Donald Trump returns to the presidency with big ambitions to shake up health care

By Sarah Owermohle - Republican Donald Trump has won the presidency, marking a new era for federal health agencies and the industries they oversee. The president-elect campaigned on promises to shake up public health institutions, reshape federal health programs, and slash high costs across the system. Trump has said he’s ready for campaign lieutenants like Robert F. Kennedy Jr. to “go wild” on health, medicine, and food policy.  Read Full Article…

HVBA Article Summary

1. Public Health and Chronic Illness Reform: Trump has pledged to focus on public health reforms, including the formation of a commission to investigate rising chronic illnesses. This could involve examining vaccine risks, restructuring agencies like the CDC, and addressing food and nutrition policies. His stance on vaccine schedules may align with Robert F. Kennedy Jr.'s views, signaling potential changes to vaccine recommendations and pharmaceutical liability protections.

2. Reproductive and Gender-Affirming Care Policies: Trump has taken a stance against a national abortion ban but may pursue policies affecting reproductive rights, including limiting insurance coverage for certain procedures and restricting the mail distribution of abortion medication. Additionally, he aims to halt federal funding for gender-affirming care and promote religious exemptions for health coverage, which may impact access to birth control and related services.

3. Health Insurance and Medicare Reforms: Trump’s plans for health insurance include potentially allowing different risk pools in the ACA, encouraging more short-term insurance options, and strengthening Medicare through private Medicare Advantage plans. He has also proposed tax credits for long-term caregivers and transparency in drug pricing, signaling an effort to control healthcare costs without repealing the ACA.

What the election results mean for employer health plans

By Allison Bell - Donald Trump has won his race for a second term as president, Republicans will have control over the U.S. Senate and, at press time, Republicans appeared to have a chance to retain control over the House. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Impact on ACA and ICHRA Programs: Changes to the ACA, such as a reduction in premium subsidies or restrictions on ACA exchange plans, could influence employer-sponsored Individual Coverage Health Reimbursement Arrangement (ICHRA) programs. If the ACA exchange system is scaled back, employers may find it challenging to offer ICHRAs that rely on stable exchange plan options, affecting benefits brokers and consultants who advise on these arrangements.

2. Alternative Group Medical Insurance Options: Shifts in policy affecting group health insurance alternatives—like short-term health insurance or association health plans—could reshape the options available to employers and plan advisors. If restrictions on low-deductible stop-loss insurance are relaxed, smaller employers might opt for self-insured plans, altering the landscape for benefits brokers and consultants focused on fully insured plans.

3. Pharmaceutical Spending and PBM Regulations: Legislative changes around drug pricing and pharmacy benefit managers (PBMs) may affect employers' prescription drug plans. Efforts to cap out-of-pocket costs or limit PBM practices could help employers negotiate better terms with PBMs, presenting new opportunities and challenges for benefits advisors aiming to manage healthcare costs in employer-sponsored plans.

Walgreens agrees to pay $100 mln to resolve lawsuit over generic drug pricing

By Brendan Pierson - Walgreens (WBA.O), has agreed to pay $100 million to settle a proposed class action lawsuit accusing it of fraudulently overcharging customers for a decade when they bought generic drugs through private insurance, Medicare or Medicaid. Read Full Article…

HVBA Article Summary

1. Allegations Against Walgreens: Walgreens was accused of charging insured customers more than members of its Prescription Savings Club, which offered significant discounts on over 500 generic drugs for low monthly fees without using insurance. Plaintiffs argued that the prices Walgreens charged to savings club members should be considered its "usual and customary" prices and alleged that Walgreens inflated the prices it reported to insurers.

2. Settlement Proposal and Walgreens’ Statement: Lawyers for the plaintiffs sought approval for a settlement in federal court, describing it as an "excellent result" for the class. Walgreens, while admitting no liability, stated that resolving the lawsuit would allow it to focus on its turnaround strategy and benefit its stakeholders.

3. Conditions and Case Background: As part of the settlement, Walgreens discontinued its Prescription Savings Club in August. The lawsuit, initially filed in 2017, sought damages for insured customers nationwide since the club's inception in 2007.

Open enrollment surprise: Expect health insurance premiums to be ‘highest in decades’ in 2025

By Cheryl Winokur Munk - Open enrollment season is underway, but many workers haven’t yet selected their benefits for next year. When they sit down to do so, they may get an unwelcome surprise: higher costs. Read Full Article…

HVBA Article Summary

1. Budget Carefully for Rising Costs: With health insurance premiums expected to rise by an average of 7% to 8% in 2024, employees should assess their budgets and determine what they can afford. Inflation and increasing medical claims are causing companies to pass some costs to employees, meaning workers may need to allocate more for benefits than in previous years.

2. Explore High-Deductible Plans and Alternative Options: For cost-conscious employees, switching to a high-deductible health plan might lower monthly premiums, though it requires paying more upfront for medical care. Additionally, some companies are introducing alternative providers to manage costs. Workers should review all available options to find a balance between premiums and out-of-pocket expenses.

3. Review Prescription and Supplemental Coverage: With mixed employer coverage for GLP-1 weight-loss drugs, employees taking these medications should examine their pharmacy benefits. Supplemental insurance like critical illness or accident coverage can help fill gaps, especially for those on high-deductible plans, providing additional financial protection for unexpected healthcare needs.

Feds win in surprise billing lawsuit, allowing insurers to include 'ghost rates'

By Lynn Cavanaugh - The federal No Surprises Act (NSA), which regulates how health provider rates are calculated in resolving surprise medical billing disputes, was upheld by the Fifth Circuit last week – further complicating the already complex system for paying health claims. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Court Reversal on NSA Dispute Resolution: The panel reversed a prior district court ruling, supporting the federal government’s dispute resolution process under the No Surprises Act (NSA). This process, active since 2022, mandates arbitration to settle most out-of-network billing disputes. The Texas Medical Association led the challenge, arguing that the process exceeded statutory limits.

2. NSA’s Impact on Surprise Billing: The NSA, aimed at preventing surprise medical bills for patients receiving out-of-network care, particularly in emergency situations or from out-of-network providers at in-network facilities, has been effective. In 2023 alone, the Act shielded patients from over 10 million surprise bills, as reported by an Association of American Hospitals survey.

3. Contention Over "Ghost Rates" in QPA Calculation: The recent legal dispute centers on the calculation of the qualifying payment amount (QPA), a critical factor in billing arbitration. The Texas Medical Association argued that the inclusion of "ghost rates"—rates from providers not delivering the billed services—unfairly lowers the median in-network rate. However, the court ruled that incorporating these rates is "reasonable," citing difficulties in distinguishing between rates for services not yet performed and those that might be.

Semaglutide 2.4 mg Reduces All-Cause Hospital Admissions

By Miriam E. Tucker - Treatment with once-weekly semaglutide 2.4 mg (Wegovy) significantly reduced hospital admissions for all causes — not just cardiac — and overall hospitalization time in people with overweight/obesity and established cardiovascular disease (CVD). Read Full Article…

HVBA Article Summary

1. Reduced Cardiovascular Events and Hospitalizations: Novo Nordisk’s SELECT trial demonstrated that weekly semaglutide 2.4 mg significantly reduced cardiovascular events (such as heart attack and stroke) by 11% compared to a placebo. This effect extended beyond heart health, as patients on semaglutide were also less likely to be hospitalized for various other medical reasons, showing a broader health benefit.

2. Potential Cost Savings in Healthcare: The reduction in hospitalizations associated with semaglutide, including for cardiovascular, infection-related, and respiratory issues, implies potential cost savings for healthcare systems. Experts at The Obesity Society’s Obesity Week conference emphasized that fewer hospital admissions could help offset the high cost of the drug, especially for health plans and employers.

3. Balanced Perspectives and Caution in Interpretation: While the trial’s outcomes suggest significant benefits of semaglutide in reducing hospitalizations, some experts urge caution due to Novo Nordisk’s involvement in the study funding. Despite potential biases, the observed consistency in hospital stay duration across both semaglutide and placebo groups suggests the findings are noteworthy, warranting further research.

ChatGPT may help physicians answer questions from parents

By Sara Kellner - ChatGPT and other large language models could help physicians field questions from patients and their caregivers, although researchers remain concerned about accuracy and HIPAA compliance, according to findings published in Pediatrics. Read Full Article… 

HVBA Article Summary

1. Potential of Large Language Models for Simplified Communication: Large language models (LLMs) like ChatGPT could offer valuable support to parents in the pediatric ICU by providing information in a simple, jargon-free way. This technology can help reduce the overwhelming stress of complex medical terminology, potentially making it easier for families to understand their child’s condition and care plan.

2. Study Findings on Accuracy and Completeness: In a study by Dr. R. Brandon Hunter and colleagues, ChatGPT-4 responded to hypothetical patient questions with a focus on patient-specific details. Six PICU physicians rated the responses for accuracy, empathy, and clarity, with most answers scoring highly on accuracy and completeness. However, some responses contained minor inaccuracies, underscoring the importance of careful evaluation in clinical settings.

3. Balancing Technology with Human Interaction: Dr. Hunter emphasized that while LLMs show promise in enhancing family engagement and education, they should complement rather than replace direct communication with healthcare providers. His team is conducting a pilot study using a HIPAA-compliant LLM, focusing on empowering parents to better understand their child's healthcare journey while retaining the essential role of the care team.