A 50-Year-Old Federal Law Makes It Nearly Impossible to Hold Big Insurance Accountable. I Testified at The Department of Labor About It.

By Wendell Potter - Fifty years ago this month, the Employee Retirement Income Security Act (ERISA) was signed into law with the promise of safeguarding employee benefits. What started as a well-intentioned attempt to protect workers’ health and retirement benefits has since become a shield for the health insurance industry’s most harmful practices. Read Full Article… 

HVBA Article Summary

1. Insurers Exploit ERISA Loopholes: The Employee Retirement Income Security Act (ERISA) was originally designed to facilitate health benefit offerings for employers. However, it has become a means for insurance companies and third-party administrators (TPAs) to profit immensely while avoiding accountability for denied care, ultimately harming patients who are left with limited recourse.

2. Barriers to Patient Care: ERISA preempts state laws that protect consumers, leaving patients with restricted options when their health plans deny coverage for necessary treatments. Appeals processes are often ineffective, with many patients feeling discouraged from even trying, despite evidence that a significant percentage of initial denials are unjustified.

3. Call for Reform: The consolidation of insurers has led to record profits at the expense of workers, necessitating reforms to ERISA. Proposed changes include mandating transparency in appeal processes, requiring accessible denial data, and enforcing penalties for non-compliance, aiming to shift the focus from corporate profits back to employee welfare and protection.

The FTC Is Suing PBMs Over Insulin Prices. Will It Be Successful?

By Marissa Plescia - Shortly after releasing a scathing interim report in July that revealed how three players dominate the pharmacy benefit manager market and raise drug costs for patients, the Federal Trade Commission is turning its words into action. Read Full Article… 

HVBA Article Summary

1. Allegations of Anticompetitive Practices: The FTC has filed a lawsuit against the three largest PBMs—CVS Caremark, Express Scripts, and Optum Rx—claiming they engage in anticompetitive practices by using restrictive drug formularies and demanding high rebates from manufacturers. This behavior is alleged to artificially inflate insulin prices and restrict patient access, despite existing caps on out-of-pocket expenses for Medicare patients.

2. Impact on Insulin Prices: The lawsuit highlights that the average price of insulin has skyrocketed from approximately $21 in 1999 to over $274 in 2017, largely attributed to the practices of these PBMs. The FTC argues that the PBMs' influence over which drugs are covered and their demand for larger rebates have contributed significantly to these inflated prices, impacting millions of Americans who rely on insulin for diabetes management.

3. Potential Outcomes and Industry Response: If the FTC is successful, the lawsuit could lead to significant changes in PBM practices, such as prohibiting the exclusion of lower-cost drugs from formularies and banning compensation based on list prices. The PBMs have defended their practices, asserting that they help lower costs for consumers, while critics argue that their actions have led to increased prices and limited access to necessary medications.

California's new pet insurance law adds some tough coverage requirements

By Allison Bell - California now has a new pet health insurance law that could serve as a laboratory showing what happens when the government adds coverage requirements to what has been a largely unrelated market. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Enhanced Transparency in Premiums and Exclusions: The new pet insurance bill mandates insurers to disclose how a pet's age and location affect premiums, as well as provide detailed information about preexisting condition exclusions.

2. Immediate Coverage Activation: The legislation requires that once an insurer accepts a pet insurance application and payment, the coverage must become effective by the second day, addressing concerns that longer wait periods deter pet owners from purchasing insurance for sick pets.

3. Industry Perspectives and Regulatory Classification: While supported by the North American Pet Health Insurance Association, the bill faced opposition from Trupanion, highlighting concerns about the coverage activation clause. Additionally, the bill underscores the distinction of pet health insurance as property and casualty coverage, despite its growing relevance to human health care trends.

WTW: Employers seeking to avoid cost-shifting even as expenses continue to rise

By Paige Minemyer - As employers face rising costs, many are looking to rethink plan designs rather than emphasize shifting expenses to workers, according to a new WTW report. Read Full Article… 

HVBA Article Summary

1. Cost Increase Expectations: Employers anticipate a significant rise in healthcare costs, predicting a 7.7% increase in 2025, up from 6.9% in 2024 and 6.5% in 2023. This trend raises concerns about the financial burden on workers and decisions related to insurance and care.

2. Strategies to Mitigate Costs: Rather than shifting costs to employees through premium hikes (only 34% intend to do so), many employers (52%) plan to implement programs aimed at reducing overall costs. Additionally, 51% will design plans and networks that encourage employees to choose lower-cost, higher-quality healthcare providers.

3. Focus Areas for Cost Management: Employers are prioritizing several health issues for cost management, including obesity and diabetes (40%), cancer and oncology (34%), cardiovascular health (28%), and women’s health (27%). Additionally, many are exploring innovative options like direct-to-consumer prescription delivery and assessing mental health offerings.

New prescription drug price hikes hit Black patients hard

By Claretta Bellamy - Prices for prescription pharmaceutical drugs have skyrocketed, disproportionately making them harder for people of color to afford, a new report finds. Read Full Article…

HVBA Article Summary

1. Significant Price Increases: Pharmaceutical companies have raised prices on over 1,000 prescription drugs in 2024, with about half of these increases exceeding the inflation rate. Notable drugs include Enhertu and Revlimid, which have seen substantial price hikes that disproportionately impact communities of color, particularly older Black and Latino patients.

2. Affordability Crisis: The report highlights that one in three Americans cannot afford their prescription medications, with the situation being more severe for Black and Latino patients aged 65 and older, who are twice as likely to report financial difficulties in obtaining their drugs. The lack of access to medications can lead to severe health complications and even premature death for those unable to afford necessary treatments.

3. Advocacy and Policy Efforts: Organizations like Patients for Affordable Drugs and Health Care for America Now are advocating for policies to reduce the financial burden of medications. They support legislative efforts such as the Inflation Reduction Act and seek to prevent pharmaceutical companies from engaging in practices that delay the entry of generics into the market, aiming to ensure that patients can access medications without sacrificing their basic needs.

US Adult Obesity Prevalence Over 40%, Severe Obesity Over 9%

By Marilynn Larkin - The prevalence of obesity among US adults is 40.3%, and the prevalence of severe obesity is 9.4%, according to the latest data (2021-2023) from the National Center for Health Statistics (NCHS) in its first update since the pandemic. Read Full Article…

HVBA Article Summary

1. Definition and Data Source: Obesity was defined using body mass index (BMI) criteria, with obesity as BMI ≥ 30 and severe obesity as BMI ≥ 40. The analysis utilized data from the National Health and Nutrition Examination Survey (NHANES) spanning four cycles (2013-2014, 2015-2016, 2017–March 2020, and August 2021–August 2023) to estimate obesity prevalence and assess 10-year trends.

2. Key Findings on Obesity Trends: The study found no significant differences in overall obesity prevalence between men and women, although severe obesity was more prevalent among women across all age groups. Additionally, obesity was more common in adults aged 40-59 (46.4%) compared to younger (35.5%) and older adults (38.9%). Education levels also played a role, with lower obesity prevalence in those with a bachelor's degree or higher (31.6%).

3. Stability of Obesity Rates: From 2013-2014 to August 2021–August 2023, the age-adjusted prevalence of obesity remained stable, while severe obesity increased from 7.7% to 9.7%. The authors noted that the current prevalence of obesity in adults exceeds the Healthy People 2030 goal of 36.0%, highlighting the ongoing challenge of managing obesity trends in the U.S.

Five Essential Nutrients for Patients on GLP-1s

By Jean Hanks, BA, MS - Fatigue, nausea, acid reflux, muscle loss, and the dreaded "Ozempic face" are side effects from using glucagon-like peptide 1 (GLP-1) receptor agonists (RAs) such as semaglutide or the dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA tirzepatide to control blood sugar and promote weight loss. Read Full Article…

HVBA Article Summary

1. Importance of Protein: Clinicians should emphasize adequate protein intake for patients on GLP-1 receptor agonists (RAs) to maintain lean body mass, particularly for older and obese individuals. The recommended intake is 1.0-1.2 g/kg of body weight, and for those with appetite suppression, spreading protein consumption over multiple meals or using protein supplements can be beneficial.

2. Nutritional Monitoring and Fiber Intake: Regular monitoring of patients’ nutritional status is crucial, especially concerning fiber intake. Due to potential constipation from reduced food intake and delayed gastric emptying, clinicians should encourage the consumption of fibrous foods like vegetables, fruits, and legumes, and consider recommending fiber supplements if necessary.

3. Key Vitamins and Minerals: Patients on these medications should be educated about the importance of specific nutrients such as vitamin B12, calcium, and vitamin D. Regular bloodwork is advised to monitor levels, as deficiencies can lead to fatigue and negatively impact bone health, particularly in those experiencing significant weight loss.