Daily Insurance Report

Pharmacy Benefit Management Market Thrives on the Back of Growing Need to Raise Affordability of Specialty Drugs

London, May 30, 2023 (GLOBE NEWSWIRE) -- The escalating demand for services with regards to pharmacy benefit management from drug manufacturing brands, retail pharmacy chains, and insurance companies underpins the growth of pharmacy benefit management market. Growing preference for specialty medications, and mail order deliveries will have a collective impact on the performance of the market. Read Full Article…

VBA Article Summary

• The demand for Pharmacy Benefit Management (PBM) services is growing, with key drivers being the need for affordable specialty medications and the desire for streamlined supply chains among pharma players​¹​.

• High prevalence of chronic diseases and the expensive price points of specialty drugs are contributing to the increased adoption of PBM services, particularly in the specialty pharmacy services segment​¹​.

• The US, home to nearly 66 PBM companies as of 2021, is leading the global PBM market in terms of revenue generation, supported by rising pharmaceutical expenditure and a favorable regulatory structure​¹​.

Medicare Part D beneficiaries projected to pay lower out-of-pocket costs

By Jeff Lagasse, Associate Editor

Recent legislation establishing a $2,000 out-of-pocket cap in Medicare Part D has the potential to lower out-of-pocket costs for more than 125,000 Part D beneficiaries who use ultra-expensive drugs and are ineligible for low-income subsidies, according to a new JAMA Health Forum analysis. Read Full Article…

VBA Article Summary:

• Recent legislation, the Inflation Reduction Act (IRA), has established a $2,000 out-of-pocket cap in Medicare Part D, potentially lowering costs for over 125,000 beneficiaries who use ultra-expensive drugs and are ineligible for low-income subsidies. The cap is designed to mitigate the higher out-of-pocket costs experienced by Medicare Part D beneficiaries transitioning from commercial insurance​¹​.

• The IRA cap, effective from 2025, is likely to benefit those switching from commercial high-deductible health plans to Medicare Part D. However, the cost of ultra-expensive medications is creating financial stress on commercial health insurance plans, with out-of-pocket costs increasing more rapidly for this group​¹​.

• The cap has the potential to significantly reduce out-of-pocket spending shocks when individuals move from commercial insurance to Part D coverage. Although this could lead to increased usage of ultra-expensive drugs and potentially improve patient outcomes, it may also result in an overall increase in Medicare spending​¹​.

Employers face soaring demand for obesity care benefits. Virtual care players are jumping in with a slew of offerings

By Heather Landi May 26, 2023 12:45pm

Employers are seeing surging demand from their workers for benefits that cover obesity treatment and this is opening up considerable market opportunities for virtual care players.

A recent survey found that 44% of people with obesity would change jobs to gain coverage for treatment. And more than half of workers would stay at a job they didn't like to retain that coverage, according to the survey from the Obesity Action Coalition. Read Full Article…

VBA Article Summary

1. Rising Demand for Obesity Treatment Coverage: A recent survey showed that 44% of people with obesity would change jobs to gain coverage for treatment, demonstrating the growing demand among employees for obesity treatment benefits. This trend is being likened to the surge in demand for mental health benefits seen 10 years ago, now manifesting in the field of metabolic health.

2. High Costs and Coverage Challenges: New obesity medications like semaglutide (sold under the brand names Ozempic, Wegovy, and Rybelsus) and tirzepatide (Mounjaro) come with high costs, around $1,000 per month, and are not covered for weight loss by most insurance plans. These costs could significantly rise if a large portion of obese individuals begins to use them. Some companies are already covering these drugs, but they express concerns about the sustainability of the costs.

3. Digital Health Innovations: Virtual care companies are responding to these market changes by creating online programs that pair prescriptions for obesity drugs with lifestyle and behavior change programs. Companies like Calibrate, Wondr Health, Ro, Teladoc, and Omada Health have introduced or are planning to introduce solutions that aim to improve clinical outcomes and reduce costs by helping people maintain weight loss. The digital health sector sees significant market opportunities in this field, with predictions that the obesity care market could grow to as much as $54 billion by 2030.

Practitioner Perspective: Sleep Strategies for Optimal Health and Wellness

By Avery St. Onge May 30, 2023

A healthy diet, physical activity, and good mental health are all essential to promoting a healthy mind and body, but according to Shane Creado, MD, without quality sleep, it’s impossible to achieve optimal health outcomes.

In his new book, Peak Sleep Performance for Athletes, Creado, a board-certified psychiatrist and integrative sleep medicine physician, details his framework for helping athletes leverage sleep to optimize their sport performance. The framework includes a three-tiered pyramid that works to help patients avoid sleep disturbances, improve their sleep quality, and achieve their true potential. And while the book is geared towards athletes, Creado said his Pyramid of Peak Performance can be applied to any patient. Read Full Article…

VBA Article Summary

1. Sleep is a crucial component of health, alongside a healthy diet, physical activity, and good mental health. Dr. Shane Creado, a board-certified psychiatrist and integrative sleep medicine physician, emphasizes that quality sleep is necessary for optimal health outcomes. He has developed a three-tiered pyramid framework to help individuals optimize their sleep, noting that sleep problems are usually a symptom of multiple underlying factors​¹​.

2. The first two levels of Dr. Creado's sleep optimization pyramid address "sleep saboteurs" and tracking sleep metrics. At the first level, individuals work to eliminate obstacles that disrupt sleep, like bright lights, watching TV before bed, or discomfort. Cognitive behavioral therapy for insomnia is a recommended treatment. The second level involves tracking sleep metrics such as testosterone levels, inflammatory markers, and levels of depression, anxiety, and daytime sleepiness. It's important to differentiate feelings of sleepiness from fatigue, which is a separate diagnosis. Persistent sleep problems may indicate the need for evaluation by a sleep doctor for disorders like narcolepsy and sleep apnea​¹​.

3. At the third and final stage of the peak sleep pyramid, specific optimization strategies are incorporated into routines. These may include adjusting to the individual's circadian rhythm, training times, and travel. Techniques like exposure to bright light in the morning and light blocking at night are suggested. One popular strategy is "sleep extension," where individuals are asked to slightly increase their sleep duration to boost daytime alertness. Strategic napping can also help normalize and maintain sleep schedules, particularly when traveling across time zones​¹​.

Using Artificial Intelligence To Improve Breast Cancer Screening and Enhance Workflow

By William Hsu, Ph.D., Associate Professor of Radiological Sciences, (UCLA)

One in 10 women undergoing breast cancer screening in the United States will get the unwelcome news that a screening mammogram shows abnormal findings that require the patient to return for further examination. Read Full Article…

VBA Article Summary

1. Dr. William Hsu from UCLA is leading a project, funded by AHRQ, to apply artificial intelligence (AI) algorithms to improve breast cancer screening procedures. The goal is to reduce unnecessary patient callbacks and provide same-day follow-up examinations when required, thus reducing patient anxiety and the time to diagnosis. This initiative could potentially enhance the screening process's accuracy and efficiency.

2. The proposed AI-enabled approach involves the algorithm providing an initial interpretation of mammogram results within minutes. If any abnormal findings are flagged, a radiologist would immediately review them. If the radiologist confirms that a callback is necessary, the aim is to schedule the diagnostic exam later that same day while the patient is still at the clinic. This process is designed to decrease waiting times and improve follow-up exam adherence.

3. However, there are recognized limitations of AI in this context. Dr. Hsu refers to a recent study published in JAMA Network Open, where an ensemble AI model didn't perform as well as radiologists in identifying mammographic findings that led to a breast cancer diagnosis within a year. The AI model's performance was particularly lacking among specific patient groups, such as Hispanic women and women with a personal history of breast cancer. These findings are being used to inform the project, shedding light on the strengths and weaknesses of AI algorithms.