PBM reform advocates preach optimism as Congress delays action

By Noah Tong - Congress is living up to its dysfunctional reputation, at least when it comes to healthcare reform. It appears unlikely that major, bipartisan priority items — like site neutral payment and pharmacy benefit manager reform, as well as substance use disorder policies — will be included in the upcoming government funding bill March 8, news outlets have reported. Read Full Article…

VBA Article Summary

1. Impending Partial Government Shutdown and Health Funding Concerns: A partial government shutdown looms on March 1 unless a consensus is reached, threatening the expiration of the Department of Health and Human Services' funding by March 8. Congressional leaders are showing frustration as health-related actions, including funding for community health centers and the reversal of cuts to Medicare physician payments and Medicaid to hospitals, are being sidelined. Despite bipartisan support for such health policies, their inclusion in upcoming bills seems uncertain due to the current focus on broader budgetary concerns.

2. Debate Over Site Neutral Payment Reform and Medicare Cuts: The American Hospital Association and the Federation of American Hospitals have expressed concerns about the potential impact of site neutral Medicare cuts on hospitals, emphasizing that such cuts would jeopardize patient access to care by exacerbating the financial strain on hospitals. Meanwhile, a coalition including the National Association of Chain Drug Stores and the National Alliance of State Pharmacy Associations is advocating for reforms on Pharmacy Benefit Managers (PBMs), arguing that failure to address PBM practices would inflate prescription drug costs and limit pharmacy access, highlighting the bipartisan appetite for PBM reform.

3. Progress and Challenges in PBM Reform Legislation: Despite setbacks, there is ongoing optimism for PBM reform, with both the House and Senate advancing bills aimed at overhauling PBM practices, including the Pharmacy Benefit Manager Reform Act. These proposed reforms aim to ban spread pricing and increase drug pricing transparency. However, the complexity of the PBM industry and broader budget negotiation dynamics have delayed the inclusion of PBM reform language in the budget package, with industry experts and CEOs remaining hopeful for eventual legislative action and greater transparency within the PBM sector.

Navigating the New Terrain: Employers Grapple with Health Plan Transparency and Compliance Demands

By BNN Correspondents - In the ever-evolving landscape of employer-sponsored health benefits, a significant shift looms on the horizon, challenging plan sponsors to navigate a complex web of legal and regulatory requirements. Read Full Article…

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1. Heightened Legal and Financial Obligations for Employers: The Consolidated Appropriations Act of 2021 introduces significant changes for plan sponsors, including heightened disclosure requirements, the prohibition of gag clauses in contracts, and the necessity to comply with the Mental Health Parity and Addiction Equity Act. These requirements aim to enhance transparency and fairness but also increase the potential for legal and financial liabilities. The act necessitates a more prudent approach in disclosing fee and cost information to avoid risks like class-action lawsuits or government audits.

2. Opportunities for Enhanced Health Benefits and Employee Satisfaction: Despite the challenges, the CAA presents opportunities for employers to improve their health benefits offerings. By adhering to the act's focus on mental health parity and inclusivity in healthcare coverage, employers can foster a more satisfied and loyal workforce. This shift towards more comprehensive coverage reflects broader societal trends and offers a chance for employers to positively impact their bottom line by improving employee retention and satisfaction.

3. Strategic Planning and Proactive Management as Key to Compliance: The complexity of the CAA's provisions underscores the importance of strategic planning and vigilant oversight in health plan management. Employers must undertake a comprehensive review of their health plans, engage actively with service providers, and stay informed about regulatory changes to ensure compliance and competitiveness. Embracing the CAA's requirements as a catalyst for improvement can help employers navigate the complexities of the legal landscape, enhance their health benefits offerings, and ensure transparency and compliance in their role as fiduciaries.

Cross-Plan Offsetting in Group Health Plans—The DOL Makes its Position Clear

By Kimberly S. Couch - Under Section 404 of ERISA, plan fiduciaries must act for the exclusive benefit of plan participants and beneficiaries and use plan assets only to provide benefits and defray reasonable expenses of administering the plan. In addition, Section 406 of ERISA prohibits a plan fiduciary from engaging in self-dealing. Read Full Article…

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1. Cross-Plan Offsetting Defined and Its ERISA Violations: Cross-plan offsetting involves a third-party administrator (TPA) using overpayments made to a healthcare provider under one health plan to offset amounts owed under a different plan it administers, which violates the ERISA Sections 404 and 406. This practice contravenes ERISA's exclusive benefit rule and prohibition against self-dealing, risking balance billing issues for patients, especially with out-of-network providers.

2. Judicial Stance and Regulatory Actions: Courts have ruled against the practice of cross-plan offsetting, noting it requires explicit authorization in plan documents to be considered permissible. The Department of Labor (DOL) has actively opposed cross-plan offsetting through amicus briefs and settlement agreements, such as the case with EmblemHealth, emphasizing the practice's potential harm to plan participants and the necessity of adhering to ERISA's fiduciary duties.

3. Implications for Employers and Future Actions: Employers are advised to review their health plans for cross-plan offsetting provisions and consult ERISA legal counsel to mitigate risks and negotiate document changes. The DOL encourages employers and participants to report instances of cross-plan offsetting and seek guidance on their rights and responsibilities under ERISA, highlighting a proactive approach towards ensuring compliance and protecting plan participants from unauthorized practices.

U.S. prescription drug market in disarray as ransomware gang attacks

By Joseph Menn and Daniel Gilbert - A ransomware gang once thought to have been crippled by law enforcement has snarled prescription processing for millions of Americans over the past week, forcing some to choose between paying prices hundreds or thousands of dollars above their usual insurance-adjusted rates or going without lifesaving medicine. Read Full Article…

VBA Article Summary

1. Major Cyberattack on UnitedHealthcare's Change Health: UnitedHealthcare Group experienced a significant cyberattack targeting its Change Health business unit, a key player in routing prescription claims from pharmacies to insurers. The hackers, identified as the Russian-speaking ransomware group ALPHV, stole patient data, encrypted files, and demanded a ransom, leading to a substantial portion of the network being shut down to mitigate the breach. This incident highlights the vulnerability of critical infrastructure within the healthcare sector to cyber threats.

2. Impact on the Pharmacy Sector and Patient Care: The attack caused widespread disruption across the U.S. pharmacy network, affecting over 90 percent of the nation's pharmacies. This disruption forced pharmacies to alter their electronic claim processing methods, with some unable to process insurance claims, leading to patients potentially facing higher costs for prescriptions. Independent pharmacies, in particular, suffered significant operational challenges, including difficulties in determining patient coverage for medications, which in some cases forced customers to pay full price for prescriptions.

3. Ongoing Threats and Responses to Cybersecurity Incidents: The attack on Change Health underscores the persistent threat posed by ransomware groups like ALPHV, despite efforts by U.S. officials and international partners to disrupt these cybercriminal networks. The incident serves as a reminder of the continuous need for robust cybersecurity measures, the importance of rapid response and recovery strategies in the wake of cyberattacks, and the critical role of law enforcement in combating these threats. Additionally, it emphasizes the resilience of ransomware groups and the complexity of permanently dismantling their operations.

Hand over the data! Why employers are fed up with payers hiding costs

By Marie Defreitas - Employers are at odds with payers over their cost and claims data. Claiming that insurers consistently block access to this data, employers are saying it is increasingly difficult or even impossible to understand what they are being charged in their health plans. Read Full Article…

VBA Article Summary

1. Implementation Challenges of The Consolidated Appropriations Act: Despite the federal mandate established by The Consolidated Appropriations Act (H.R. 133) in 2021, which aimed to eliminate "gag clauses" in contracts to ensure transparency of cost and quality data in healthcare, employers are facing significant challenges in accessing this crucial data from insurers. This struggle is largely due to insurers refusing to share claims data, which has prompted federal investigations and a growing dissatisfaction among employers and plan sponsors. This resistance from insurers is leading to increased legal battles, as seen with companies like Kraft Heinz and labor unions suing insurers for not providing access to claims data and charging higher rates.

2. Financial and Operational Impact on Employers and Health Systems: The refusal of insurers to provide claims data not only hampers the ability of employers to verify the accuracy of payments to medical providers but also impedes their capacity to design cost-effective health plans. This lack of transparency and access to data results in employers facing higher fees, which studies have shown can be significantly reduced when they have the necessary data. The ongoing disputes and potential for increased litigation underscore a critical challenge in the healthcare sector, affecting both employers and health system leaders who are keen on reducing benefit costs amidst rising labor expenses.

3. Potential for Future Legal and Regulatory Changes: The current situation indicates a push from both Congress and some states to strengthen legal requirements for insurers to share cost and claims data with health plans. This movement, coupled with the growing frustration among employers over high healthcare costs and lack of data transparency, may lead to more stringent regulations and possibly more legal actions against insurers. The ongoing struggle for data access underscores the importance of claims data in healthcare decision-making, emphasizing the need for a more collaborative approach between insurers, employers, and healthcare providers to ensure the effective management and reduction of healthcare costs.

Change Healthcare cyberattack having ‘far-reaching’ effects on providers

By Emily Olsen and Susanna Vogel - A cyberattack against UnitedHealth-owned technology company Change Healthcare has shut down its systems for more than a week, hamstringing providers and disrupting pharmacy and other key operations. Read Full Article…

VBA Article Summary

1. Cyberattack on Change Healthcare by AlphV/Blackcat: Change, acquired by UnitedHealth Group's Optum in 2022, faced a significant cybersecurity issue on February 21, later identified as a ransomware attack by AlphV, also known as Blackcat. This technology company is crucial in the healthcare sector, providing services like payment and billing, prescription processing, and data analytics, handling 15 billion healthcare transactions annually and impacting one in every three patient records in the U.S.

2. Impact on Healthcare Providers and Urgent Responses: The cyberattack's effects have been extensive and significant, affecting a wide range of healthcare services from revenue management to prescription-filling processes, with no definitive timeline for service restoration. Healthcare systems have had to implement workarounds, causing delays and operational challenges. The Medical Group Management Association (MGMA) has reached out to HHS Secretary Xavier Becerra, emphasizing the urgent need for Change Healthcare's operations to be safely and swiftly restored to ensure patient care continuity.

3. Rising Cybersecurity Threats and the Response of the Healthcare Sector: This incident highlights the increasing cyber threats facing the healthcare industry, with a significant rise in data breaches and ransomware attacks over the past five years. The attack on Change underscores the vulnerability of healthcare organizations to cyberattacks and emphasizes the need for robust contingency plans and cybersecurity measures. It also reflects the interconnected nature of the healthcare ecosystem, complicating the response and recovery process from such cybersecurity incidents.

National Alliance of Healthcare Purchaser Coalitions Releases Employer Recommendations to Address Obesity Coverage

By Cary Conway - Obesity affects more than 40% of the US population with far-reaching consequences for not only individuals but employers grappling with the negative impact to workforce health. With the recent introduction of innovative new therapies to treat obesity, the standard of care is rapidly evolving. Read Full Article…

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1. Guidance Release by National Alliance: The National Alliance of Healthcare Purchaser Coalitions has released guidance from its National Obesity Advisory Council to assist employers and purchasers in making informed decisions about obesity care coverage. The guidance aims to manage the rising use of costly anti-obesity medicines by establishing reasonable guardrails based on medical evidence and current standards of care.

2. Comprehensive and Holistic Approach Recommendations: The council recommends adopting comprehensive guidelines that support high-quality, interdisciplinary care encompassing prevention, treatment, and maintenance. It emphasizes the need for plan designs that reimburse providers in line with emerging standards, individualized treatment plans with realistic goals, and the inclusion of behavior modification programs to support overall wellbeing.

3. Promotion of Education and Support for Obesity Management: The guidance suggests promoting education on the science of obesity, using person-first language to reduce bias, and ensuring the availability of affordable management options. It advises clear conditions for advanced obesity management, ensuring coaching supports diverse demographics, incentivizing physicians for comprehensive obesity care, and considering environmental and biological factors in treatment plans. Additionally, it highlights the importance of providing coverage for appropriate anti-obesity medications and considering the long-term cost benefits of preventive management.

‘They’re Freaking Out:’ Letters Warn Patients They Risk Losing Their Doctor

By Melanie Evans - Patients are getting ominous warnings in their mail and inboxes: They are about to lose insurance coverage of their doctors. Read Full Article…

VBA Article Summary

1. Increasing Tension and Uncertainty: Patients are experiencing heightened anxiety due to the escalation of contract disputes between major health insurers and hospital systems. Threatening letters and emails from both sides have left patients unsure about the future of their coverage, prompting them to flood doctors with inquiries and seek appointments to secure their healthcare.

2. Implications for Patients: The stakes for patients caught in these disputes are significant. If their insurer drops coverage for their preferred hospital or doctor, they could face substantial out-of-pocket expenses for treatment or be forced to switch providers. The potential loss of coverage has already affected some patients, while others await resolution with mounting concern.

3. Growing Complexity and Limited Protections: The evolving landscape of healthcare contracts presents challenges for patients, with limited protections under federal and state regulations. While some regulations offer temporary coverage extensions or protections against surprise medical bills, patients like A.J. Palumbo and May Chan find themselves navigating uncertain territory, unsure if their insurer will cover critical medical procedures amidst ongoing contract disputes.

RSV shots may be tied to neurological condition

By Ashleigh Hollowell - Fall of 2023 was the first time a vaccine for respiratory syncytial virus became available for those most at risk, but now data shows the shots may have caused a few cases of Guillain-Barré syndrome, The New York Times reported March 1. Read Full Article…

VBA Article Summary

1. Uncertainties in GBS Risk: Despite early data, the CDC cannot definitively establish an increased risk of Guillain-Barré Syndrome (GBS) following RSV vaccination in the mentioned age group. Dr. Thomas Shimabukuro stressed the limitations and uncertainties during a CDC briefing on February 29.

2. Adverse Event Reports: The CDC's Vaccine Adverse Event Reporting System identified 37 preliminary reports of adverse effects from RSV vaccines, with 23 verified by medical records. Pfizer's Abrysvo and GSK's Arexvy vaccines were associated with 15 and 8 reports, respectively, raising concerns about their safety profiles.

3. Risk-Benefit Analysis: While acknowledging the rarity of GBS cases caused by vaccines, health officials emphasize the importance of ongoing surveillance and monitoring. Despite higher-than-expected rates of GBS associated with Abrysvo, the benefits of RSV vaccines in preventing outpatient visits, hospitalizations, and deaths in older adults still outweigh the risks.

Average pay for 5 largest physician specialties, by state

By Mariah Taylor - Nebraska is the highest paying state for anesthesiologists, while emergency medicine physicians make the most in Kentucky, according to the most recent Bureau of Labor Statistics data. Read Full Article…

VBA Article Summary

1. Variability Across States and Specialties: The average wage for physician specialties exhibits significant variability across different states and specialties. For example, anesthesiologists' mean annual wages range from $205,800 in Wyoming to $422,040 in Nebraska, indicating a wide disparity based on geographic location. Similarly, the wages for emergency medicine, family medicine, general internal medicine, and pediatrics also vary widely across states, reflecting differences in demand, cost of living, and other regional factors.

2. Highest Paying Specialties and States: Among the five largest physician specialties by employment, anesthesiologists generally command the highest mean annual wages across several states, with Nebraska ($422,040), Washington ($419,950), and Maryland ($395,320) being among the top-paying states for this specialty. This highlights the high value placed on anesthesiology across various regions. Conversely, family medicine, despite being the largest specialty by employment with 100,940 physicians, tends to have lower mean annual wages compared to other tracked specialties.

3. Data Gaps and Variations: The dataset reveals several instances where data is not available (NA) or where wages are indicated as being above a certain threshold (≥$239,200), suggesting limitations in the data collection or reporting mechanisms. These gaps and variations underscore the complexity of accurately capturing wage data across the diverse landscape of physician employment and emphasize the need for comprehensive data collection methods to provide a clearer picture of physician compensation trends.