Senators Whitehouse, Cassidy propose bipartisan primary care payment reform, seek industry feedback

By Heather Landi - U.S. Sens. Sheldon Whitehouse and Bill Cassidy, M.D., want to reform how primary care providers get paid through Medicare, and they also want to hear from the healthcare industry about the best way to do it. Read Full Article…

HVBA Article Summary

1. Introduction of Bipartisan Legislation: Senators Whitehouse and Cassidy introduced the Pay PCPs Act, aiming to enhance support and compensation for primary care providers (PCPs). This bipartisan bill underscores a collaborative effort to address key challenges in primary care.

2. Focus on Quality and Value: The legislation proposes establishing hybrid payments through CMS to incentivize high-quality primary care. These payments would reward PCPs for delivering effective care that reduces costly healthcare utilization, such as emergency visits and hospitalizations, emphasizing a shift towards value-based care.

3. Call for Feedback and Support: Whitehouse and Cassidy issued a request for information to gather input on policy questions regarding primary care. The proposed legislation aims to address longstanding issues of underinvestment in primary care, signaling a proactive step towards improving healthcare outcomes and access for Medicare beneficiaries.

As a Nightmare Brews on Wall Street for CVS, Executives Scramble to Quell Investors

By Wendell Potter - I wrote Monday about how the additional Medicare claims CVS/Aetna paid during the first three months of this year prompted a massive selloff of the company’s shares, sending the stock price to a 15-year low. During CVS’s May 1 call with investors, CEO Karen Lynch and CFO Thomas Cowhey assured them the company had already begun taking action to avoid paying more for care in the future than Wall Street found acceptable. Read Full Article…

HVBA Article Summary

1. Prioritizing Profit Over Patients: Aetna's strategy, as articulated by CVS Chief Financial Officer Tom Cowhey, underscores a prioritization of shareholder interests over the wellbeing of patients. Measures such as tightening prior authorization policies, reassessing provider networks, and adjusting benefits highlight a trend where profit margins supersede patient care.

2. Implications for Medicare Advantage Members: With a potential 10% reduction in its Medicare Advantage "membership," Aetna's actions raise concerns about the fate of vulnerable individuals, including retirees and those with physical and mental impairments. The shift towards Medicare Advantage plans, driven by financial motives, may result in limited access to essential healthcare services for these individuals.

3. Wall Street Influence on Healthcare: Aetna's history of aggressively cutting ties with unprofitable accounts and the stock market's reaction to fluctuations in medical loss ratios demonstrate the significant influence of Wall Street on healthcare decisions. This financial pressure creates a dilemma for executives like Karen S. Lynch, torn between shareholder demands and the ethical responsibility to ensure access to quality healthcare for all members.

Pfizer offers up to $250 mln to settle Zantac cancer lawsuits, FT reports

By Reuters - Pfizer (PFE.N), opens new tab will pay up to $250 million to settle more than 10,000 U.S. lawsuits over cancer risks associated with its discontinued heartburn drug Zantac, the Financial Times reported on Thursday. Read Full Article…

HVBA Article Summary

1. Legal Settlement: Pfizer, a prominent drugmaker, faces a significant financial settlement estimated between $200 million and $250 million. This agreement, aimed at mitigating Pfizer's potential liability, was revealed in a recent court filing in Delaware.

2. Zantac History and Recall: Zantac, initially approved in 1983 and once a global top-selling medication, encountered controversy when the U.S. FDA demanded its removal from the market in 2020. This action followed the discovery of NDMA, a carcinogenic substance, in samples of the drug and its generic versions.

3. Pfizer's Response: Despite the disclosure of the settlement and its potential impact, Pfizer refrained from an immediate response to Reuters' request for comment. This silence hints at the complexity and sensitivity surrounding the legal proceedings and the company's strategic approach.

BlueCross BlueShield of Vermont says it needs double digit increases in premiums in 2025

By Dan D’Ambrosio - More double-digit increases to health insurance premiums are headed our way in 2025, according to BlueCross BlueShield of Vermont. It's the price we have to pay for cutting wait times for health care and for getting older. Read Full Article…

HVBA Article Summary

1. Substantial Rate Increases: BlueCross BlueShield of Vermont (BCBSVT) has announced significant rate increases for both individual and small group health plans, with individual plans facing a 16.3% hike and small group plans seeing a 19.1% increase. These increases are necessary to cover the rising costs of healthcare for Vermonters covered by Vermont Health Connect, with hospital expenses representing nearly two-thirds of the rate hike.

2. Factors Driving Rate Increases: BCBSVT attributes the need for higher premiums to several key factors. Firstly, growing utilization of hospital services, driven by efforts to reduce wait times and the increasing needs of an aging population, contributes significantly to rising healthcare costs. Secondly, escalating hospital and drug costs are identified as major culprits, with almost half of all premiums spent on hospital procedures and double-digit retail pharmaceutical trends exacerbating the situation. In particular, BCBSVT highlights the exponential growth in drug treatments for conditions like diabetes and weight loss as significant contributors to premium pressures.

3. Regulatory Oversight and Affordability Concerns: The final decision on the extent of rate increases lies with the Green Mountain Care Board (GMCB), which regulates the healthcare system in Vermont. While BCBSVT's rate increase requests have been partially granted in the past, the GMCB remains focused on balancing affordability and access to quality healthcare. Despite efforts to mitigate rate hikes, the GMCB acknowledges the ongoing challenge Vermonters face in affording healthcare and pledges to continue leveraging all available tools to improve affordability and access to healthcare services.

House Energy and Commerce Committee presents own 2-year telehealth extension, with more rural health wins

By Emma Beavins - The House Energy and Commerce Committee released telehealth extension legislation today that will be voted on during a health subcommittee markup Thursday. The markup will also include bills to change billing requirements for remote patient monitoring, expand the Medicare Diabetes Prevention Program to virtual-only providers and to prevent fraud in Medicare and Medicaid. Read Full Article…

HVBA Article Summary

1. Legislative Variations and Amendments: The Energy and Commerce Committee has introduced amendments to the Telehealth Modernization Act (TMA), initially proposed by Rep. Buddy Carter, R-Georgia. While these changes align with major provisions of the House Ways and Means Committee's telehealth extension bill, there are notable differences that require attention from stakeholders.

2. Key Amendments and Payment Disparities: The amended TMA seeks to address longstanding billing issues for rural providers, particularly in rural health clinics (RHCs) and federally qualified health centers (FQHCs). These providers have historically received lower reimbursement rates for telehealth services compared to fee-for-service providers. The amendment aims to rectify this by reimbursing RHC and FQHC telehealth visits at parity with in-person visits, which has garnered support from the National Association of Rural Health Clinics.

3. Debated Provisions and Future Considerations: One significant difference in the Energy and Commerce version is the requirement for billing modifiers, including one for "telehealth virtual platforms" and incident-to provider billing. The lack of clarity on the definition and intent of the telehealth virtual platform modifier has sparked debate among lobbyists. Additionally, the legislation mandates a modifier for telehealth services provided incident to a physician, necessitating further discussion and resolution by the committees involved.

When It Comes to Preventive and Proactive Wellness, Accessibility Is Key

By Erin Gadhavi - Healthcare is an ever-evolving field built on new understanding derived from emerging information provided by consumers, providers, analysts and scientists. Our understanding of “wellness” as a concept has shifted dramatically over the past decade to encompass significantly more than it once did. As a society, we previously looked at “wellness” as one-dimensional and synonymous with measurable physical health. Read Full Article…

HVBA Article Summary

1. Holistic Wellness Understanding: The contemporary view of wellness acknowledges its multifaceted nature, encompassing physical, mental, spiritual, and emotional dimensions. This holistic perspective demands healthcare providers to adopt comprehensive and integrative approaches, moving beyond mere physical health care to address interconnected aspects of well-being.

2. Proactive Healthcare Strategies: Embracing preventive care emerges as a crucial strategy in modern healthcare. Recognizing the causal links between symptoms and potential ailments underscores the importance of early intervention. Proactive care not only enhances personal well-being but also mitigates the financial burden associated with late-stage treatments, highlighting its dual benefits for individuals and healthcare systems alike.

3. Overcoming Financial Barriers: Despite the recognition of preventive care's value, financial constraints hinder its widespread adoption. A significant portion of households delay or forego medical care due to cost concerns, perpetuating a cycle of escalating health issues and expenses. Healthcare providers bear a responsibility to educate patients about available payment options, facilitating access to essential services and promoting a more inclusive approach to comprehensive wellness.

Weight-loss drug shortages have patients stressed over missing doses

By Tina Reed - Patients prescribed highly effective anti-obesity medications are growing anxious about the increasing difficulty of obtaining them amid long-running shortages driven by blockbuster demand for the drugs. Read Full Article…

HVBA Article Summary

1. Supply Chain Strain: The shortage of drugs like Novo Nordisk's Wegovy is causing significant distress among patients and doctors alike. Ethan Lazarus, a family medicine and obesity doctor, coined the term "GLP-1 discontinuation anxiety" to describe the widespread difficulty patients face in obtaining their prescribed dosage, reflecting a nationwide challenge in drug availability.

2. Patient Concerns and Disruption: Patients are experiencing heightened anxiety as they struggle to locate their prescribed medications. With soaring demand and limited supply, individuals are resorting to frantic calls to pharmacies and often facing the need to switch dosages or even drugs entirely. This disruption not only disrupts their treatment regimen but also reintroduces distressing thoughts about food, reversing the progress they've made in managing their condition.

3. Treatment Challenges and Solutions: The shortage poses challenges for both patients and healthcare providers. Discontinuation of GLP-1 agonists, even for a short period, can disrupt the treatment process, necessitating a return to lower doses and potentially impacting progress. While some patients may opt for alternative medications like Ozempic or other GLP-1 brands, these alternatives may not be covered by insurance or may come with side effects like nausea. The efforts of pharmaceutical companies like Novo Nordisk and Eli Lilly to ramp up production and develop oral alternatives signify a collective response to address this pressing issue and ensure consistent access to crucial medications for patients battling obesity and related conditions.

These 3 benefits are wanted by all generations in the workforce

By Lee Hafner - When you have an age-diverse workforce, putting together benefits and policies that satisfy all employees is a tough task. But there are a few perks that each generation feels are essential. Read Full Article…

HVBA Article Summary

1. Flexibility is Paramount: According to a recent Forbes Advisor survey, 79% of respondents rated flexible work options as the most crucial benefit a company can provide. Whether it's flexible parental leave or paid time off, building trust among employees is essential for successful implementation. Embracing flexibility allows employees to balance personal and professional obligations, ultimately fostering higher job satisfaction.

2. Prioritizing Mental Health: Across all generations, insurance coverage for mental health services emerged as the most significant aspect of mental health initiatives. However, the specific needs vary, with baby boomers valuing designated office wellness spaces, while Gen Z and millennials seek workshops, counselors, and access to specialists. Businesses can enhance employee satisfaction by actively involving them in designing mental health support programs.

3. Investing in Upskilling: Professional development opportunities are not limited to younger generations. The survey highlighted the importance of upskilling for all age groups, including access to learning management systems, cross-departmental training, and continued learning stipends. Companies that prioritize employee growth and skill enhancement contribute significantly to overall job satisfaction and morale across the workforce.

RAND Study Confirms Higher Reimbursement from Private Payers

By Pietje Kobus - According to a new RAND report, prices paid to hospitals during 2022 by employers and private insurers averaged 254 percent of what Medicare would have paid. Research organization RAND stated in a press release on May 13 that there is a wide price variation among states. RAND concluded that while some states had relative prices under 200 percent of Medicare, other states had relative prices above 300 percent of Medicare. Read Full Article…

HVBA Article Summary

1. Relative Price Disparities: The study conducted in 2022 revealed significant gaps in relative prices for healthcare services compared to Medicare rates. Inpatient hospital services averaged 255 percent, outpatient hospital services averaged 289 percent, and associated professional services averaged 188 percent of Medicare prices, underscoring substantial variations in pricing across different healthcare sectors.

2. Policy Implications: Peter S. Hussey, the director of Rand Health Care, emphasized the relevance of the report for policymakers grappling with healthcare expenditure. As hospitals represent the largest share of healthcare spending in the United States, understanding these pricing differentials can inform strategies aimed at mitigating healthcare costs and improving affordability for patients.

3. Controversy and Critique: The American Hospital Association (AHA) challenged the findings of the RAND report, questioning its methodology and scope. AHA's Molly Smith criticized RAND for its sample selection and alleged oversight of the role of commercial insurers in inflating healthcare costs. Despite this criticism, RAND reiterated the significance of hospital spending, which accounted for 42 percent of total U.S. personal healthcare spending for privately insured individuals in 2022, underscoring the importance of ongoing scrutiny and dialogue surrounding healthcare pricing practices.

Biosimilars are gaining ground. The IRA could push them even further next year.

By Amy Baxter - When biosimilars crashed into AbbVie’s Humira in 2023, the pricing impact was mostly negligible. Now, that’s beginning to change, and the Inflation Reduction Act could exacerbate how biosimilars affect branded medications, potentially slashing billions from healthcare costs. Read Full Article…

HVBA Article Summary

1. Slow Uptake of Biosimilars: Despite the potential cost-saving benefits, biosimilars have struggled to gain traction in the market, with low sales and minimal market share, particularly evident in Medicare. Physicians and patients have been hesitant to switch from brand-name biologics to biosimilars, citing concerns about safety and effectiveness.

2. Barriers in Reimbursement Design: Reimbursement structures, especially within Medicare, historically favored biologics over biosimilars, hindering the latter's competitiveness. However, recent legislative changes, such as increased reimbursement rates for biosimilars, are expected to foster greater competition and uptake of biosimilars in the market.

3. Impact of Legislative Changes: The Medicare Part D benefit design has significantly influenced coverage decisions, often favoring more expensive biologic drugs over cheaper biosimilar alternatives. Legislative changes, like those introduced in the Bipartisan Budget Act of 2018 and the anticipated effects of the IRA starting in 2025, are projected to drive increased coverage and utilization of biosimilars, potentially reshaping the landscape of biologic drug utilization in Medicare.