Insurers: Mental health parity rule will have 'severe unintended consequences'

By Rylee Wilson - Insurers and employers are pushing back on new rules that would toughen requirements for mental health parity. Read Full Article… 

HVBA Article Summary

1. Unintended Consequences and Operational Challenges: The final rules, set to be enforced from September 9, 2024, will ban health plans from imposing more restrictive prior authorization requirements for mental health care compared to other forms of care. Critics, including AHIP and the ERISA Industry Committee, argue that this could lead to increased costs and operational difficulties without significantly improving mental health access.

2. Potential Legal Action: The ERISA Industry Committee, representing large employers, is considering legal action against the new regulations. The committee contends that the rules exceed Congressional intent and add unnecessary complexity, potentially leading to worse patient outcomes.

3. Impact of Chevron Deference Overturn: The new rules might face greater vulnerability to legal challenges due to the recent Supreme Court decision overturning Chevron deference, which previously allowed federal agencies broader interpretive authority. This shift could impact the enforceability of the new regulations.

Sickest 10% drive employer plan spending increases, researchers find

By Allison Bell - U.S. employer health plan medical spending has been rising more quickly for the plan enrollees who rank in the top 10% in terms of claims than for other enrollees, researchers report in a new paper published by the American Journal of Managed Care. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Spending Trends: Between 2012 and 2019, medical spending for the top 10% of high-spending enrollees increased by 16%, reaching an average of $32,732, while average spending for other enrollees rose by only 4.7%, to around $1,400.

2. Out-of-Pocket Costs: Out-of-pocket spending for the highest-spending 10% of enrollees increased by 12%, reaching $2,879. In contrast, out-of-pocket costs for other enrollees rose by 22%, amounting to $421. This disparity suggests a varied financial burden on different segments of enrollees.

3. Research Insights: Erin Duffy and her team from the University of Southern California conducted a comprehensive analysis using commercial insurance claims data from 2012 to 2021. Their findings indicate that while coinsurance and co-payment expenses remained steady, the increase in out-of-pocket costs primarily stemmed from rising deductibles, which for the 70%-90% claim category enrollees, increased by about 23% or $191.

Weight-loss drug boom sparks battle over pharmacy copycats

By Tina Reed - A fight is brewing between drug giants and pharmacy compounders that have seized on the consumer demand for blockbuster obesity drugs. Read Full Article…

HVBA Article Summary

1. Regulatory Tension: The ongoing clash between Eli Lilly, Novo Nordisk, and compounding pharmacies highlights a critical test of FDA policy. The policy, designed to allow pharmacies to create drug versions during shortages, is now being scrutinized as pharmacies produce lower-cost alternatives to patented GLP-1 drugs like Eli Lilly's Zepbound and Novo Nordisk's Wegovy.

2. Market Disruption: Compounding pharmacies, driven by the high cost and scarcity of branded GLP-1 drugs, are producing and selling versions of these drugs at reduced prices. This has led to regulatory challenges for states, consumer warnings from the FDA, and legal action from the drug manufacturers seeking to protect their market dominance.

3. Future Implications: The legal battles and regulatory scrutiny surrounding the compounding of GLP-1 drugs could reshape FDA policies on drug compounding and personalization. While the FDA’s framework allows for customization to meet specific patient needs, critics argue that its application in mass production of drug copies could lead to significant safety and quality control issues.

Eli Lilly Moves Closer to Bringing Diabetes Patients a Once-Weekly Insulin Alternative

By Frank Vinluan - An Eli Lilly insulin engineered for once-weekly dosing now has preliminary results from two more pivotal studies showing the injection was comparable to once-daily insulin, a new slate of data that brings the experimental insulin closer to competing with a Novo Nordisk product that’s already commercially available in some parts of the world. Read Full Article…

HVBA Article Summary

1. Efsitora Alfa Performance: In recent Phase 3 trials, Lilly's experimental once-weekly insulin, efsitora alfa, demonstrated comparable efficacy to daily basal insulins. In a 52-week study of insulin-naïve patients, efsitora reduced hemoglobin A1C by 1.31%, slightly outperforming the 1.27% reduction seen with insulin glargine (Lantus). In a separate 78-week study of patients switching from daily basal insulin, efsitora achieved a 0.86% reduction in A1C, surpassing the 0.75% reduction with Tresiba, meeting the non-inferiority goals.

2. Patient Impact and Advantages: Efsitora's once-weekly dosing regimen may ease the burden of insulin therapy for patients. Jeff Emmick from Lilly emphasized that this regimen could simplify management for people with diabetes, potentially increasing adherence and reducing the daily impact of insulin administration.

3. Regulatory Landscape and Competition: Novo Nordisk's once-weekly insulin, icodec, is already approved in several countries but faced a setback with the FDA in July. The FDA's rejection focused on manufacturing concerns and potential issues with hypoglycemia rates in type 1 diabetes patients. Meanwhile, Lilly plans to present further data from its Phase 3 trials at upcoming conferences, with additional studies on efsitora in type 1 diabetes still pending.

Important Reads: New Reporting Details Ghost Networks and Fighting Denials

By Wendell Potter - Navigating behavioral health care in the United States can feel like a cruel game of hide and seek. Millions of Americans, already struggling with mental health and substance use issues are forced to confront a system that dangles the promise of in-network therapists and doctors. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. The "Ghost Network" Phenomenon: Many health insurance directories list providers who either don't exist or aren't accepting patients, creating what's known as a "ghost network." This misleading network design leaves patients stranded when they seek care and contributes to the broader issue of inadequate mental health support.

2. Profitability of Ghost Networks: Big health insurers, such as UnitedHealth, Cigna, and CVS/Aetna, benefit from ghost networks because they allow insurers to appear as if they offer comprehensive coverage while actually reducing the number of claims filed. This deceptive practice helps insurers minimize their costs and regulatory burdens.

3. Impact on Patients and Advocacy: Patients often face significant out-of-pocket costs when forced to seek out-of-network care due to ghost networks. Consumer advocates stress the importance of pushing back against denials and delays, urging patients to file appeals and remain persistent in their quest for necessary care.

GLP-1s and insurance coverage: 10 key numbers

By Jakob Emerson - Insurers and employers face ongoing challenges in covering costly GLP-1 medications, with coverage rates varying significantly based on the individual's insurance plan and employer. Read Full Article…

HVBA Article Summary

1. Public and Employer Coverage Trends: A significant portion of U.S. adults support insurance coverage for weight loss drugs, with 80% in favor, even if it raises premiums. In response to this demand, 34% of large employers covered GLP-1 drugs for weight loss in 2023, and 26% of large employers plan to offer such coverage in 2024.

2. Insurance Utilization Disparities: There is a notable disparity in the utilization of GLP-1 drugs. While over 61% of Ozempic prescriptions went to patients with commercial insurance, less than 10% were allocated to Medicaid enrollees. This indicates a potential gap in access to these medications based on insurance type.

3. State and Medicaid Coverage: As of mid-2023, at least 16 states provide coverage for GLP-1 drugs for weight loss to state employees, and eleven state Medicaid programs offer broad coverage for these drugs. However, the majority of ACA marketplace plans cover GLP-1 drugs only for diabetes, with less than 1% covering them solely for obesity.

Class is in session: 3 ways to boost benefits engagement this back-to-school season

By Kate Winget - With students heading back to school and open enrollment just around the corner, it's a great time to realign efforts around benefits education to support your busy employees — especially those who are also juggling school schedules, family costs, and end-of-year planning. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Customize Benefits Education for Diverse Employee Needs Ensure your benefits education program addresses the unique financial goals and challenges of your multi-generational workforce. Tailor your communication and support to different groups, from retirees focused on long-term savings to younger employees managing student loans or starting families. Providing targeted resources and guidance for various financial situations, such as debt reduction or retirement planning, will help employees better understand and utilize their benefits.

2. Seek Continuous Feedback and Adapt Your Strategy Regularly gather employee feedback on their benefits experience and stay agile in your communication approach. Use surveys and direct feedback to identify areas for improvement and adjust your strategies accordingly. Offering various communication channels and keeping content relevant and accessible will help ensure that employees of all generations stay informed and engaged with their benefits.

3. Provide Ongoing Financial Support and Resources Expand your support beyond open enrollment by offering financial wellness programs, personal financial coaching, and flexible work arrangements. Access to a financial advisor or comprehensive educational resources can significantly benefit employees in managing their finances and maximizing their benefits. Ensuring continuous support will help employees navigate their financial challenges more effectively and stay engaged with their benefits throughout the year.