ERISA Preemption Reaffirmed: Tenth Circuit Limits State PBM Regulation

By Jon Breyfogle, Tamara Killion, Matthew Lanahan, Seth Perretta, Ryan Temme - ERISA’s broad preemption language has historically prevented states from regulating ERISA-covered plans if the state law included an impermissible reference to or had an impermissible connection with the ERISA-covered plan. The courts have found that an impermissible reference to an ERISA plan arises when the state law directly regulates the plan by its terms or where the existence of the ERISA plan is necessary for the operation of the state law. Read Full Article…

VBA Article Summary

1. State Law vs. ERISA Preemption: The article highlights the tension between state law regulations and ERISA preemption. The recent ruling in the Mulready case reinforced that state laws regulating Pharmacy Benefit Managers (PBMs) can be preempted by ERISA if they dictate the design of ERISA-covered plans or impose burdens that affect plan administration. In particular, when state law mandates the benefit design, disrupts nationally consistent plan administration, or imposes additional requirements on core aspects of plan administration governed by ERISA, it might be preempted.

2. Tenth Circuit's Decision in Mulready: The Mulready court ruling underscored that ERISA preemption can apply even if the state law primarily regulates PBMs and not directly ERISA plans. The Tenth Circuit concluded that some provisions of Oklahoma's law mandating benefit structures prevent the uniform application of ERISA plan terms across the nation. For instance, these state provisions limit PBMs' capacity to design tailored pharmacy networks. The Tenth Circuit viewed such provisions as dictating plan designs, which is prohibited by ERISA.

3. Potential Implications and Future Directions: Following the Tenth Circuit's decision, the case returns to the initial district court for further proceedings. While the article suggests that the Mulready decision appears as a conservative application of previous jurisprudence, the potential for the case to reach the Supreme Court remains. This could impact both ERISA preemption and state regulation of ERISA plans, particularly given that many states have introduced PBM regulations akin to Oklahoma's. Regardless of the court's final verdict, plan sponsors and service providers need to stay updated on state legislative changes and enforcement activities, especially as this legal area continues to evolve.

How is Inflation Impacting 2024 Open Enrollment?

By CBIZ - Inflation continues to cause financial strain for many employees. As open enrollment approaches, members of your workforce may be considering which benefits matter most to them and how to optimize the money they spend on those offerings. As a result, this year’s open enrollment may be more challenging than usual for both employers and benefits providers. Read Full Article… 

VBA Article Summary

1. Impact of Inflation on Employees: 63% of U.S. employees have experienced increased financial stress over the past year due to inflation. To combat this, they have been taking various measures such as cutting back on expenses (40%), paying off debts (30%), and looking for additional or better-paying employment. Employees are now expecting their employers to help them get the most value from their benefits, including retirement savings, HSAs, and voluntary benefits.

2. Changed Employee Expectations During Open Enrollment: Employees are expected to be more deliberate in reviewing and selecting their benefits, in contrast to the 72% who previously spent less than an hour on these decisions. Given the financial pressure, employees will be looking to their employers for guidance on maximizing the value of their benefits.

3. Supporting Employees Amid Inflation: Employers should start communicating any changes to benefits due to inflation early to prevent confusion. Using multiple communication channels and clear language can help cater to a diverse workforce and ensure comprehension. Highlighting all the services and perks included in the benefits can help employees understand and appreciate the full value of what they're offered.

If you think you can't afford long-term-care insurance, here are some options

By Morey Stettner - Once you hit your 60s, you'll want to develop a long-term-care plan. As you near retirement, you may worry that the cost of long-term care can sabotage your future. Spending thousands of dollars a month on home health aides or an assisted-living facility can sink your retirement plans, especially if you need such care for many years. Read Full Article…

VBA Article Summary

1. Evolving Nature of Long-Term-Care Insurance: The appeal and feasibility of long-term-care insurance have changed over time. Though these policies were designed to assist with costs for at-home care, assisted-living communities, or nursing homes, they have increasingly become more expensive and offer less coverage than in the past. Factors like misguided pricing and flawed underwriting standards have caused many insurers to stop selling these policies, making them unaffordable for many, especially those with modest assets.

2. Weighing the Decision to Self-Insure: Given the high costs and limited coverage of long-term-care insurance, self-funding or self-insuring has emerged as an alternative. This requires individuals to set aside enough savings to cover potential long-term care needs. However, self-funding is unpredictable due to numerous variables like an individual’s financial situation, life expectancy, and medical history. It's essential to assess risk tolerance and the most efficient use of capital, keeping future scenarios in mind, such as the possibility of outliving savings or needing to make significant life changes later in life.

3. Potential Limitations and Considerations of Self-Insurance: Jesse Slome, the director of the American Association for Long-Term Care Insurance, highlights concerns about retirees' willingness to spend their own money for care services. They might delay seeking care or settle for cheaper, potentially lower-quality options. Future developments, like advances in dementia treatment, could impact the need and timing for long-term care, presenting yet another variable in the decision-making process for individuals considering whether to buy insurance or self-insure.

Are New Primary Care Sites an Opportunity for Nurses?

By Anne Dabrow Woods - With physician staffing shortages and a lack of appointment openings across traditional primary care settings, patients are faced with inaccessibility to care. As a result, patients are looking beyond the traditional primary care office and instead looking to non-traditional care sites. As Andy Jassy, Amazon’s CEO, appropriately said in February 2023, “If you fast forward 10 years from now, people are not going to believe how primary care was administered.” Today, primary care is moving closer to the patient, bringing us toward a future where it will be easier to access healthcare when and where it’s needed. Read Full Article…

VBA Article Summary

1. The Role of Nurses in New Primary Care Settings: With nurses being the most trusted profession and often the main point of contact for patients, they are primed to be the consistent face of care in emerging non-traditional primary care sites. While many nurses have left or plan to leave the profession due to stressors and burnout, new primary care settings offer them a change from the high-intensity acute care environments. These settings can provide a fresh, patient-focused approach while still tapping into the strong patient-nurse relationship that has always been foundational in healthcare. With this, there’s potential for an uptick in nursing school enrollment and better retention.

2. Challenges and Solutions in Staffing: The migration of nurses from traditional settings to new primary care sites presents staffing challenges. As a significant number of nurses with years of experience plan to leave the profession, the guidance they provide to new nurses might be lost. However, non-traditional sites have the potential to attract and retain these experienced professionals if they ensure consistent staffing, making these environments appealing. Addressing the ongoing nurse shortage and promoting safe staffing ratios, both in acute care and primary care settings, will be essential in reducing nurse burnout and ensuring high-quality patient care.

3. Interdisciplinary Collaboration in Primary Care: The evolution of primary care will necessitate an interdisciplinary approach. With Americans becoming more open to the involvement of professionals like pharmacists in their healthcare, a collaborative model becomes inevitable. Utilizing the unique skills of pharmacists, nurses, and NPs can lead to a more comprehensive and efficient healthcare delivery system. For instance, while nurses can act as the initial patient contact, assessing needs and triaging accordingly, pharmacists can advise on medication-related issues, and NPs can provide specialized care. This integrated model ensures patients receive a holistic care experience, maximizing the strengths of each healthcare professional.

4 tactics for turning client referrals into introductions

By Ayo Mseka - While a recent survey found that 92% of clients expressed some inclination to continue working with their current advisors, that same study also uncovered frequently overlooked opportunities for advisors to build a client's confidence. Developing an understanding of your client's needs is paramount, and will have many benefits, including increased referrals, according to the experts. Read Full Article…

VBA Article Summary

1. Significance of Client Confidence and Satisfaction: Julie Littlechild of Absolute Engagement highlighted the deep-rooted connection between client self-confidence and satisfaction, loyalty, and the Net Promoter Score. The 2023 investor research survey unveiled that while 43% of clients value a clear retirement vision through their advisor, only half felt their advisors aided them in strategizing non-financial life goals. A significant disparity exists between client satisfaction (93%) and actual client referrals (35%), showcasing the potential area of growth for advisors.

2. Strategies for Effective Client Referrals: Bill Cates, the president of Referral Coach International, shared actionable tactics to convert client referrals into introductions. Advisors should be "assumptive" about making the introduction after the client agrees to referrals. The introduction process should be designed to protect the mutual relationship, ensuring it's comfortable for all involved. Advisors should collaborate with the introducer to make the referral process both comfortable and effective. Time should be taken to know the prospect well, ensuring a relevant and effective introduction.

3. The Shift from Traditional Metrics to Client Needs: Traditional metrics, while essential, are based on lagging indicators, according to Littlechild. Prioritizing understanding and addressing client needs rather than just financial goals is the way forward for successful advisory relationships. Kathleen Owings emphasizes the significance of strengthening client relations, utilizing tools like weekly video content to stay in regular touch and engage clients. Absolute Engagement's Self-Confidence Index shows 31% of clients with low to moderate confidence, emphasizing the need for advisors to address market-related concerns and risk perceptions.

3 Tips to Get the Most Out of Your Health Insurance Renewal

By Richard Westmeyer - Companies are reviewing their benefits options for 2024, and these tips are worth considering to ensure employees get the best plan for the lowest premium. What does everyone want? Lower costs! When do they want it? Now! With the fourth quarter quickly approaching, many businesses will review benefit options for the 2024 plan year. If you find yourself in this situation, here are some tips to ensure that you get the best health plan for the lowest cost. Read Full Article…

VBA Article Summary

1. Competition Creates Opportunity: Many businesses continue to work with the same broker without exploring alternatives. Different brokers might have access to different markets, which could provide more diverse options. Pushing your broker to compete for your business can reveal hidden opportunities and potential savings.

2. Choose the Proper Funding Arrangement for Your Health Plan: Many small to mid-size businesses are in fully-insured plans that might not be the most cost-effective. Options like level-funded, captive, or self-funded health plans can provide more control over costs and incentivize lower-cost care. Despite misconceptions, many smaller companies are successfully utilizing self-funded plans to decrease costs.

3. Shift Your Focus from the Lowest Premium to the Lowest Cost of Care: A low premium doesn’t always equate to the lowest overall health care cost. Options to reduce costs include effective network design, medical management, and direct contracting. Strategies such as direct contracting for specific services can drastically lower costs and out-of-pocket expenses for employees.

By Bill Fotsch - "More than wages, employees trying to organize say they want to be treated with dignity," reads an article in Harvard Business School Working Knowledge: "Why Better Pay Didn't Stop Amazon Employees From Trying to Unionize." Maybe, to some people, this is a hot take. If you're like me, you stared too long at the word dignity, shaking your head. Read Full Article…

VBA Article Summary

1. Employee Engagement Crisis: Despite companies spending billions on enhancing employee engagement, the results remain lackluster. The Gallup's G-12 questions, introduced 30 years ago, show that the percentage of U.S. employees engaged in their work is less than one-third. This disengagement costs companies an estimated $605 billion each year. Many companies focus on superficial perks and environmental enhancements to drive engagement, but these efforts seem insufficient and misaligned.

2. The Core Purpose for Engagement: The foundational element to drive genuine employee engagement is aligning employees' purpose and motivation to the core function of the business: serving customers profitably. William Kahn, who coined "employee engagement", and motivational expert Dan Pink, both highlight the significance of finding purpose in work. Historically, the prosperity and well-being of employees were tied directly to their work's outcomes, making their roles essential in the company's success.

3. Economics-Based Employee Partnership: Companies that successfully engage their employees often involve them in understanding and enhancing the economic aspects of the business. Asking employees about areas of improvement and ways to boost sales and customer relations tends to drive profitability. Examples include Capital One's "CEO" initiative, Southwest Airlines' "Plane Smart Business", and Carlson Wagonlit Travel's profitability growth. When employees are genuinely involved in the economics of a business, they develop essential skills, contribute to profitability, and can share in the wealth they help generate.

Complex Path to Cancer Drug Shortages Leads to Hard Realities for Patients

By Peter Page - Delivering a scary diagnosis in an honest way is an unhappy part of an oncologist’s job. But as tough as it is to tell a patient they have cancer, many oncologists are now confronting how to tell patients with cancer that the drugs used to treat them are so scarce that they may not receive a full dose. And that’s assuming the preferred therapy will be available at their next appointment. Read Full Article… 

VBA Article Summary

1. Shortage of Vital Cancer Drugs: As of late July 2023, multiple oncology drugs were listed by the FDA as being in short supply, notably cisplatin and carboplatin. This shortage has severely affected the standard treatments for cancer patients, forcing medical practitioners to resort to alternative treatments that might not be as effective. Both drugs have been the staple chemotherapy treatments for decades, and a shortage significantly impacts the quality of care cancer patients receive.

2. Underlying Causes of the Shortage:

   Single-point failure - One primary reason for the acute shortage is the suspension of manufacturing at the Intas Pharmaceuticals Ltd plant in India, which contributes approximately half of the cisplatin used in the U.S. and a significant portion of carboplatin. This situation highlights the precariousness of relying heavily on a single manufacturing source.
   Complex Market Dynamics - The profitability dynamics of the generic drug market, especially sterile injectable cancer drugs, have moved manufacturing mostly to India and China. U.S. dependence on overseas production, particularly from India and China, makes the supply chain vulnerable. Factors like low profit margins, short usage durations for patients, and complex manufacturing processes contribute to this problem.

3. Challenges in Addressing the Shortage:

   Financial and Regulatory Issues - Distorted drug pricing structures and regulatory programs in the U.S. contribute to drug shortages. Initiatives such as the 340B Drug Pricing Program, meant to aid hospitals serving low-income patients, have faced criticism for not delivering their intended benefits and have distorted the market dynamics further.
   Public Perception and Political Polarization - The vilification of pharmaceutical companies and the public's frustration with high drug prices make it challenging for lawmakers to address the underlying causes. The bipartisan divide in Congress further complicates the search for solutions.