The J&J lawsuit should be a wakeup call to the PBM industry — and to companies everywhere

By Jake Frenz - The ongoing legal dispute involving Johnson & Johnson has again thrust the topic of pharmacy benefit managers (PBMs) into the spotlight. Ann Lewandowski, a J&J employee, sued the company for overpaying for its employees’ prescription drugs through its PBM, Express Scripts, claiming that these overpayments resulted in higher health insurance premiums and out-of-pocket drug costs for employees. Read Full Article…

HVBA Article Summary

1. Exposing the Opaque Practices of Big 3 PBMs: The lawsuit against Johnson & Johnson sheds light on the traditional PBM industry's opaque pricing structures and outdated evaluation models. With government probes and congressional attention already underway, this legal action marks a significant step in bringing the conversation about PBM practices into the mainstream, highlighting concerns over hidden fees, markups, and monopolistic control.

2. Challenges with Traditional PBM Evaluation: The lawsuit underscores the pitfalls of traditional PBM evaluation methods, particularly the emphasis on discount-based approaches over cost-based ones. By prioritizing discounts and rebates without considering the actual net costs to the employer and employees, companies like J&J may inadvertently increase drug costs and insurance premiums for their workforce. This highlights the need for a more comprehensive and transparent evaluation process.

3. Call for Reform and Transparency: The J&J lawsuit serves as a wake-up call for employers and policymakers, urging them to rethink PBM evaluation and selection criteria. With the current system favoring the interests of Big 3 PBMs and lacking transparency, there's an urgent need for reforms that prioritize the lowest net drug spend for both employers and employees. This moment presents an opportunity to push for a more transparent and equitable approach to pharmacy benefits management, ultimately ensuring access to affordable medications for all.

Medical Debt May Be Removed From Credit Reports

By Solcyre Burga - Medical bills may soon be banned from credit reports under a new rule proposed Tuesday by the Consumer Financial Protection Bureau (CFPB). Read Full Article…

HVBA Article Summary

1. Closing Loopholes in Credit Reporting: The proposed change aims to address a long-standing issue by closing loopholes in federal legislation that allowed lenders to use medical information for credit decisions. By barring credit reporting companies from disclosing medical debts to lenders, the change seeks to prevent the exploitation of medical debt in lending practices.

2. Alleviating the Burden of Medical Debt: With medical debt reaching staggering levels, disproportionately affecting Black and Hispanic populations, the proposed rule seeks to alleviate the strain on Americans burdened by healthcare costs. By removing medical debt from credit reports and minimizing its impact on credit scores, the Biden Administration aims to provide relief to consumers facing financial hardships due to healthcare expenses.

3. Protecting Consumer Rights: In addition to addressing the financial impact of medical debt, the proposed rule also aims to protect consumer rights by prohibiting companies from repossessing medical devices, such as wheelchairs or prosthetic limbs, if individuals are unable to repay a loan. Through public comment and the rulemaking process, the Consumer Financial Protection Bureau (CFPB) is working to finalize a rule that could potentially raise credit scores for Americans with medical debt, offering them greater financial stability and opportunities.

Insurer strategies to control costs associated with weight loss drugs

By Justin Lo and Cynthia Cox - A class of drugs called GLP-1 agonists, which includes Ozempic (semaglutide), has been used to treat type 2 diabetes for over a decade. Due to their potential to trigger weight loss, focus on these drugs has shifted in application to obesity, with new drug products using these same ingredients gaining FDA approval for such treatment. Read Full Article…

HVBA Article Summary

1. Obesity Prevalence and GLP-1 Agonist Demand: With obesity affecting 42% of adults aged 20 and over nationwide, the demand for GLP-1 agonists is poised to rise, especially as these drugs are increasingly approved for conditions like preventing heart attacks or strokes. This surge in demand, coupled with the high cost of GLP-1 agonists, is expected to have a significant impact on healthcare costs for both patients and payers.

2. Utilization Management Strategies in ACA Marketplace Plans: Analysis of ACA Marketplace formularies reveals varying coverage for GLP-1 agonists. While drugs solely approved for obesity treatment often have minimal to no coverage, those approved for diabetes treatment, like Ozempic, are more commonly covered. However, even among plans including these drugs, utilization management tools like prior authorization and quantity limits are frequently employed, although step therapy is less commonly used.

3. Challenges in Access and Affordability: Despite insurance coverage, many patients face challenges in affording GLP-1 agonists, with over half experiencing difficulty paying for them. Utilization management tools, while intended to balance cost control and access, may still pose barriers for individuals with medical necessity. This has led some to seek these drugs from alternative sources, raising concerns about safety and efficacy, as products from online vendors or compounding pharmacies may not be FDA-evaluated and may contain different ingredients.

Supreme Court will hear case claiming US underpays hospitals serving needy patients

By Brendan Pierson - The U.S. Supreme Court has agreed to hear a lawsuit by more than 200 hospitals that serve low-income populations accusing the federal government of shortchanging them on Medicare funding by about $1.5 billion per year. Read Full Article…

HVBA Article Summary

1. Legal Challenge on Funding Calculation: The hospitals, spanning across 32 states, are appealing to the Supreme Court to overturn a decision by the U.S. Court of Appeals, which upheld the current method used by the U.S. Department of Health and Human Services (HHS) to determine funding. This challenge revolves around the calculation of disproportionate share hospital (DSH) funding, a crucial aspect of Medicare reimbursement for hospitals serving low-income populations.

2. Impact on Rural Healthcare: The hospitals argue that the current underfunding, stemming from HHS's method of calculation, has contributed to the closure of rural hospitals. They emphasize that disadvantaged patients bear the brunt, facing longer travel distances and increased waiting times for care, potentially compromising access to essential medical services.

3. Dispute over Eligibility Criteria: A key point of contention lies in how HHS calculates DSH funding based on patients' eligibility for supplemental security income (SSI). The hospitals assert that HHS's practice of only counting patients who receive SSI benefits during hospital stays, rather than all SSI-eligible patients, violates federal law and jeopardizes the financial stability of safety net hospitals. HHS counters, arguing that Medicare eligibility, unlike SSI benefits, is consistent and permanent for senior citizens, reflecting their ongoing financial need.

Mental Health and Aging: The Role of Primary Care in Overcoming Barriers to Treatment

By Renee Buckingham - Over the last several years, especially since the onset of the pandemic, there has been a great deal of focus on the high levels of depression and anxiety experienced by young Americans who have been open and vocal about their mental health challenges. Read Full Article…

HVBA Article Summary

1. The Interplay of Physical and Mental Health: The prevalence of chronic illnesses among older adults significantly impacts their mental well-being. Conditions like diabetes, Parkinson's disease, heart disease, and cancer are not only physically taxing but also increase the risk of depression and other mental health issues. Neglecting mental health in seniors with chronic conditions can lead to poor adherence to treatment, exacerbating physical ailments and reducing overall quality of life.

2. Combatting Loneliness through Social Connection: Social isolation and loneliness pose grave threats to the mental and physical health of older adults, with nearly four in ten seniors affected. The detrimental effects range from heightened rates of depression, anxiety, and suicide to increased risks of heart disease, stroke, and dementia. Addressing social disconnection among seniors is crucial for mitigating these risks, requiring interventions that foster meaningful social connections and combat isolation.

3. Economic Strain and Mental Health: Economic stressors compound the mental health challenges faced by millions of older Americans. With a significant portion living in poverty and struggling to meet basic needs like housing and food, anxiety and depression rates are exacerbated. Limited access to transportation further isolates seniors, hindering their ability to seek support. Bridging the gap between economic strain and mental health care through integrated primary care models is essential for delivering comprehensive support to vulnerable older adults.

Cyber risk rises as a commercial health threat

By Allison Bell - S&P Global Ratings sees commercial group health insurance as a relatively calm segment of the U.S. insurance market, with specialty drug costs being the top focus of conversation and cyberattacks rising as an emerging threat. Read Full Article…

HVBA Article Summary

1. Stability in Commercial Group Health Insurance: Health insurance analysts in New York assert a stable outlook on the U.S. health insurance market, particularly emphasizing the consistent nature of commercial group health insurance. Unlike Medicare and Medicaid plans facing government funding pressures and eligibility rule changes, the commercial group sector remains steady.

2. Challenges in Drug Coverage and Behavioral Health Services: Discussions among insurers highlight the significant costs associated with covering new GLP-1 drugs for obesity treatment within the commercial group sector. Additionally, there's a growing emphasis on the increased utilization of behavioral health services, reflecting evolving healthcare needs and priorities.

3. Emerging Concerns on Cybersecurity: While S&P's 2024 health insurance market report did not initially identify cyberattacks as a top risk, recent events, such as the hacking incident at UnitedHealth's subsidiary, have underscored the pressing importance of cybersecurity. Analysts are now integrating cyber risk assessment into their evaluation frameworks, recognizing its potential impact on company governance and overall market stability.

Employees and ASD: One benefit manager's story

By Kristen Donahoe - Right before my youngest son's fourth birthday, I was called in to the office at his daycare. My son, Ben, had been screaming in class, and the manager told me that I had to find a new place for my son because "we can't handle kids like him." I was completely blindsided. I didn't know it at the time, but I was raising a child with Autism Spectrum Disorder (ASD). Read Full Article…

HVBA Article Summary

1. Awareness and Education: Understanding autism spectrum disorder (ASD) is crucial as it continues to evolve in medical understanding. HR leaders and brokers have a unique opportunity to educate both clients and employees about ASD, its prevalence, and the latest developments in research and treatment options. Resources such as Autism Speaks and the Autism Society can aid in disseminating information through wellness fairs, employee communications, and corporate intranets.

2. Health Benefits and Support: Employers must recognize the diverse needs of individuals with ASD and their families. Comprehensive health benefits should cover essential treatments like Applied Behavior Analysis (ABA) therapy, which is widely acknowledged as a gold standard treatment for autism. Moreover, offering flexible work arrangements, such as telecommuting and part-time options, can alleviate the stress faced by parents who often need to balance work commitments with medical appointments and therapy sessions. Employee Assistance Programs (EAPs) can provide crucial emotional support and resources, reducing the sense of isolation and uncertainty experienced by families navigating the challenges of ASD.

3. Creating a Supportive Workplace Culture: Establishing a supportive workplace culture is essential for families with children on the autism spectrum. By advocating for inclusive policies and benefits that accommodate the unique needs of employees with ASD dependents, HR leaders and brokers can foster a more empathetic and understanding environment. Investing in resources and benefits that prioritize the well-being of families affected by ASD not only supports employee retention and productivity but also contributes to a more compassionate society overall.

Novel Glucagon/GLP-1 Receptor Dual Agonist Improved MASH in Phase II Study

By Katherine Kahn - Survodutide, a novel glucagon/GLP-1 receptor dual agonist, improved metabolic dysfunction-associated steatohepatitis (MASH) with no worsening of fibrosis, according to results of a phase II trial. Read Full Article…

HVBA Article Summary

1. Efficacy of Survodutide in Improving NAFLD: Among patients with biopsy-confirmed MASH and fibrosis stages F1 to F3, significant improvement in MASH occurred with no worsening of fibrosis in those treated with survodutide. Notably, 47%, 62%, and 43% of patients in the 2.4-mg, 4.8-mg, and 6-mg groups respectively showed improvement compared to only 14% in the placebo group.

2. Fibrosis Regression: The subgroup analysis of patients with paired liver biopsies revealed remarkable results. A substantial proportion (83%) of participants in the 4.8-mg survodutide group exhibited improvement in MASH with no worsening of fibrosis, a stark contrast to the 18.2% in the placebo group. Furthermore, approximately 34% to 36% of patients treated with survodutide experienced improvement in fibrosis by at least one stage compared to 22% in the placebo group.

3. Additional Benefits and Safety Profile: Beyond liver health, survodutide demonstrated positive effects on MRI-measured liver fat content and serum transaminase levels. Moreover, improvements in weight, blood pressure, hemoglobin A1C, and low-density lipoprotein cholesterol were observed. However, the treatment's side effect profile, including nausea, diarrhea, vomiting, and increased heart rate, warrants consideration, with 20% of patients discontinuing treatment due to adverse events.

California could curb private equity health deals

By Allison Bell - Lawmakers in California are hoping that keeping private firms out of their health care market will help down the cost of health care there and maintain the quality. Read Full Article…

HVBA Article Summary

1. Overview of California Assembly Bill 3129:

   • AB 3129, sponsored by California Attorney General Rob Bonta, aims to grant the state attorney general the authority to review acquisitions of healthcare facilities and provider groups by private equity firms and hedge funds.

   • The bill proposes empowering the attorney general to intervene in deals involving nonphysician providers with annual revenues exceeding $4 million, or other healthcare providers generating revenues ranging from $4 million to $10 million.

   • It delineates exceptions for certain transactions involving investor groups and nonphysicians, while establishing regulations permitting partnerships, nonprofit organizations, and health maintenance organizations (HMOs) to engage in medical practice, with restrictions against for-profit entities practicing medicine in California.

2. Recent Legislative Progress and Current Status:

   • Assemblymember Jim Wood introduced AB 3129 in February, with Assemblymember Mia Bonta presiding over an April hearing as the Chair of the Assembly Health Committee.

   • The bill passed the Assembly with a 50-16 vote on May 21, and it now awaits deliberation in the Senate Health Committee and the Senate Judiciary Committee.

   • The Senate Health Committee has scheduled a hearing for June 26, marking the next phase of the legislative process.

3. Stakeholder Perspectives and Controversies:

   • Opposition to AB 3129 includes the California Chamber of Commerce and the California Hospital Association, advocating for increased investor participation to address the state's healthcare capacity shortage.

   • Conversely, support for the bill comes from groups like the Purchasers Business Group on Health and the Small Business Majority, citing studies linking private equity acquisitions to adverse effects on healthcare costs, quality, and access.

   • Notably, concerns over rising prices and healthcare-associated conditions under private equity ownership underscore the contentious debate surrounding the bill's objectives and potential impacts on California's healthcare landscape.

Intestinal Flora Could Affect Decision-Making

By Anne-Gaëlle Moulun - Increasing evidence suggests that the gut microbiome influences socio-affective behavior, particularly in animals. However, such studies are more challenging to conduct in humans. Read Full Article…

HVBA Article Summary

1. Microbiome Intervention: Researchers administered a mixture of prebiotics and probiotics to 101 healthy men, aiming to modulate their gut microbiome composition. This intervention, consisting of Lactobacillus and Bifidobacterium, facilitated easier colonization of beneficial bacteria over a 7-week period, without altering participants' usual diets.

2. Behavioral Impact: Through the "ultimatum game," researchers assessed participants' sensitivity to injustice before and after the microbiome intervention. Results revealed that individuals who received the supplements were more inclined to reject unequal offers, showcasing heightened sensitivity to fairness. Notably, this effect was absent in the placebo group, indicating a direct correlation between microbiome modulation and social behavior.

3. Biological Mechanisms: The study observed biological changes accompanying the behavioral shifts. Participants with initial imbalances in gut flora, specifically between Firmicutes and Bacteroidetes, displayed greater microbiome alterations post-supplementation. Moreover, blood tests indicated a reduction in tyrosine levels, a dopamine precursor, potentially implicating the gut-brain axis in modulating social decision-making processes. These findings suggest a mechanistic link between microbiome composition, neurotransmitter regulation, and social behavior, warranting further investigation.