Sen. Rand Paul’s new bill would allow ‘super’ association health plans

By Allison Bell - Sen. Rand Paul has reintroduced a bill that could let any membership organization provide a self-insured, multi-state health plan. The Kentucky Republican, who is a medical doctor, brought back the Health Marketplace for All Act bill. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Expansion of ERISA Rules through Health Marketplace Pools: Senator Rand's new bill aims to classify any group forming a "health marketplace pool" as an "employer" under ERISA, enabling them to establish self-insured health plans. This would exempt these plans from state mandates and place them under the regulation of the U.S. Department of Labor's Employee Benefits Security Administration.

2. Prohibition on Discrimination and Retention of Medical Underwriting: The proposed legislation prohibits health marketplace pools from discriminating against potential members based on health status-related factors. However, it maintains health insurers' ability to use medical underwriting, allowing pricing variations based on individual health risks.

3. Debate over Cost Savings versus Market Stability: Supporters argue that association health plans, enabled by the bill, could help participants avoid costly state mandates, potentially lowering premiums. Critics contend that such arrangements might destabilize the fully insured group market by attracting healthier individuals and groups, thereby increasing costs for those remaining in traditional plans.

PBMs strike back at FTC, claim administrative process is unconstitutional

By Noah Tong - The country’s largest pharmacy benefit managers and group purchasing organizations are going on offense against the Federal Trade Commission (FTC). Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. PBM Lawsuit Challenges FTC Authority: Express Scripts, Caremark, and Optum Rx, major pharmacy benefit managers (PBMs), have filed a lawsuit arguing that the Federal Trade Commission's (FTC) recent actions and administrative processes violate the U.S. Constitution by attempting to reshape their industry through "regulatory fiat." The PBMs claim the FTC is exceeding its authority and interfering in private contracts and transactions, with the suit brought before an administrative law judge who they assert is "insulated from democratic authority."

2. FTC Accuses PBMs of Inflating Insulin Costs: The lawsuit is a response to a September FTC complaint alleging PBMs and group purchasing organizations, vertically integrated with insurers, acted as drug middlemen inflating insulin costs while claiming to save consumers money by lowering net drug costs. The PBMs counter that the FTC’s perspective on their pricing and contracting strategies is subjective and would force them to overhaul longstanding agreements.

3. Debate on Federal Power and Regulatory Overreach: The lawsuit underscores broader tensions over federal agency power, particularly in light of recent Supreme Court decisions curbing regulatory authority. PBMs argue that the FTC’s actions reflect an overreach of executive power, a sentiment echoed by officials seeking to recalibrate the balance between the executive branch, Congress, and regulatory agencies. The case also highlights the potential political implications for the FTC, with its leadership and policies likely to face shifts under future administrations.

1 in 4 Americans Now Struggling to Cover Medical Costs

By Carole Tanzer Miller - U.S. health care costs are among the world's highest, and 1 in 4 adults with health coverage struggle with high out-of-pocket costs, a new survey shows. The survey -- by the Commonwealth Fund, a health-care focused think tank -- finds that most people have coverage offered by employers, but their policies don't always provide timely or affordable access to care. Read Full Article… 

HVBA Article Summary

1. Financial Barriers and Health Impact: High medical costs prevent millions of Americans from accessing essential care, with 57% of respondents in a recent survey forgoing needed care due to financial constraints. This leads to worsening health conditions, particularly for individuals with chronic illnesses, and increases overall healthcare costs due to preventable hospitalizations.

2. Challenges Despite Insurance Coverage: The survey revealed that even insured individuals face significant financial challenges, with 23% enrolled in plans with high out-of-pocket costs and 44% carrying medical debt. Many underinsured Americans struggle to afford care, and 40% of those delaying or skipping care report a decline in their health.

3. Policy Recommendations for Affordable Care: To address these issues, experts advocate for policy changes such as extending tax credits for healthcare marketplace coverage, reducing out-of-pocket expenses, enforcing stricter hospital billing practices, and expanding Medicaid eligibility. These measures aim to make healthcare more accessible and financially sustainable for all Americans.

'A fox in the henhouse': Owens & Minor sues Anthem in latest data transparency lawsuit

By Jakob Emerson - Healthcare logistics company Owens & Minor has filed a lawsuit against Anthem Blue Cross and Blue Shield of Virginia, accusing the insurer of failing to uphold its fiduciary duties under ERISA through mismanagement of its employee health plan. Read Full Article… 

HVBA Article Summary

1. Employer-Administrator Conflicts Over Transparency: The lawsuit filed by Owens & Minor against Anthem underscores a growing trend of legal disputes between employers and health plan administrators over access to plan data and cost management. Employers are increasingly leveraging transparency requirements, such as those introduced by the Consolidated Appropriations Act of 2021, to ensure fiduciary compliance and protect plan assets from alleged mismanagement.

2. Allegations of Financial Mismanagement: Owens & Minor accuses Anthem of failing to control healthcare costs, mismanaging plan assets, and increasing administrative expenses for self-enrichment. The company claims these actions resulted in tens of millions of dollars in losses, with potential damages escalating as additional data becomes available. Similar cases, such as Kraft Heinz's lawsuit against Aetna, highlight the broader issue of fiduciary duties being tested in court.

3. Wider Legal and Industry Implications: This case is part of a broader wave of litigation targeting health plan practices, including lawsuits against PBMs for inflated drug prices and allegations of hidden fees. With increased scrutiny on benefit management practices and prominent voices like Mark Cuban predicting class-action lawsuits, the healthcare industry faces mounting legal and regulatory challenges to ensure compliance and cost-effectiveness for beneficiaries.

Hospital price transparency dips: report

By Maya Goldman - The percentage of hospitals fully complying with federal price transparency rules fell since February, making it harder for patients and consumers to obtain meaningful data on how much common services cost, Patient Rights Advocate said in a new review shared first with Axios. Read Full Article…

HVBA Article Summary

1. Why It Matters: Lax enforcement by the Centers for Medicare and Medicaid Services (CMS) may be enabling hospitals to backslide on price transparency requirements, according to Patient Rights Advocate (PRA). This has significant implications for consumers' ability to make informed healthcare decisions and shop for services based on cost.

2. Key Findings: Only 21% of the 2,000 hospitals reviewed were in full compliance with federal price transparency requirements. Nearly 450 hospitals previously deemed compliant have since become noncompliant, highlighting a troubling trend. While all reviewed hospitals posted machine-readable files, 532 failed CMS' validation tool, and others omitted critical details like payer names or accurate charge ranges.

3. Enforcement and Trends: Since 2021, CMS has issued over 1,596 warning notices and 918 corrective action requests but fined only 15 hospitals, raising questions about enforcement effectiveness. Compliance levels vary widely by health system, with Prime Healthcare leading (90% compliance) and major systems like Ascension and Kaiser Permanente showing no compliance among reviewed hospitals. With a new administration set to enforce the rules, advocates are calling for stronger penalties and revisions to ensure true price transparency for consumers.

Rising prices, pharmacy closures raise concerns about access to medication

By Alan Goforth - Americans are concerned about continued convenient access to affordable medications as prices increase and more drugstore and retail clinic closures are announced. At the same time, many are more open to new technologies to support their medication needs. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Access and Convenience Challenges: As chain and community-based pharmacies close, nearly 6 in 10 Americans express concerns about obtaining medications close to home. While alternatives like online pharmacies and pharmacy benefit managers exist, only 16% of consumers prefer these options, highlighting the ongoing need for accessible, brick-and-mortar pharmacy services. Additionally, one-third of respondents reported that medication shortages have affected their ability to access prescriptions.

2. Rising Costs and Adaptive Strategies: Although over half of consumers (52%) have experienced increased prescription costs in recent years, this marks a slight improvement from 2023 levels. To manage these expenses, 44% of respondents utilize prescription coupon services like GoodRx, reflecting a growing trend of consumers actively seeking cost-saving solutions.

3. Technology and Medication Management: Americans are increasingly open to using technology to simplify medication management. Three out of four respondents favor digital solutions like QR codes for medication information, while mobile alerts, smart pill organizers, and adherence apps are gaining traction. However, receptivity to advanced innovations like AI chatbots and drone-delivered medications remains relatively low, with less than half of consumers showing interest.

Most American adults qualify for semaglutide. Will employers cover the cost?

By Advisory Board - Recent research has found that a majority of American adults qualify for the weight-loss drug semaglutide. And with obesity rates in the United States continuing to rise, drugmakers are lobbying employers to cover the expensive drug, arguing it will save them money in the long run. Read Full Article… 

HVBA Article Summary

1. Widespread Eligibility for Semaglutide: A recent JAMA Cardiology study revealed that an estimated 136.8 million U.S. adults qualify for semaglutide treatments for various conditions, surpassing the number of adults eligible for statins. This includes 97.5 million for weight management, 7.6 million for diabetes, and 8.9 million for secondary cardiovascular disease prevention.

2. Barriers to Access: Despite the high eligibility, the costly price of semaglutide—often exceeding $1,000 monthly—along with limited insurance coverage, especially for weight management indications, has hindered widespread adoption. Manufacturers are lobbying employers to provide coverage by highlighting the long-term cost-saving potential of obesity treatment.

3. Economic and Health Impacts: Manufacturers like Eli Lilly and Novo Nordisk are emphasizing the chronic nature of obesity and its financial burden on healthcare and workplace productivity. They argue that covering semaglutide could reduce overall healthcare costs related to obesity and its complications, presenting a compelling case for broader employer and insurer coverage.