How New Advancements in Pharmacy are Shifting the Managed Care Landscape
Pharmacies are changing, sending ripples into the managed care landscape. In a new Managed Healthcare Executive article, Joe Johnson, Todd Clark, and Brendan Mitchell of LEK Consulting discuss new disruptive pharmacy models and how they are affecting managed care and other payers. The first such shift is a move towards better patient access to care decided upon by their provider.
Biden Administration Appeals Texas District Court Loss in ACA Preventative Care Case
A US District Court’s decision on preventative care recommendations under the ACA has been appealed by the Biden administration. A Texas judge ruled that the federal government cannot make states follow preventative care recommendations under the ACA. The move sends the case to the 5th Circuit Court of Appeals for future litigation.
State Level Look at Who’s About to Lose Medicaid Coverage
With the imminent end to the COVID-19 public health emergency looming large, pandemic-era Medicaid expansions are set to kick millions off the program in the US. A newly published report from the Urban Institute and Robert Wood Johnson Foundation predicts that up to 18 million people are set to be dropped from Medicaid in the coming weeks and months. Examine this at the state-by-state level in a new Becker’s Payer Issues article.
UnitedHealthcare Drops 20% of Prior Authorizations and Introduces Gold-Card Program
The payer giant UnitedHealthcare announced plans to cut down on prior authorizations by introducing a new gold-card program. The gold-card program would be implemented nationwide and would cut the number of prior authorizations by 20%. Once implemented, the program will relieve a significant work burden for the provider groups involved.
Study Finds Most Employers Provide Multiple Options for Health Insurance Plans
Results from Alight’s 2023 Benefits and Enrollment Trends report show that the vast majority of employers who provide health insurance give employees multiple options for plans. Over 90% offered more than one plan and three-quarters put money into employee health savings accounts for those with high-deductible plans.
Provider Groups Call on US CMS for Hybrid Payment Model
Almost 30 provider groups have written a letter asking the US Centers for Medicare and Medicaid Services (CMS) to implement a hybrid system that mixes fee-for-service and prospective payments for primary care. According to the letter, doing so would incentivize primary care physicians (PCPs) to serve rural areas. The letter is, in part, in response to a push from the agency to get PCPs in rural and underserved areas to move to value-based care models.
AMCP 2023 Panel Argues for Patient-Centered Prior Authorization
Prior authorization is a complex, lengthy process that stands between patients and the drugs they need. In a panel at the Academy of Managed Care Pharmacy 2023, Heather Odem, PharmD, of UnitedHealthcare and Richard Ogletree, PharmD, of Alliant Health Solutions spoke about the need to shift measures used in prior authorization decision-making to benefit patients.
Value-Based Care as a Solution for Healthcare Workforce Shortages
Widespread healthcare workforce shortages and high employer-sponsored health insurance costs are impacting health systems and increasing healthcare costs. One potential solution for this problem is value-based care (VBC), which bases reimbursement on quality of care and patient outcomes. According to a new article in Benefits Pro, this can keep employees healthier and happier while reducing organizational health insurance costs.
CMS Approves Coverage for VR Pain Relief Solution
In the first approval of its kind, the US Centers for Medicare and Medicaid Services (CMS) have approved AppliedVR’s RelieVRx immersive virtual reality (VR) platform as a durable medical device. This opens up funding for not only RelieVRx, but also other therapeutic immersive VR programs. With the move, AppliedVR expects other payers to eventually follow suit.
Eisai CEO Not too Worried About Leqembi After CMS Keeps Anti-Amyloid Rule
Eisai’s CEO Ivan Cheung told Fierce Pharma he is not too worried about the long-term success of Leqembi in light of the US Centers for Medicare and Medicaid Services (CMS) declined to change its rule about reimbursement for drugs in its class. The rule states that drugs targeting amyloid, a key protein in Alzheimer’s disease, can only be covered for patients in clinical trials.
New Startup Launches Platform to Simplify Telehealth Insurance Verification Process
The new startup Opkit, formed by two former Brex software engineers, has launched a new platform to simplify the process [...]
Beneficiaries File Appeal Against UnitedHealth Victory in Mental Healthcare Coverage Case
A group of UnitedHealth members are filing an appeal to a recent court case against the company regarding its mental healthcare coverage practices. The class-action lawsuit alleged that United was basing its coverage decisions on patient claims based on the whims of the finance department, ignoring medical needs. The patient group had orgininally won their case in 2019 and 2020, but these wins were undone by court reversal last year.
Medicare Advantage AI Tools Stripping Care from Older Adults
Medicare Advantage insurers, like many payers, are increasingly relying on artificial intelligence (AI) to make reimbursement decisions, resulting in some older adults being denied access to adequate care. The tools are used to determine exactly when the plan can stop paying for care, often long before it is medically advisable to pull back.
US Veteran’s Administration to Cover Alzheimer’s Drug Leqembi
The US Veteran’s Administration has decided that it will cover Leqembi, Eisai and Biogen’s new therapeutic for Alzheimer’s disease. The announcement comes just weeks after the Centers for Medicare and Medicaid Services (CMS) decided not to expand coverage of the drug to patients outside of clinical trials, a restriction put in place after last year’s approval and failed market release of Aduhelm.
Biden, the GOP, and the Future of Medicare
As the US Congress deliberates over the Biden administration’s recently released budget proposal, uncertainty looms over the future of Medicare funding. President Biden and most Republicans have pledged not to cut funding from the program, but some outliers within the GOP are pushing for cuts. These potential cuts could take one of a three different forms, according to Kaiser Health News correspondent Julie Rovner in a new NPR interview.
Patient Advocacy Groups Embroiled in Copay Suit with PBMs
A rule from the Centers of Medicare and Medicaid Services (CMS) allows pharmacy benefit managers (PBMs) to ignore copay assistance programs from drug manufacturers when accounting for out-of-pocket drug costs for patients. Patient advocacy groups have filed suit against CMS to contest this rule from the Trump Administration.
Talking Remote Care and Reimbursement with Bronwyn Spira of Force Therapeutics
The US Centers for Medicare and Medicaid Services (CMS) introduced new CPT codes last year, reducing barriers via remote care. In a new video by Managed Healthcare Executive, Force Therapeutics’ Bronwyn Spira talks about how these new codes affected outcomes and why outcomes-based reimbursement models may help support these efforts going forward.
Medicare Advantage Insurer’s Margins on the Rise
An analysis from the Kaiser Family Foundation shows that insurers in Medicare Advantage saw strong margins in 2021, twice that of other markers. This is leading many insurers to enter into the market and many others to redouble their efforts, Humana which announced it is pivoting away from the commercial market.
Supporting Comprehensive Care at Safety-Net Providers Through Value-Based Pricing
Although safety-net care systems are essential for providing healthcare to under- and uninsured people, often from marginalized backgrounds, comprehensive care is often out of reach due to a dearth of funding. One way to help address this care disparity, according to a newly published article in Health Affairs, is to implement value-based care pricing models.
ADA Calls for More Oversight and Transparency from Medicaid Managed Care Plans
In a new letter to the Centers for Medicare and Medicaid Services (CMS), representatives from the American Dental Association have asked for increased transparency regarding medical loss ratio (MLR) reporting from Medicaid managed care plans. The authors pointed out that many states were missing substantial chunks of MLR data in recent years.
Do Commercial Payers Rely on ICER Assessments During Specialty Drug Coverage Deliberations?
The Institute for Clinical and Economic Review (ICER) releases value assessment reports that determine cost-effectiveness ratios (CERs) for new and existing therapeutics. A newly published study in the Journal of Managed Care + Specialty Pharmacy, examines whether and how commercial insurance plans in the US incorporate these reports into their reimbursement decision-making process.
US Senators Call for Expansion of Medicare Coverage for Amyloid Alzheimer’s Treatments
Following the controversial approval of the Alzheimer’s drug Aduhelm, the US Centers for Medicare and Medicaid Services (CMS) agreed to only pay for drugs in its class, amyloid-targeted therapies, when used in patients enrolled in clinical trials. A group of Senators have penned a letter to Xavier Becerra, Secretary of the Department of Health and Human Services (DHS) and the CMS Administrator Chiquita Brooks-Lasure.
High-deductible Insurance Plans Harm Patients
To cope with the cost of health insurance, over half of patients in the US with private insurance sign up for high-deductible plans that leave them paying list price for most of their medications and care. While some payer orgs tout the benefits of these plans, researchers are finding that these plans worsen health outcomes for members.
Medicaid Preps for Glut of Expensive New Gene Therapies
Patients, providers, and payers alike are anticipating the release of new gene therapies for conditions like cancer and sickle cell disease. The US Centers for Medicare and Medicaid Services (CMS) released an experimental outcomes-based payment model to help manage the high prices of these therapies. Payouts would be based on patient outcomes, like symptom reduction or remission.
Cystic Fibrosis Patients Stuck with Exorbitant Drug Costs Due to Vertex Feud with Payers
Many patients with cystic fibrosis have been shocked to find that the price of Orkambi, a key drug for the chronic disease, has skyrocketed, with some facing a +200X increase in yearly co-pays. This comes as payers, pharmacy benefit managers (PBMs), and Vertex, the drug’s manufacturer duke it out over reimbursement, copay assistance programs, and a new insurance tool called a copay accumulator.
