State Affordability Boards Taking On Drug Makers Where The Feds Have Failed
Frustrated by high drug prices and inadequate policy changes at the federal level (save for slow-moving Medicare drug price negotiations), states are setting up drug affordability boards that can have vast powers to reduce drug costs. This includes setting an upper limit for sales in their state for certain coverage and the uninsured. This is similar to the Medicare drug price negotiations.
Due to federal pre-emption, these boards only apply to commercial plans. Medicaid has a federal rebate law that allows for federal and state rebates. Medicare is not covered as private plans negotiate prices with drug makers through pharmacy benefits managers or directly. Under the self-insured employer ERISA law, employer groups appear to be able to opt in and thus this has been built into some state laws.
So far, eleven states have approved establishing drug affordability boards, and about a dozen more are considering doing so. Drug makers are suing, claiming the boards are unconstitutional and override several federal laws and due process.
#drugpricing #ira #branddrugmakers #employercoverage #erisa
Touching Story Of One Physician-Mother’s Crusade To Get Her Daughter Life-Saving Treatment
Wonderful story in MedPage today of one physician-mother’s crusade to get her infant daughter critical, life-saving cancer treatment to shrink a rare brain cancer tumor. The story has a lot of agony but happiness with coverage in the end. Imagine what would happen to a family, though, that did not have the health literacy and medical knowledge of this courageous mother. While I am a defender of prior authorization (PA) at health plans, it is clear the insurer was sloppy and only responded to public pressure on this one. It seems to me that novel treatment should be put in a different PA category. Insurers should embrace saving life.
#healthplans #priorauthorization
https://www.medpagetoday.com/special-reports/exclusives/111352
Hospitals Get 2.9% in FFY 2025 For Medicare
The Centers for Medicare & Medicaid Services (CMS) finalized the Medicare inpatient FFY 2025 payment rates at 2.9%, slightly up from the proposed 2.6%. Hospitals decried the initial proposal and will do so for this as well.
Additional article: https://www.modernhealthcare.com/policy/ipps-final-rule-medicare-pay-2025-cms
(Some articles may require a subscription.)
#hospitals #medicare #rates
https://www.fiercehealthcare.com/regulatory/cms-finalizes-29-pay-bump-inpatient-hospitals-fy2025
Employer Survey Shows Struggles With Healthcare Cost Increases
A new survey of employers show that employer health plans are struggling with weight-loss drugs, specialty drugs, and mental health costs, among others.
(Article may require a subscription.)
#employercoverage #erisa #healthcare #weightlossdrugs #drugpricing
NCQA Announces HEDIS Quality Measure Changes
NCQA, the nation’s non-profit quality regulator, is announcing major changes to the HEDIS quality measure data sets. These include refining and introducing measures for major disease states and mental health. A major focus is on health equity and minority populations at risk of disease. While not all these measures impact Medicare Advantage (MA), they do parallel many of the themes of Medicare.
(Article may require a subscription.)
#ncqa #quality #stars #healthcare #medicareadvantage
https://www.modernhealthcare.com/safety-quality/ncqa-hedis-measures-updated-2025
Private Equity Backing Hybrid ER-Urgent Care
Good story about private equity teaming up with hospitals on a new hybrid ER-Urgent Care approach with leading hospitals. On the face of it, the idea sounds good – triage people out of the ER to urgent care. But the ugly part is the rather large facility fee and triage fee being charged as part of the urgent care services. It is clear that patients could receive the care at lower cost at other urgent care centers or through primary care.
#healthcare #providers #privateequityfirms #er #urgentcare
Lilly Says GLP-1s Is Out of Drug Shortage
Drug Maker Lilly says its GLP-1 weight-loss drugs are out of shortage. Lilly and other manufacturers have been battling to boost manufacturing and supply.
Additional article: https://www.reuters.com/business/healthcare-pharmaceuticals/lilly-ceo-says-weight-loss-drug-shortage-end-very-soon-bloomberg-news-reports-2024-08-01/
#weightlossdrugs #drugpricing #branddrugmakers
https://thehill.com/policy/healthcare/4808402-eli-lillys-weight-loss-drugs-shortage
Hospitals Continue To Struggle With Star Quality Ratings
The latest hospital Star results show that hospitals continue to struggle. More hospitals performed more poorly from last year. In part, the drops could be tied to the fact that COVID-pandemic-year data is in this year’s assessment period. About half of the hospitals stayed the same.
(Article may require a subscription.)
#hospitals #medicare #stars #quality
https://www.modernhealthcare.com/safety-quality/cms-hospital-ratings-health-equity
— Marc S. Ryan
