Pharmacy benefit managers, version 2.0 (post J&J lawsuit)

By Allison Bell - Everyone seems to want to kill the pharmacy benefit managers, but the PBMs exist for a reason. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Innovative, Transparent PBM Solutions
   Prescryptive Health leverages blockchain technology and artificial intelligence to offer a fast, transparent alternative to traditional Pharmacy Benefit Managers (PBMs). By eliminating secretive side deals, the company ensures that health insurers and self-funded employer health plans can manage prescription benefits programs with greater clarity and efficiency.

2. Fiduciary Commitment to Customers
   As a fiduciary PBM, Prescryptive Health adheres to strict legal standards that prioritize the interests of their customers. This approach contrasts with legacy PBMs by focusing on transparency in pricing and rebate management, ensuring that employers and their employees receive the best possible outcomes without hidden financial incentives.

3. Leadership and Industry Transformation
   Under the guidance of Rae McMahan, Prescryptive Health is actively addressing industry challenges such as legal pressures on traditional PBMs and the rising costs of specialty drugs. The company is driving significant changes in plan design, promoting the use of biosimilars and generics, and empowering employers and employees through direct pharmaceutical marketplaces and digital prescription tools to achieve more sustainable and cost-effective pharmacy benefits.

Why We Still Kill Patients (And What We Need to Stop Doing It)

By Michael Millenson - Since I started researching and writing about patient safety, one question has continually haunted me: given the grievous toll of death and injury from preventable medical harm that has been documented in the medical literature for at least 50 years, why have so many good and caring people – friends, family, colleagues – done so little to stop it? Read Full Article… 

HVBA Article Summary

1. Invisibility of Patient Harm: Patient harm often remains hidden from public view compared to high-profile incidents like plane crashes. This invisibility is perpetuated by the lack of involvement from influential disease groups in patient safety efforts and the omission of specific hospital details in patient advocate stories. The use of technical jargon like "iatrogenesis" and euphemisms such as "healthcare-acquired conditions" further obscures the true scale and responsibility for patient harm.

2. Inertia in Healthcare Systems: Despite awareness of patient safety issues, there is significant inertia within healthcare systems. This is evidenced by the lack of proactive measures and accountability, such as the Joint Commission's vague hand hygiene requirements. The general tendency to label harm as inevitable and the limited focus on patient safety by hospital management and boards contribute to this inertia.

3. Income-Driven Priorities: Financial considerations often overshadow patient safety concerns. The focus on cost-benefit analyses for preventing adverse events, such as infections and falls, reflects a troubling trend where economic factors are prioritized over patient well-being. The lack of substantial investment in patient safety improvements, even when the costs are minimal, highlights a broader issue of amoral decision-making driven by income rather than patient care.

Top tips to help employers explain health benefits to their workforce

By Brian Hutchin - With open enrollment season approaching, now is the perfect time to begin having conversations with your employees about their health benefits, such as health savings accounts (HSAs) and the plethora of benefits these types of accounts offer. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Emphasize HSA Education
   Provide comprehensive education on Health Savings Accounts (HSAs) to ensure employees understand their benefits and how to maximize them. Highlight key features such as the triple tax advantage (tax-free deposits, earnings, and withdrawals), ownership of funds, and the ability to use HSA dollars for non-health care expenses after age 65 with tax implications.

2. Inform About COBRA Premium Assistance
   Educate employees on how HSA funds can be used to pay for COBRA premiums, allowing them to maintain their current health insurance coverage during life transitions like job loss or divorce. This can provide financial relief and stability during uncertain times.

3. Promote Holistic Financial Security
   Encourage employees to adopt a comprehensive approach to financial wellness by integrating health care savings, retirement planning, and emergency funds. Highlight the importance of building an emergency fund and considering increased 401(k) contributions or investing HSA funds to enhance their long-term financial security.

Optum joins CVS, Cigna in dropping Humira

By Rylee Wilson - Optum Rx will join the other major pharmacy benefit managers and exclude Humira from some formularies. Read Full Article…

HVBA Article Summary

1. Optum's New Policy: Starting in 2025, Optum will exclude Humira from its formulary for new patients and will prefer biosimilar alternatives. Existing patients can continue using Humira until biosimilars are designated as interchangeable by the FDA, which is anticipated in 2025.

2. Express Scripts' Decision: In August 2024, Express Scripts, Cigna’s pharmacy benefit manager (PBM), announced it will remove Humira from its largest commercial formularies starting in 2025, favoring biosimilars instead.

3. CVS Caremark's Shift: CVS Caremark has already transitioned from Humira to biosimilars as of April 2024. Following this change, 97% of its member prescriptions for Humira were switched to a preferred biosimilar, demonstrating a significant uptake of these alternatives.

AMA study: The 4 largest PBMs control 70% of the market nationally

By Paige Minemyer - The four largest pharmacy benefit managers in the U.S. control 70% of the national market, and most regional PBM markets are highly concentrated, according to new data from the American Medical Association (AMA). Read Full Article… 

HVBA Article Summary

1. Market Share Breakdown: The study reveals CVS Health's Caremark as the largest pharmacy benefit manager (PBM) with a 21.3% market share, closely followed by UnitedHealth Group's Optum Rx at 20.8%. Express Scripts, a subsidiary of Cigna, holds a 17.1% market share, while Prime Therapeutics, jointly owned by multiple Blues plans, controls 10.3% of the market.

2. Concentration and Regulation: The report highlights that 82% of regional PBM markets are considered highly concentrated, indicating a lack of competition among PBMs. The American Medical Association (AMA) has called for increased regulatory oversight to address potential anticompetitive practices resulting from high vertical integration and low competition.

3. Vertical Integration Trends: At the national level, 72% of individuals covered by PBMs are under plans where the insurer and PBM are vertically integrated, with higher integration in Medicare Part D (77%) compared to commercial plans (69%). The study notes significant variation in vertical integration across different markets.

Charted: The top benefits employers are offering to retain workers

By Advisory Board - According to a new report from the International Foundation of Employee Benefit Plans (IFEBP), employers are offering several different benefits to help retain their workers, including telemedicine services, fertility services, work-life balance options, and more. Read Full Article…

HVBA Article Summary

1. Expanded Telemedicine Services: 78% of employers offer telemedicine, maintaining the same level as 2022. The most commonly provided telemedicine services include general medicine, mental health, behavioral healthcare, primary care, and dermatology.

2. Increased Fertility Benefits: 42% of U.S. organizations now offer fertility benefits, up from 30% in 2020. These benefits include medications, in vitro fertilization, genetic testing, and egg harvesting or freezing services, reflecting their growing importance for employee retention and inclusivity.

3. Enhanced Work-Life Balance and Flexible Options: Employers are focusing on work-life balance by offering dependent-care flexible spending accounts (69.4%) and hybrid work arrangements (68.8%). Additionally, various miscellaneous benefits are available, including wellness programs, at-work perks, and financial/retirement planning.

New Mental Health Rule Introduces Employer Benefit Parity Test

By Lauren Clason and Rebekah Mintzer - The Biden administration is poised to issue a final rule toughening mandates for employer-sponsored health plans to provide mental health and substance abuse coverage on par with their traditional medical benefits. Read Full Article…

HVBA Article Summary

1. New Rule for Mental Health Parity: The Departments of Labor, Health and Human Services, and the Treasury will release a new rule requiring employers with self-insured plans to conduct detailed analyses to ensure compliance with the Mental Health Parity and Addiction Equity Act. This rule aims to address disparities in access to mental health care by scrutinizing non-quantitative treatment limitations, such as prior authorizations, and eliminates the exemption for non-federal government health plans.

2. Controversies and Adjustments: While the rule seeks to improve mental health parity, it has faced opposition from employer groups who argue that it imposes complex and costly requirements. The final rule, however, includes delays in enforcement and adjustments, such as revised measures for network adequacy and flexibility in handling prior authorizations. Additionally, a controversial safe harbor provision related to fraud detection has been removed, but plans will still have opportunities to address deviations from the new requirements.

3. Support and Criticism: The rule has garnered mixed reactions. Supporters hope it will encourage better provider recruitment and reduce treatment barriers, while opponents fear it may lead to increased premiums or even result in some employers dropping mental health coverage altogether. Concerns have also been raised about potential overreach and the impact on health plan flexibility, particularly in light of recent Supreme Court rulings affecting regulatory authority.