US judge refuses to block Medicare from negotiating drug prices

By Brendan Pierson - The U.S. government's Medicare health insurance program can begin negotiating prices for some prescription drugs this fall under a new program, a federal judge ruled on Friday, vindicating one of President Joe Biden's signature initiatives. Read Full Article…

VBA Article Summary

1. Judge Newman's Preliminary Ruling in Favor of Biden Administration: U.S. District Judge Michael Newman in Dayton, Ohio, issued a preliminary order in favor of the Biden administration against a lawsuit brought by the U.S. Chamber of Commerce, the largest business lobbying group in the nation. The Chamber of Commerce had argued that the drug price negotiation program is unconstitutional as it would force drug manufacturers to accept low prices, thereby hindering innovation. Judge Newman rejected this argument, stating that participation in Medicare, through which the program operates, is voluntary for drugmakers and, as such, cannot constitute a constitutional violation.

2. Overview of the Drug Price Negotiation Program: The program in question is part of the Inflation Reduction Act signed by President Biden, aimed at reducing the cost of prescription drugs for Americans, who currently pay more for these medications than residents of any other country. The program mandates that drugmakers negotiate the prices of selected high-cost drugs with the Centers for Medicare and Medicaid Service (CMS), potentially saving $25 billion annually by 2031. Drug companies that refuse to negotiate may face significant penalties or be excluded from government healthcare programs, which form a substantial segment of their U.S. sales. The first round of negotiations involves 10 drugs, including prominent ones from major pharmaceutical companies, with the negotiated prices to be implemented in 2026 at a minimum discount of 25% from the list prices.

3. Ongoing Legal Challenges and Future Implications: Despite the preliminary ruling allowing the program to commence, the lawsuit by the Chamber of Commerce will continue, as Judge Newman denied the government's motion to dismiss it entirely. This lawsuit is one among several, with others filed by individual pharmaceutical companies and industry groups, challenging the program's legality and constitutionality. The outcome of these legal challenges may significantly impact the future of the drug price negotiation program, the pharmaceutical industry's pricing strategies, and the cost of prescription drugs for American consumers. The Biden administration maintains that the Constitution does not prohibit drug price negotiations, a practice already in place in many other countries.

Will new Senate bill curb the power of the PBMs - and drive down drug costs?

By Alan Goforth - A bipartisan bill introduced on Thursday is the latest move by Congress to rein in pharmacy benefit managers. Sens. Ron Wyden, R-Ore., and Mike Crapo, R-Idaho, the chair and ranking member of the Senate Finance Committee, formally introduced the Modernizing and Ensuring PBM Accountability Act, or MEPA. Read Full Article…

VBA Article Summary

1. Bill Overview and Committee Approval: The committee, responsible for overseeing Medicare and Medicaid, substantially endorsed a bill in July aimed at addressing various issues within the prescription drug marketplace. The committee’s approval signals strong bipartisan support and readiness to tackle the challenges presented by Pharmacy Benefit Managers (PBMs), who are perceived as contributors to the escalation of drug prices. The introduced legislation outlines crucial provisions designed to safeguard consumers, support independent community pharmacies, and promote transparency and accountability in drug pricing.

2. Key Provisions of the Legislation: The legislation explicitly prohibits the compensation of PBMs in Medicare from being linked to drug prices, ensuring that these middlemen do not profit from the escalation of prescription costs. It mandates increased audit and enforcement measures to hold PBMs accountable for their practices. The bill is particularly supportive of independent community pharmacies that have been adversely affected by PBM practices. These provisions are expected to alleviate some of the financial strains experienced by these pharmacies and ensure their continued service to the community. Additionally, the legislation calls for a comprehensive survey to ascertain the national average cost of acquiring covered outpatient drugs. This survey will take into account price concessions extended to pharmacies, like discounts and rebates, providing a clearer understanding of the financial dynamics within the drug market.

3. Stakeholder Responses and Future Steps: While the bill is backed by several organizations, including the Alliance for Transparent and Affordable Prescriptions and the National Community Pharmacists Association, it faces opposition from the Pharmaceutical Care Management Association (PCMA). The PCMA argues that the proposed laws will not effectively lower drug prices. However, legislators are intent on pushing forward with this foundational legislation and are open to incorporating additional policies to strengthen pharmacy access, enhance accountability, and ultimately reduce out-of-pocket expenses for patients. The bill represents a coordinated effort to reform and improve the pharmaceutical care system, with lawmakers expressing commitment to continued collaboration and refinement of policies to achieve these objectives.

Labor unions renew legal fight against BCBS Massachusetts over alleged overpayments

By Jakob Emerson - The Massachusetts Laborers' Health and Welfare Benefit Fund is suing Blue Cross Blue Shield of Massachusetts again for allegedly overcharging for healthcare and administrative services as the fund's third-party administrator. Read Full Article…

VBA Article Summary

1. Allegations of Breach of Contract and Deceptive Practices: The self-funded health plan for union members has filed a complaint against BCBSMA in Massachusetts state court, alleging breach of contract and violations of state law. The complaint, dated September 26, asserts that BCBSMA did not adhere to the agreed payment provisions and instead adopted internal policies to pay claims in a way that primarily favored its own financial interests, contrary to the terms of the contract established with the labor fund in 2006. The plaintiff's attorneys accuse the payer of deliberately hiding these policies and paying claims inconsistently with the contractual agreement.

2. History of Similar Legal Disputes: This is not the first legal dispute between the fund and BCBSMA; a previous lawsuit was filed in 2021 for similar reasons. In that case, the fund accused BCBSMA of violating fiduciary duties under the Employee Retirement Income Security Act (ERISA) by prioritizing its relationships with healthcare providers and its profitability over accurately pricing claims for the fund. However, both a federal court and the First Circuit Court of Appeals ruled that BCBSMA did not act as a fiduciary to the fund in that instance.

3. Increased Litigation Trend: The recent case against BCBSMA is part of a larger trend in which large, self-insured employers or health plans are taking legal action against insurers. The objective of these lawsuits is to gain access to comprehensive medical claims data and to ensure that insurers fulfill their fiduciary duties under federal law. Other notable examples include a June lawsuit where Kraft Heinz accused Aetna of using its position as a TPA to financially benefit at Kraft Heinz's expense through undisclosed fees and unreviewed claims processing. In December 2022, unions representing bricklayers and metal workers filed a lawsuit against Elevance Health, accusing the payer of denying access to claims data and charging self-insured plans higher rates than those negotiated with hospitals.

How workplace benefits help clients win the war for talent

By Susan Rupe - The American workforce has reached a generational tipping point. Millennials and Generation Z are taking over the workplace even as baby boomers remain on the job longer. The old ways of doing business no longer apply in the days of remote work and five generations in the workplace. Read Full Article…

VBA Article Summary

1. Addressing Diverse Needs of Multi-Generational Workforce: The workforce is now predominantly comprised of Millennials and Generation Z, necessitating a reevaluation and modernization of benefit plans initially designed for Baby Boomers and Generation X. As the younger generations value mental health equally with physical health, benefit offerings must be diverse and adaptable to cater to varying priorities across different age groups. Additionally, as the emphasis on corporate culture, work-life balance, and diversity has intensified post-pandemic, employers need to continually adapt their benefit offerings to mirror these values and expectations.

2. Holistic Wellness Focus & Non-Traditional Benefit Offerings: Workers are increasingly demanding benefits that contribute to their overall well-being, including mental, financial, societal, and professional wellness. With only 28% of Americans describing their financial health as excellent or very good in 2023 (down from 44% in 2022), there’s a growing stress and uncertainty regarding finances amongst employees. Consequently, employers are encouraged to offer benefits that not only ensure physical wellness but also contribute positively to the financial wellness of their workforce. This holistic approach, encapsulated by the Wheel of Wellness developed by LIMRA and EY, serves as a guiding framework for employers, brokers, and organizations to structure benefit packages effectively.

3. Enhanced Communication & Personalization of Benefits: With 45% of employees acknowledging a lack of understanding of certain aspects of their benefit packages, there’s a clear need for improved communication strategies from employers. Multichannel approaches to communication about benefits, which cater to the preferred receiving methods of diverse workforce groups, are essential. Moreover, to foster loyalty and satisfaction, employees require personalized benefit offerings aligned with their unique needs and life stages. Employers and benefit providers should collaborate closely to devise and communicate a comprehensive and personalized array of benefits that can efficiently support and enhance the well-being and happiness of their employees.

WHO recommends dropping component of many flu vaccines

By Helen Branswell - A team of researchers, looking at hospital pricing using posted prices, in the wake of the transparency rules that have been implemented for hospitals, has come to conclude that hospital organizations’ rates negotiated with commercial health insurers are typically double those of the rates provided to health plans through their Medicare Advantage (MA) contracts with those health plans. Read Full Article…

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1. B/Yamagata Viruses Absent Since March 2020: The influenza B/Yamagata viruses have not been detected since March 2020, when the global circulation of flu significantly decreased due to the Covid-19 pandemic and preventive measures adopted worldwide. Despite the resumption of flu transmission, there has been no sighting of the B/Yamagata viruses among the tens of thousands of influenza B viruses subtyped since.

2. No Benefit of B/Yamagata in Vaccines: Experts, including David Wentworth of the Centers for Disease Control and Prevention and Florian Krammer of Mount Sinai School of Medicine, concur that incorporating the B/Yamagata component in flu vaccines is currently pointless as the viruses are non-existent. Additionally, there's a hypothetical risk involved in including them: leaks from manufacturing plants could accidentally reintroduce these viruses into the population. The committee therefore has recommended the removal of the B/Yamagata component from vaccine formulations as promptly as feasible.

3. Implications for Flu Vaccine Formulations: For countries utilizing trivalent vaccines, the removal recommendation won’t induce any changes as these vaccines protect against H1N1, H3N2, and one influenza B virus, recently the B/Victoria lineage. However, nations that adopted quadrivalent vaccines might witness alterations in vaccine manufacturing. Executing these changes won’t be instantaneous as they necessitate regulatory approvals, involving entities like the FDA in the United States, which is contemplating the endorsement of the B/Yamagata component's exclusion from flu vaccines. The adjustment process varies across different companies and depends on the retention of licenses for former trivalent formulations. Experts underline that while there’s no downside for individuals receiving a quadrivalent vaccine now, there's also no advantage from the B/Yamagata component.

Consumer Survey Highlights Problems with Denied Health Insurance Claims

By Karen Pollitz, Kaye Pestaina, Lunna Lopes, Rayna Wallace, and Justin Lo - A KFF survey of adults with health insurance found that roughly 6 in 10 insured adults experience problems when they use their insurance. Problems studied include denied claims, network adequacy issues, preauthorization delays and denials, and others. Read Full Article…

VBA Article Summary

1. Prevalence and Disparities in Denied Claims: According to the KFF Survey of Consumer Experiences with Health Insurance, 18% of insured adults experienced denied claims within the past year. This issue is notably prevalent among individuals with employer-sponsored (21%) and marketplace insurance (20%). Additionally, high utilizers of health services (those with over ten provider visits annually) face higher denial rates at 27%. The survey highlights significant disparities, with LGBT individuals experiencing a nearly doubled rate of denied claims (30% vs. 17% for non-LGBT individuals).

2. Challenges in Understanding and Resolving Denied Claims: Insured adults who have had claims denied often struggle to understand their coverage details, with 65% reporting difficulty comprehending their health insurance's extent, 57% uncertain about out-of-pocket costs, and 52% confused by Explanation of Benefits (EOBs). These difficulties might be either a precursor or a result of having claims denied. Furthermore, individuals who've experienced denied claims find it challenging to satisfactorily resolve insurance issues. Only 29% of these individuals reported satisfactory resolution to their major insurance problems, compared to 59% of those without denied claims.

3. Consequences of Denied Claims and Awareness Gaps: Denied claims not only result in access issues and declined health status but also lead to unexpected out-of-pocket expenses. Consumers facing denied claims are twice as likely to encounter problems accessing care and three times more likely to incur higher costs. Furthermore, there is a lack of awareness and understanding among consumers regarding their rights and avenues for appeal, with 69% unaware of their appeal rights and only 15% filing formal appeals. Despite the establishment of Consumer Assistance Programs (CAPs) to aid in resolving insurance problems and appeals, only 3% of affected adults sought help from CAPs. This points towards a need for increased awareness, simplified appeal processes, and more prominent consumer notices about appeal options.

What can team leaders do about employee engagement that HR can’t?

By Joe Espana - The Foundation of Employee Engagement: The Team. But it’s self-evident that team leaders play a crucial role in driving employee engagement and creating a thriving work environment. They can have significant impact on employee engagement and can employ practical strategies to create a motivated and engaged team. I’ve always held the view that the most fundamental unit of employee engagement is the team itself. Read Full Article…

VBA Article Summary

1. The Dynamic Nature of Employee Engagement: Employee engagement is an ever-changing experience that can be influenced by the relationship dynamics between team members and their managers. The level of engagement within a team doesn't remain constant but fluctuates due to various factors including leaders’ communication style, behavior, and management practices. Acknowledging this dynamism is crucial. Instead of relying solely on annual surveys, organizations should incorporate regular check-ins or continuous measurements to grasp an accurate understanding of engagement levels at any given time.

2. Essential Pillars for Amplifying Engagement: Team leaders play a significant role in shaping the work environment, setting the tone for open communication, and connecting their teams to the organization’s overarching vision. They not only facilitate information flow but also inspire team members by providing clarity on how individual contributions align with the overall strategy, fostering a sense of purpose and alignment within the team. Engagement can be further strengthened through building trust, establishing emotional connections, promoting a positive workplace climate, and encouraging a sense of ownership among team members, all of which are areas team leaders can actively influence.

3. Leadership at Every Level Matters: Engagement is not exclusively a concern for leaders at the frontline; it's vital at every organizational level. Leaders, irrespective of their hierarchical position, hold significant influence over team engagement, commitment, and performance. They should consciously work towards fostering an environment where employees feel valued and engaged. The notion that higher organizational levels naturally possess stronger engagement is misleading. In fact, increased responsibility at higher levels can sometimes lead to stress and burnout, adversely affecting engagement. Therefore, it is imperative for leaders at all levels to actively promote and embody engagement, setting a positive example for their teams to follow.

An inside look at Walgreens' primary care and pharmacy model

By Noah Tong - Despite a recent leadership shake-up and subpar third-quarter financial results, Walgreens’ executives maintain that its transformation from a retail store to a full-blown healthcare company is the correct long-term strategy. Read Full Article…

VBA Article Summary

1. Walgreens Expansion into Healthcare Services: Walgreens is leveraging its relationship with VillageMD to enhance its presence in the healthcare provider space, notably by acquiring Summit Health for $9 billion and forming a strategic alliance with Pearl Health. With over 220 Village Medical locations co-located within Walgreens stores, the pharmacy giant aims to become a comprehensive hub for customers, providing accessible primary care services, prescription pick-ups, and healthcare resources for chronic disease management in underserved areas.

2. Leadership Transition and Financial Adjustments: The departure of CEO Rosalind Brewer, succeeded by interim CEO Ginger Graham, indicates a shift in the company’s strategic direction. Despite a nearly 9% increase in sales in the last quarter, Walgreens has adjusted its profit outlook downwards for the year, causing its stock value to drop significantly. However, executives remain optimistic, emphasizing growth and potential in its healthcare segment, which comprises specialty pharmacy Shields Health and home care provider Care Centrix.

3. Investment in Technology and Service Enhancement: Walgreens is investing significantly in technological innovations and infrastructure to improve patient and customer experience while also relieving pharmacists of mundane tasks. Automated systems in their micro-fulfillment centers handle a substantial volume of prescription sorting, filling, and labeling. This automation allows pharmacists to focus more on patient care and consultation. The company plans to expand these centers to serve its widespread network of stores efficiently, aiming to redefine and enhance the role of pharmacists in its service model.