Daily Industry Report - September 19

Your summary of the Voluntary and Healthcare Industry’s most relevant and breaking news; brought to you by the Health & Voluntary Benefits Association®

Jake Velie, CPT
Vice Chairman & President
Health & Voluntary Benefits Association® (HVBA)
Editor-In-Chief
Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF
Chairman & CEO
Health & Voluntary Benefits Association® (HVBA)
Publisher
Daily Industry Report (DIR)

Litigator Pries Open Access to Health Plan Info, Helps Improve Fiduciary Duties

By Wendell Potter - The U.S. health care landscape is riddled with endless schemes that place profits ahead of patients. That’s why Congress has enacted a series of laws through the years designed to protect health care consumers from unscrupulous practices. Read Full Article…

HVBA Article Summary

  1. Fiduciary Duties Under ERISA: The Employee Retirement Income Security Act (ERISA) imposes strict fiduciary responsibilities on health plan sponsors, emphasizing prudence and loyalty in plan administration. Recent legislation, like the Consolidated Appropriations Act (CAA) of 2021, enhances these responsibilities by providing tools for better oversight of vendors and ensuring compliance with claims and compensation practices.

  2. Key Provisions of the CAA: The CAA includes crucial provisions aimed at increasing transparency in health benefit plans, such as removing gag clauses that restrict access to plan data, mandating compensation disclosures for service providers, and addressing mental health parity. These measures are designed to empower fiduciaries to make informed decisions and reduce potential fraud and waste in health plans.

  3. Evolving Employer Strategies: In response to the CAA, employers are re-evaluating their health benefits by adopting innovative strategies, such as replacing high-cost medications with biosimilars, switching to transparent pharmacy benefit managers (PBMs), and exploring alternative plan designs. These proactive changes not only enhance compliance but also aim to reduce costs for both employers and plan participants.

HVBA Poll Question - Please share your insight

If you offered “travel as a benefit with an optional employer contribution/match,” what do you believe would be the biggest impact to your organization?

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Our last poll results are in!

54.72%

of Daily Industry Report readers who responded to our last polling question when asked how well plan members understand their healthcare related benefits stated “Plan members largely don’t understand their benefits or how to access healthcare, and we would consider alternatives to provide additional support.” 

32.08% responded that in their experience “Plan members have some questions about their benefits, but we’re able to easily help them,” while only 13.20% shared “Most plan members I encounter understand how their benefits work and how to get the healthcare they need, including how to access quality care in appropriate costs. 

Have a poll question you’d like to suggest? Let us know!

Millions are Taking a Drug that Falls Short of its Promise to Lower Risk of Heart Attack

By Dr. John A. Osborne - For the past century, heart disease has remained the leading cause of death in the United States. Read Full Article…

HVBA Article Summary

  1. Advances in Cardiovascular Treatment: As our understanding of cardiovascular disease has evolved, treatment options have improved. However, it is crucial for both healthcare providers and patients to stay informed about the latest science and FDA guidance to ensure safe and effective treatment.

  2. Misinformation and Regulatory Action: Misinformation regarding treatment options poses a significant public health risk. HealthyWomen has filed a citizen petition with the FDA, urging updates to the labeling of fibrates, a medication class that has been shown to be ineffective in reducing cardiovascular event risk when used with statins, despite ongoing off-label prescriptions.

  3. Need for Updated Practices: The FDA’s withdrawal of the indication for fenofibrates in combination with statins highlights the importance of adhering to current research. Continued use of fibrates poses potential risks without proven benefits, particularly for vulnerable populations, emphasizing the need for healthcare providers to prioritize safe, effective alternatives.

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We’re Overcomplicating Healthcare AI — Here’s How We Achieve Impact Beyond The Hype

By Sourav Dey - The early days of any foundational technology are characterized by overhype and skepticism. Read Full Article… 

HVBA Article Summary

  1. Transformation of Data Management: AI, particularly large language models (LLMs), is revolutionizing clinical research by automating data harmonization, enabling researchers to process and analyze large volumes of messy clinical data significantly faster—potentially reducing months of work to mere days.

  2. Extraction of Valuable Information: AI can extract structured data from unstructured sources, such as free-text notes in electronic medical records (EMRs), allowing researchers to access critical information that was previously overlooked. This capability enhances the quality and scope of clinical research by making previously unusable data available for analysis.

  3. Democratization of Data Access: AI-powered user interfaces are changing how researchers interact with data, allowing them to pose queries in natural language instead of needing technical coding skills. This accessibility fosters greater participation in research by medical professionals who may lack coding expertise, accelerating the pace of discovery in healthcare.

The next big ACA fight: Subsidies

By Jakob Emerson - Debates over the Affordable Care Act have evolved in Washington, D.C., moving away from "repeal and replace" toward navigating premium subsidies set to expire at the end of 2025, The Washington Post reported Sept. 12. Read Full Article…

HVBA Article Summary

  1. Trump's Stance on the ACA: During the Sept. 10 debate, former President Trump expressed intentions to replace the Affordable Care Act (ACA) if a "better and less expensive" plan is developed, indicating that he has concepts in mind but has not provided specifics.

  2. Growth of the ACA Marketplace: The ACA marketplace is experiencing unprecedented growth, with over 20 million individuals enrolling in exchange plans for 2024, largely due to federal premium subsidies that are set to expire at the end of 2025. However, making these subsidies permanent could significantly increase the national deficit.

  3. Fraud Concerns and Regulatory Changes: Republican lawmakers have raised alarms about potential fraud on ACA exchanges, leading the Centers for Medicare & Medicaid Services (CMS) to implement stricter regulations. In July, CMS restricted unassociated agents and brokers from making changes to enrollment statuses, requiring them to work directly with enrollees or through agency call centers.

CGM Cuts Hospitalization in T2D, Even in Non-Insulin Treated

By Miriam E. Tucker - The use of continuous glucose monitoring (CGM) reduced the risk for hospitalization and improved glucose control in people with type 2 diabetes, regardless of insulin use, a new analysis of real-world data found. Read Full Article… 

HVBA Article Summary

  1. Significant Reductions in Hospitalizations: The study involving over 74,000 individuals with type 2 diabetes demonstrated that continuous glucose monitoring (CGM) significantly reduced all-cause hospitalizations by 10.1% to 22.6% across different treatment groups, with acute diabetes-related hospitalizations showing reductions of up to 52.7%.

  2. A1c Improvements Across Treatment Groups: Participants in the study experienced notable decreases in A1c levels after 12 months of CGM use, regardless of insulin treatment status. A1c values dropped from baseline averages of 8.6% to 7.5% in non-insulin users, highlighting the efficacy of CGM in managing blood glucose levels.

  3. Potential Cost Savings and Economic Impact: The study suggests that wider adoption of CGM could lead to substantial healthcare cost savings by reducing hospitalizations, with the authors planning further analysis to support these findings. This could influence future coverage decisions by insurers and the American Diabetes Association's standards of care.

Express Scripts sues FTC over drug pricing report

By Jody Godoy - Pharmacy benefit manager Express Scripts sued the U.S. Federal Trade Commission on Tuesday over the regulator's recent drug pricing report, calling the report's conclusion that the prescription middlemen raise drug costs defamatory. Read Full Article…

HVBA Article Summary

  1. Lawsuit Details: Express Scripts, owned by Cigna Corp, has filed a lawsuit requesting a federal judge in St. Louis to compel the FTC to retract a July report that criticized market consolidation and its impact on independent pharmacies. The company also seeks the recusal of FTC Chair Lina Khan from any related actions.

  2. FTC Report Critique: The FTC's report argues that Pharmacy Benefit Managers (PBMs) favor their affiliated businesses, leading to conflicts of interest that disadvantage smaller independent pharmacies. Express Scripts contends that the report heavily relies on public comments while disregarding substantial evidence provided by the PBMs.

  3. Market Context: The FTC defends its findings, noting that three major PBMs—UnitedHealth Group's Optum, CVS Health's Caremark, and Express Scripts—control nearly 80% of the market. The agency emphasizes its commitment to clarifying the complexities of the PBM market for the public and policymakers.

Ozempic, Mounjaro Help People With Type 1 Diabetes Control Blood Sugar, Lose Weight

By Dennis Thompson - Initially approved to treat type 2 diabetes, Ozempic and Mounjaro also can help people with type 1 diabetes lose weight and control their blood sugar levels, a new study finds. Read Full Article…

HVBA Article Summary

  1. Weight Loss and Insulin Reduction: Overweight or obese type 1 diabetics using Mounjaro experienced an average weight loss of over 21%, leading to an 18% reduction in daily insulin needs. Ozempic users lost about 9% of their body weight, with both drugs contributing to improved blood sugar control.

  2. Mechanisms of Action: Although Mounjaro and Ozempic primarily aid type 2 diabetics by enhancing insulin production, they also slow digestion and reduce liver glucose production, mechanisms that can benefit type 1 diabetics in managing blood sugar levels.

  3. Study Implications and Future Research: The study suggests that these medications could be valuable adjuncts to insulin therapy for type 1 diabetes, potentially lowering the risk of obesity-related complications. However, further research through larger, prospective trials is necessary to assess their long-term safety and efficacy in this population.