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July 10, 2024

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FTC To Sue Big Three PBMs

The Wall Street Journal (WSJ) is reporting that the Federal Trade Commission (FTC) will sue the Big 3 pharmacy benefits managers (PBMs) – United’s Optum, Cigna’s Express Scripts, and CVS’ Caremark — over anti-competitive behavior. The suits could center on the vertical integration with their sister health plans, which means the PBMs favor corporate-owned pharmacy assets at higher costs to the public. The suit may also challenge rebate deals with brand drug makers and concomitant formulary restrictions. The move likely means more pushes on Capitol Hill to reform PBMs.

While some of this may be true, I continue to believe that brand drug makers are the biggest problem in terms of high drug prices.

Additional article: https://www.fiercehealthcare.com/payers/wsj-ftc-sue-pbms-over-drug-pricing-tactics

#pbms #drugpricing #ftc #antitrust

https://www.healthcaredive.com/news/ftc-to-sue-pharmacy-benefit-managers-caremark-express-scripts-optumrx-wsj/72102

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New FTC Investigation Report Targets PBMs

In its initial report on an antitrust investigation into the role of pharmacy benefits managers (PBMs), the competitiveness watchdog Federal Trade Commission (FTC) says PBMs have vast power that disadvantages consumers and independent pharmacies. It reports the following:

Consolidation and vertical integration of health plans and PBMs have impacted price and accessibility and led to anti-competitive behavior.
Independent pharmacies suffer broadly from the trends in the PBM industry.
It criticized narrow and preferred network strategies, formulary and rebate arrangements, and specialty pharmacy arrangements.
It noted that 80% of all PBM business is controlled by just three major entities – United’s Optum, CVS’ Caremark, and Cigna’s Express Scripts.
Arrangements with owned entities, including retail pharmacies, mail-order pharmacies, and specialty pharmacies, hurt consumers.

The major PBM lobbying group pushed back on the findings vigorously. While PBMs need reform and more transparent approaches, I feel the FTC has put the entire onus for high prices and anti-competitive behavior on PBMs and not brand drug makers. The FTC has adopted the same whipping boy mentality as Congress.

Additional articles: https://www.fiercehealthcare.com/payers/ftc-report-pbms-may-urgently-require-potential-regulation and https://www.modernhealthcare.com/politics-policy/pharmacy-benefit-managers-pbms-higher-prices-ftc-cvs-cigna-unitehealth and https://thehill.com/policy/healthcare/4762024-federal-trade-commission-report-pharmacy-middlemen-price-hikes/

(Some articles may require a subscription.)

#pbms #drugpricing

https://www.healthcaredive.com/news/ftc-pharmacy-benefit-manager-investigation-interim-report/720814

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New Wall Street Journal Study To Generate Huge Capitol Hill Focus

A Wall Street Journal (WSJ) analysis published today finds that Medicare Advantage (MA) plans filed numerous questionable diagnoses in the risk adjustment program to generate about $50 billion between 2018 and 2021. The WSJ found diagnoses for patients that did not have certain conditions or could not possibly have such conditions. It also found that many conditions were diagnosed at a much higher rate in MA than in the traditional fee-for-service (FFS) prorgam. This adds to numerous other private and public studies that will be fodder for reforms coming from Capitol Hill on MA overpayments.

As many of you know, I am a defender of MA and feel that some accusations of overpayments are not accurate. I do not doubt there are some inaccuracies in what the WSJ found as well. At the same time, I have said there are some bad actors who are disproportionately benefiting from certain unscrupulous risk scoring activities. In addition, I have questioned the manual chart review and health risk assessment submission processes. See my blog on all this here: https://www.healthcarelabyrinth.com/will-cms-rein-in-risk-adjustment-submissions/ . See my podcast on all this here: https://www.healthcarelabyrinth.com/25-ma-plans-should-ready-for-changes-to-risk-adjustment-submissions/ .

Additional articles: https://science.slashdot.org/story/24/07/08/1540200/insurers-pocketed-50-billion-from-medicare-for-diseases-no-doctor-treated and https://www.beckerspayer.com/payer/insurers-brought-in-50b-through-medicare-advantage-coding-wsj.html .

(Some articles may require a subscription.)

#medicareadvantage #riskadjustment #overpayments #cms

https://www.wsj.com/health/healthcare/medicare-health-insurance-diagnosis-payments-b4d99a5d

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Brand Pharma Spends More On Stock Buybacks And Marketing Than R&D

A report from Accountable, a nonpartisan watchdog group, found that brand drug makers spent more on stock buybacks, marketing, and other related spending than on research and development (R&D). Accountable said the companies spent $95.9 billion on R&D expenditures in 2023, but spent 70% more on stock buybacks, dividends, and marketing and administrative costs. It also found that the companies spent nearly $500 million collectively on executive and board compensation, at least $83.2 million on trade association dues, $10.6 million on political contributions and $57.8 million on lobbying. This is consistent with a report from Sen. Bernie Sanders, I-VT, and Democrats on the Senate HELP Committee.

Accountable argues that these are areas that spending could be reduced to offset any potential impact on margins and a commensurate reduction in R&D due to Medicare drug price negotiations.

As they always do, the drug maker lobby said information got cherry picked. It is always someone else’s fault that America has disproprtionately high drug prices.

(Article may require a subscription.)

#drugpricing #ira #branddrugmakers

https://insidehealthpolicy.com/inside-drug-pricing-daily-news/report-drug-makers-spending-2023-failed-prioritize-rd

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CMS Published Recalculated 2024 Medicare Advantage Star Scores

The Centers for Medicare and Medicaid Services (CMS) made public its revised Star scores for 2024 for Medicare Advantage (MA) plans today. The agency will have to fund an additional $1.3 billion after being rebuked by two courts on how it ignored regulations when setting guardrails for 2024. Actuarial firm Milliman says seventy-six MA contracts from 44 insurers (with almost 3.5 million members) saw increased Star scores.

(Article may require a subscription.)

#medicareadvantage #stars #cms

https://www.modernhealthcare.com/medicare/medicare-advantage-star-ratings-recalculation-scan-elevance

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KFF Analysis Says MA Still Has Highest Margins

A Kaiser Family Foundation (KFF) analysis says that the highest gross margins were found in Medicare Advantage (MA) in 2023. At the end of 2023, gross margins per enrollee in MA were $1,982 on average compared to $1,048 in the individual market. Medicaid was the lowest at $753. Group plans fell in the middle at $910.

Despite some of the troubles health plan are having with MA right now, the data proves MA is still a good place to be, with high revenues per enrollee and the ability to reduce spending to generate good margins.

KFF Analysis: https://www.kff.org/medicare/issue-brief/health-insurer-financial-performance/

#medicareadvantage #healthplans

https://www.fiercehealthcare.com/payers/kff-insurance-market-had-highest-gross-margins-last-year

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Healthcare World Panicking Over Chevron Deference Being Struck By Supreme Court

With the Supreme Court striking down the Chevron deference as the backbone of promulgating regulations, the healthcare world is officially in panic. Most argue it will grind rule-making to a halt, create court backlogs and inconsistent rulings, and jeopardize health. I touch upon many of these points in my Thursday blog. I have mixed views on the ruling. I am not sure the world comes to an end as many think, but it will have vast implications.

#chevrondeference #cms #hhs #regulations #healthcare

https://kffhealthnews.org/news/article/supreme-court-chevron-deference-doctrine-health-care-policy-shockwaves/

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Supreme Court Takes Out Chevron Deference

In an expected move, the Supreme Court ruled that the Chevron deference precedent is no more. It has pulled back on the precedent and has now thrown it out. The precedent said that courts must give deference to regulatory agencies when they make reasonable interpretations of ambiguous laws. Proponents of deference said that it is a necessary power of regulatory agencies and that its elimination will now lead to a Wild West of court decisions in the future. Opponents argued that it created an administrative state that was far-reaching and one that went well beyond legislative intent. I will write a blog on the possible implications for healthcare. The removal of the deference rule does not change the fact that the Centers for Medicare and Medicaid Services (CMS) has often just got its regulations wrong or ignored them entirely. But it does have vast implications for healthcare policy.

Additional Articles: https://www.modernhealthcare.com/government/supreme-court-chevron-ruling-federal-regulation and https://insidehealthpolicy.com/daily-news/cms-fda-face-weakened-authority-following-scotus-chevron-decision and https://insidehealthpolicy.com/inside-drug-pricing-daily-news/chevron-ruling-could-chill-fda-s-public-health-efforts-stem-ai-ldt and https://www.fiercehealthcare.com/regulatory/supreme-court-overrules-chevron-deference-dealing-blow-federal-healthcare-agencies and https://www.healthcaredive.com/news/scotus-overturns-chevron-doctrine-healthcare/720219/

(Some articles may require a subscription.)

#chevron #cms #hhs #regulations

https://www.washingtonpost.com/politics/2024/06/28/supreme-court-chevron-federal-agency-authority

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Walgreens’ Bleeding Continues

Walgreens’ stock fell 24% as the drugstore chain slashed its profit outlook. It will reduce the size of its pharmacy footprint and continue to evaluate and right size its investment in VillageMD, primary care clinics tied to retail settings.

Additional articles: https://www.healthcaredive.com/news/walgreens-to-reduce-villagemd-stake-close-stores/719984/ and https://www.modernhealthcare.com/providers/walgreens-villagemd-ownership-majority-stake and https://www.modernhealthcare.com/providers/walgreens-boots-alliance-shares-drop-store-closings-ceo-tim-wentworth

(Some articles may require a subscription.)

#walgreens #retailmeetshealthcare #primarycare

https://www.fiercehealthcare.com/providers/walgreens-slashes-profit-guidance-plans-close-more-pharmacy-stores-turnaround

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Quarterly Drug Inflation Rebate Caps Save More Dollars For Medicare And Enrollees

The Centers for Medicare & Medicaid Services (CMS) announced 64 new drugs subject to quarterly caps because price increases exceeded allowable inflation. This will mean additional rebates and lower out-of-pocket costs for 750,000 enrollees. The provision was passed as part of Medicare drug price negotiations in the Inflation Reduction Act (IRA).

In addition, states increasingly are passing protections on drug manufacturers limiting 340b discounts to certain providers. This came after the Supreme Court upheld such state laws. I do not agree generally with the ruling as it perpetuates an abuse of 340b’s intent.

Additional articles: https://thehill.com/policy/healthcare/4740963-biden-lower-prescription-drug-costs-medicare-inflation-reduction-act/ and https://www.modernhealthcare.com/supply-chain/340b-drug-program-discounts-arkansas-missouri-laws

Press Release Here: https://www.cms.gov/newsroom/press-releases/hhs-announces-cost-savings-64-prescription-drugs-thanks-medicare-rebate-program-established-biden

(Some articles may require a subscription.)

#drugpricing #ira #medicare #partd #pdp #medicareadvantage

https://www.fiercehealthcare.com/payers/hhs-lowers-64-prescription-drug-prices-under-medicare-rebate-program