More than 49 million in US covered by ACA over the past decade

By Amina Niasse - One in seven Americans have signed up for health insurance coverage through Affordable Care Act marketplaces since their 2014 launch, according to data released on Tuesday by the U.S. Department of the Treasury. Read Full Article… 

HVBA Article Summary

1. Enrollment Surge: As of 2024, a record 20.8 million Americans are enrolled in health insurance plans under the Affordable Care Act (ACA), commonly known as Obamacare. This represents a significant increase, contributing to a total enrollment of 49.4 million Americans in these plans.

2. Coverage Disparities: Marketplace coverage is notably higher in states that have not expanded Medicaid under the ACA or did so later. For instance, Florida, Utah, and Georgia lead in marketplace enrollment, with 20% of their populations participating, compared to 12% in states that have expanded Medicaid.

3. Premium Cost Reduction: The average annual premium for ACA marketplace plans has decreased to $800 under the Biden administration, reflecting a commitment to reducing healthcare costs for American families and entrepreneurs.

Marty Makary: Groupthink is a chronic health plan condition that must be cleaned up

By Dr. Marty Makary - As physicians, none of us take an oath to heal patients and then ruin their lives financially. Yet the prevailing groupthink today is that there is nothing we can do about it. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Examine and Revise PBM Contracts: Employers should scrutinize their pharmacy benefit manager (PBM) contracts to uncover hidden costs and inefficiencies. The recent lawsuit against Wells Fargo highlights how inflated pricing and poor contract terms can lead to significant waste in healthcare spending. By actively reviewing and renegotiating these contracts, businesses can reduce costs and enhance transparency in their healthcare benefits.

2. Challenge Groupthink in Health Benefits: The tendency to follow conventional practices without questioning their efficacy leads to higher healthcare costs. Employers often stick to major PBMs and traditional health plans due to a lack of awareness or fear of change. Breaking away from this mindset by exploring alternative strategies and providers can lead to more cost-effective and beneficial healthcare solutions for employees.

3. Seek Expert Guidance and Alternatives: Engaging with knowledgeable consultants who understand the intricacies of PBM contracts and healthcare benefits is crucial. A good consultant will help navigate complex agreements, uncover potential savings, and present alternative options. This proactive approach helps avoid the pitfalls of groupthink and ensures that employers make informed decisions that truly benefit their workforce.

Biden Administration Releases Final Rules on Mental Health Parity

By Remy Samuels - The administration of President Joe Biden announced Monday a series of final rules to expand access and lower costs for mental health and substance use care. Read Full Article…

HVBA Article Summary

1. Strengthening Mental Health Coverage: The final rules from the departments of Health and Human Services, Labor, and Treasury enhance the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 by requiring health insurance plans to provide mental health and substance use disorder benefits at the same level as physical health benefits. This includes evaluating provider networks, payment rates, and prior authorization practices to ensure equitable access.

2. Expanded Compliance Requirements: The new regulations close a loophole by extending MHPAEA requirements to non-federal government health plans, impacting over 200 additional health plans for public employees. This expansion is expected to cover 120,000 more consumers, ensuring broader access to mental health care.

3. Mixed Reactions and Compliance Timeline: Immediate reactions to the final rules have been mixed, with some concerns about added complexity and potential increased costs for employers. The rules will take effect on January 1, 2025, for group health plans, with certain new standards having a compliance deadline of January 1, 2026. Meanwhile, existing requirements and amendments from the Consolidated Appropriations Act of 2021 remain in effect.

Payers' PBMs ranked by market share

By Rylee Wilson - The four largest pharmaceutical benefit managers account for 70% of the market, an analysis from the American Medical Association found. Read Full Article…

HVBA Article Summary

1. Market Share Leadership: CVS Caremark remains the largest pharmacy benefit manager (PBM) by market share, leading in rebate negotiation, retail network management, and claims adjudication. Optum Rx, owned by UnitedHealth Group, follows closely, with significant shares across these categories as well.

2. Smaller Market Players: Elevance Health's IngenioRx, Humana Pharmacy Solutions, and Centene hold notably smaller market shares compared to the leading PBMs. For example, Centene has the smallest market presence with less than 2% in rebate negotiation, retail network management, and claims adjudication.

3. Stability in Roles: The distribution of market share across different PBMs remains relatively stable, with the largest players—CVS Caremark, Optum Rx, Express Scripts, and Prime Therapeutics—dominating key functions such as rebate negotiation and claims adjudication, while smaller PBMs like Kaiser Pharmacy and IngenioRx have more modest shares.

House passes Biosecure Act, sending Chinese biotech ban to Senate

By Zachary Brennan - The US House of Representatives on Monday evening passed the Biosecure Act with broad bipartisan support, advancing a controversial bill that could upend many drugmakers’ supply chains. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Bipartisan Passage and Senate Uncertainty: The House passed the bipartisan Biosecure Act with a significant majority vote of 306-81, including support from 111 Democrats. However, the bill faces an uncertain future in the Senate, which is considering its own version of the legislation. The Senate's version may differ significantly or be attached to larger bills, creating additional complexities.

2. Concerns and Opposition: The bill aims to force biopharma companies to sever ties with specific Chinese contract manufacturers and genetic sequencing companies by 2032, citing security concerns related to the Chinese military and intellectual property theft. Despite this, some lawmakers and industry groups, such as James McGovern and the Biotechnology Innovation Organization, have expressed concerns over the bill's transparency and potential negative impact on drug development.

3. Industry Impact and Response: The proposed legislation could affect numerous companies that rely on WuXi and other named entities for contract manufacturing, potentially leading to delays in drug development and procurement. WuXi has contested the bill’s claims, while industry groups have criticized the bill as being driven by geopolitics rather than factual concerns.

Will Tirzepatide Vials Help Patients? Endos Weigh in

By Marilynn Larkin - Tirzepatide (Zepbound) is not in shortage for now, but the weight loss drug has remained inaccessible to people without insurance coverage who can't afford to pay out of pocket. Read Full Article… 

HVBA Article Summary

1. New Formulation and Pricing: Eli Lilly and Company has introduced single-dose vials of tirzepatide, offering a 50% or greater discount compared to other GLP-1 medicines for obesity. The 2.5-mg vials are priced at $99.75 each, and the 5-mg vials at $137.25 each, intended to make the medication more affordable for self-pay patients. However, these vials are not available through community or retail pharmacies.

2. Endocrinologists’ Concerns: Some endocrinologists are critical of the new formulation, noting that the available doses (2.5 mg and 5 mg) may not be sufficient for patients who require higher doses for significant weight loss. Concerns include the potential difficulty in maintaining effective treatment without access to higher doses and the financial burden of purchasing multiple vials to achieve the necessary dosage.

3. Impact on Compounded Alternatives: The new vials are aimed at reducing reliance on compounded versions of tirzepatide, which have been used due to shortages of the FDA-approved drug. While Lilly's initiative is seen as a step toward improving access and ensuring medication purity, some question whether the pricing and dosing options will be adequate to meet patient needs compared to compounded alternatives.

9 payers recently fined by states

By Jakob Emerson - Payers have faced state penalties in 2024 for slow reimbursements, improper claims denials, or the sale of unapproved products. Read Full Article…

HVBA Article Summary

1. Anthem Blue Cross of California faced significant fines: The insurer was penalized a total of $1,540,000 across multiple incidents in 2024. This includes $850,000 in August for limiting coverage of gender dysphoria treatments and $690,000 in January for delays in reimbursements to providers and members.

2. Cigna was fined in multiple states: The company paid $236,900 to Virginia in July to resolve various violations, and an additional $600,000 to Texas in June for failing to meet independent claims dispute resolution requirements.

3. Highmark and Blue Shield of California were also penalized: Highmark was fined $363,570 in Delaware in September for issues with ambulance company claims, while Blue Shield of California paid $285,000 in August for charging copays for contraceptive services.

AMA calls for transparency about ‘jeopardizing’ impact of CMS physician payment cuts

By Andrew Rhoades - A letter from AMA's executive vice president called for CMS to be “fully transparent” on the impact that payment cuts in the 2025 Physician Fee Schedule will have on patients and physicians. Read Full Article…

HVBA Article Summary

1. Proposed Payment Cuts: CMS's proposed 2025 Physician Fee Schedule suggests a 2.93% reduction in physician payments from the previous year, alongside a $0.93 decrease in the conversion factor. This proposal has raised concerns among medical professionals about its impact on the quality of patient care and the sustainability of physician practices.

2. Economic Concerns: The Medicare Economic Index is expected to rise by 3.6%, indicating increased practice-cost inflation. Despite this, the proposed rule does not address the widening gap between Medicare payments and the actual costs of providing care, exacerbating fears that continued payment cuts will negatively affect the accessibility and quality of care.

3. Call for Transparency and Action: The AMA has criticized CMS for not including the expiration of temporary statutory increases in the specialty impact table and has called for a permanent, inflation-based update to Medicare physician payments. The AMA also warned that the proposed cuts could undermine key health initiatives and urged the Biden Administration to support legislative measures to counteract these reductions.