White House strengthens legislation on equal access to mental health, substance use care

By Stephanie C. Viguers - The White House moved to strengthen the Mental Health Parity and Addiction Equality Act to ensure individuals with private insurance have the same access to mental health services as they do for physical health services. Read Full Article… 

HVBA Article Summary

1. Enhanced Coverage Requirements: The new rule mandates that insurers modify health plans to better cover mental health and substance use care. This includes ensuring adequate provider networks and addressing previously inadequate coverage.

2. Increased Transparency and Accountability: Insurers are required to perform and document comparative analyses of non-quantitative treatment limitations, such as prior authorizations and step therapy, making these analyses accessible to regulators and beneficiaries.

3. Expansion of Compliance Requirements: The rule closes a loophole, extending Mental Health Parity and Addiction Equality Act (MHPAEA) requirements to over 200 additional health care plans, which will benefit approximately 120,000 enrollees by improving access to necessary treatments.

Judge won't block Maryland law mandating discounts for hospitals' outside pharmacies

By Brendan Pierson - The largest U.S. drug industry group and several drug companies have lost a bid to block a Maryland law requiring drugmakers to offer discounts on drugs dispensed by third-party pharmacies that contract with hospitals and clinics serving low-income populations. Read Full Article…

HVBA Article Summary

1. Judge's Decision: U.S. District Judge Matthew Maddox in Baltimore declined to issue a preliminary injunction against a new Maryland law while he reviews a challenge by several pharmaceutical companies, including PhRMA, Novartis, AbbVie, and AstraZeneca. His order did not provide detailed reasoning but referenced statements made during a recent hearing.

2. Background on 340B Program: The Maryland law in question deals with the 340B program, a federal initiative that offers discounts on prescription drugs to hospitals and clinics serving low-income populations. Drugmakers must participate in this program to receive government health insurance funds, such as Medicare and Medicaid.

3. Legal Challenges and State Laws: The pharmaceutical companies argue that state laws requiring 340B discounts through contract pharmacies conflict with federal regulations governing the 340B program. This legal battle is part of a broader trend of drug companies challenging similar state laws across the country.

Republican proposals would help association health plans: Analysts

By Allison Bell - Two health policy analysts say Republicans could expand employers' access to association health plans. Allison Orris and Claire Heyison make that prediction in a review of Republican health coverage proposals prepared for the Center on Budget and Policy Priorities. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Association Health Plans (AHPs) and Federal Regulation: Association Health Plans (AHPs) offer small employers a way to bypass state health insurance regulations by joining groups with self-insured plans, which are overseen by the federal Employee Benefit Security Administration.

2. Criticism of AHP Expansion: Analysts Orris and Heyison argue against expanding AHPs, claiming that such an expansion could lead to healthier individuals leaving the Affordable Care Act (ACA) marketplace for less regulated AHPs. This could leave sicker individuals in the ACA market, potentially increasing premiums for fully insured group insurance.

3. Republican Policy Proposals: Key Republican policy documents, such as the Republican Study Committee budget and Project 2025, advocate for the expansion of AHPs and the revival of pre-Biden administration rules for short-term health insurance. They also propose using health savings accounts for non-ACA-compliant arrangements like health care cost-sharing ministries and direct primary care, which may offer limited benefits compared to comprehensive coverage.

Providers, vendors building health AI have 'shared responsibility' to ensure safe adoption industrywide

By Dave Muoio - There’s no shortage of providers and vendors working to develop and deploy artificial intelligence in healthcare—but not all who are delivering care are in a position to make use of these novel technologies without risking harm. Read Full Article…

HVBA Article Summary

1. Shared Responsibility in AI Integration: Industry experts emphasize a collaborative approach to AI integration in healthcare, highlighting that both health systems and solution developers have crucial roles. Developers must support healthcare providers, especially those lacking tech expertise, by delivering AI solutions that are safe and effective. Health systems must understand what to expect from these tools and ask the right questions to ensure they meet safety and performance standards.

2. Importance of User-Centered Design and Lifecycle Monitoring: Ensuring the accuracy and effectiveness of AI tools requires a focus on the entire AI lifecycle. This involves a user-centered design approach, continuous performance monitoring, and transparent communication about AI capabilities and limitations. Stakeholders should work together to validate AI solutions, address performance drift, and adapt to various clinical contexts to maintain trust and efficacy.

3. Regulatory Compliance and Beyond: While regulatory compliance is essential, experts stress the need for AI vendors to exceed basic requirements. Effective AI solutions should not only meet regulatory standards but also undergo rigorous internal and external testing to ensure safety and usability. Vendors must anticipate potential issues and provide clear, context-sensitive outputs to prevent adverse outcomes and support high-quality clinical care.

PBMs vs. patients: The hidden battle for affordable biosimilars

By Maria T. Abreu, MD and Deborah Dyett Desir, MD - Biosimilar medications — drugs developed to be very similar, but not identical, to an FDA-approved biologic — were intended to play a vital role in increasing affordable options for patients struggling with a range of chronic conditions. Read Full Article…

HVBA Article Summary

1. Impact of PBM Practices on Physicians and Patients: Pharmacy Benefit Managers (PBMs) make it difficult for physicians to provide treatments, including biosimilars, by frequently changing the medications they will cover. This disruption imposes burdens on physicians and interrupts patients’ continuity of care. The rebates PBMs secure from drug manufacturers do not affect acquisition costs for practices, leading to significant financial losses for small, independent practices using biosimilars.

2. Lack of Transparency and Accountability: PBMs, which control a significant portion of the market, oversee critical decisions about medication access and affordability without adequate transparency or accountability. This results in patients suffering as rebates to PBMs do not translate into reduced out-of-pocket costs, contrary to the initial promises of PBMs and biosimilars.

3. Need for Legislative Reform: The compensation structure of PBMs, which is tied to a drug’s list price, creates perverse incentives that profit more from higher list prices. Congress is considering bills to reform this system by delinking PBM compensation from drug prices, aiming to ensure that formularies are based on clinical data and cost minimization for patients, thereby improving biosimilar access and addressing the issue of profit-driven practices.

20 payers requesting the largest raises for ACA premiums in 2025

By Jakob Emerson - New York state residents will see some of the largest premium increases on the ACA marketplace in 2025, according to an analysis from Peterson-KFF. Read Full Article…

HVBA Article Summary

1. Overall Premium Trends: In 2025, 324 insurers will offer ACA coverage across all 50 states and Washington, D.C., with a median proposed premium increase of 7%. This rate is consistent with the increase seen in 2024.

2. Influencing Factors: Insurers attribute the premium increases primarily to inflation and the growing use of weight loss and specialty drugs. However, lingering COVID-19 costs and Medicaid redeterminations have had minimal impact on the proposed rates.

3. Significant Rate Hikes: Several insurers have proposed substantial premium increases for 2025, with EmblemHealth (New York) leading at a 51.1% increase. Other notable increases include Highmark Western and Northeastern New York at 30.7% and MetroPlus (New York) at 28.3%.

New tracker finds 5.4M likely dementia cases

By Maya Goldman - More than 5.4 million Medicare recipients likely have Alzheimer's or another type of dementia, according to researchers developing a first-ever national surveillance system for tracking the dreaded neurological conditions. Read Full Article…

HVBA Article Summary

1. Importance of Monitoring and Resource Allocation: The lack of a universally accepted tool for monitoring dementia prevalence has hampered efforts to accurately gauge the disease's impact and direct appropriate resources for care. This shortfall persists even as advancements in clinical diagnosis and treatments for cognitive decline progress.

2. Introduction of New Surveillance Model: A newly launched model, incorporating around 40 criteria including specific dementia symptoms and medication use, aims to provide a more accurate picture of dementia prevalence. This model, developed by NORC and the Milken Institute School of Public Health, reveals that approximately 9% of Medicare beneficiaries show evidence of Alzheimer's or related dementia.

3. Future Implications and Challenges: While the new prevalence model and data tracker represent a significant step toward understanding dementia's impact, experts emphasize that actionable steps are needed to improve care. Effective surveillance must be complemented by policy changes, such as increased Medicare reimbursements, to enhance patient care and support the health system's response to dementia.

Insurance brokers face increased pressure to deliver affordable costs

By Lucy Peterson - A 2024 survey by Zywave, a leading insurtech provider, revealed that an increased number of employers had a positive outlook of their insurance brokers over the past year. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Performance Outlook and Broker Satisfaction: Employers reported a positive outlook for 2024, with many noting their performance is expected to be about the same or better than the previous year. Additionally, nearly 86% of employers expressed satisfaction or high satisfaction with their insurance broker's services.

2. Top Employee Benefits Challenges: The primary challenges identified by employers include managing healthcare costs, offering a competitive benefits package, and attracting and retaining employees. These challenges highlight the ongoing pressures in the employee benefits landscape.

3. Valued Broker Services and Expertise: Employers emphasized the importance of client service and broker expertise, with nearly 60% prioritizing prompt and effective service. They preferred brokers who act as trusted advisors rather than mere salespeople, reflecting the need for brokers to stay informed and responsive to client needs.