employee's preferences. Virtual assistants can provide 24/7 support, answering questions and guiding employees through complex benefits information. Employ AI-driven analytics to gain insights into benefits utilization and tailor communication initiatives accordingly.

5. Adapt Benefits to Shifting Needs: Implement a dynamic benefits approach that evolves alongside your workforce's changing needs. Offer a range of benefits catering to different life stages and personal circumstances. Leverage technology to proactively identify and address these shifting needs, ensuring your benefits package remains relevant and valuable throughout employees' tenure.

Americans’ Challenges with Health Care Costs

By Lunna Lopes, Alex Montero, Marley Presiado, and Liz Hamel - For many years, KFF polling has found that the high cost of health care is a burden on U.S. families, and that health care costs factor into decisions about insurance coverage and care seeking. Read Full Article…

HVBA Article Summary

1. Widespread Affordability Challenges: Nearly half of U.S. adults find it difficult to afford health care costs, with significant proportions reporting problems paying for care in the past year. This struggle is more pronounced among younger adults, those with lower incomes, individuals in fair or poor health, and the uninsured, underscoring the broad impact of health care expenses on Americans' financial well-being.

2. Impact on Access to Care: High health care costs often force individuals to forgo necessary medical services, with one in four adults admitting to skipping or postponing care due to financial concerns. Alarmingly, even insured individuals are not insulated from these challenges, as evidenced by a substantial portion reporting unmet health care needs due to cost, highlighting the pervasive nature of affordability issues across different demographic groups.

3. Prescription Drug Affordability Crisis: Prescription drug costs pose a significant barrier to accessing essential medications for many Americans, particularly those with lower incomes. A considerable proportion of adults have had to forego filling prescriptions or resort to cost-saving measures such as switching to over-the-counter alternatives or rationing medication doses, underscoring the urgent need for solutions to address this pressing issue in the healthcare system.

Is Semaglutide the 'New Statin'? Not So Fast

By Kevin Fernando - There has been much hyperbole since the presentation of results from the SELECT cardiovascular outcomes trial (CVOT) at this year's European Congress on Obesity, which led many to herald semaglutide as the "new statin." Read Full Article…

HVBA Article Summary

1. Semaglutide's Cardiovascular Benefits: In the SELECT trial, semaglutide demonstrated a significant 20% relative risk reduction in major adverse cardiovascular events (CV death, nonfatal myocardial infarction, or nonfatal stroke) among participants with overweight or obesity and established cardiovascular disease (CVD), irrespective of baseline weight or amount of weight lost. This suggests potential direct effects on vasculature and atherosclerosis reduction beyond mere weight reduction.

2. Assessing Treatment Impact: Absolute Risk Reduction and NNT: Sensationalist coverage often focuses on relative risk reduction figures, but in SELECT, the absolute risk reduction was 1.5 percentage points, translating to a number needed to treat (NNT) of 67 over 34 months to prevent one major adverse CV event. Comparing to statin trials, the NNT for semaglutide is notably higher, indicating a less effective treatment compared to statins in secondary prevention of CVD.

3. Contrast with Statins and Economic Viability: While semaglutide offers weight loss benefits, its efficacy in preventing CVD in people with overweight/obesity is yet to be fully understood. In contrast, statins have well-established benefits in both primary and secondary prevention of CVD, with lower NNTs. Moreover, the cost-effectiveness of semaglutide for CV risk reduction remains uncertain, contrasting with the well-established cost-effectiveness of statins, particularly for high-risk individuals.