Insurers Say PA Reforms Taking Hold
The two main insurer trade groups say definitive progress is being made to implement voluntarily agreed-upon prior authorization (PA) reforms. AHIP and the Blue Cross Blue Shield Association released a report that found leading health plans reduced prior authorizations for an array of services by 11% since the pledge was made. This equates to 6.5 million fewer prior auth requests for patients. Reductions in Medicare Advantage were 15%.
The insurers say that PAs were removed where there were clear clinical guidelines and consistent utilization trends for providers. The groups say insurers have introduced more consumer-friendly language and appeals steps.
About 50 plans signed on to the initiative, including all six of the largest, publicly traded plans.
#priorauthorization #healthplans
Wakely’s BALANCEd Assessment
Wakely released a great analysis on what health plans need to consider if they join the BALANCE model, which would bring GLP-1 coverage to Medicare Part D enrollees who have obesity. The drugs are already covered for other disease states, such as heart disease and diabetes.
Wakley made some interesting observations:
Higher risk scores among currently eligible GLP-1 utilizers do not correspond to higher claims costs relative to non-users (they have lower risk scores but higher claim costs).
GLP-1 utilizers have the lowest net claims costs after normalizing using MA risk scores for all GLP-1 eligible populations under BALANCE. But that could change as plan sponsors accept more Part D liability.
Net claims costs for the utilizer cohort are materially lower in inpatient and outpatient spending in all years than for the non-utilizing eligible population but higher in professional and other medical. Wakely says it cannot definitively associate GLP-1 usage to lower inpatient costs.
#glp1s #weightlossdrugs #medicareadvantage #partd #pdp #balance
— Marc S. Ryan
