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Passage Of Stop Gap Measure In Limbo

The passage of a government shutdown bill is now in limbo after a group of House Republicans as well as President-elect Donald Trump, VP-elect JD Vance, Elon Musk, and Vivek Ramaswamy came out against the measure, arguing it is irresponsible and not a straight government-funding extension.

The bill includes provisions to bolster the accuracy and reliability of Medicare Advantage (MA) provider directories and cost-sharing protections for those who receive care from out-of-network providers due to inaccuracies in those directories.

The bill also includes reform of pharmacy benefit managers’ practices in Medicare, Medicaid and the commercial market and reforming so-called patent thickets to delay generic competition.

Trump and Vance also argue the debt ceiling should be raised under Biden’s watch to avoid issues with Democratic support in 2025.

In other news, the final health piece of the bill left out site-neutral payments and prior authorization reforms.

House Democrats have said they will not support a clean CR to keep government operating.

Additional articles: https://www.fiercehealthcare.com/payers/how-healthcare-orgs-are-reacting-proposed-government-funding-bill and https://www.modernhealthcare.com/politics-policy/donald-trump-government-spending-bill-debt-ceiling and https://insidehealthpolicy.com/daily-news/congress-moves-forward-25-physician-pay-fix-omits-site-neutral-prior-auth-reforms and https://insidehealthpolicy.com/daily-news/trump-jeopardizes-two-year-telehealth-extension-broader-health-deal and https://insidehealthpolicy.com/daily-news/medicare-advantage-ghost-network-reforms-risk-trump-urges-lawmakers-oppose-cr and https://insidehealthpolicy.com/inside-drug-pricing-daily-news/cr-flux-pbm-generic-drug-transparency-drug-patent-reforms-uncertain and https://thehill.com/homenews/administration/5047382-trump-government-spending-deal/ and https://thehill.com/homenews/house/5047510-hakeem-jeffries-democrats-government-funding/

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#governmentshutdown #crs #healthcare

https://thehill.com/homenews/house/5047285-mike-johnson-spending-plan-b

PBMs Took Payments From Drug Makers During Opioid Crisis

A New York Times multi-part expose continues its attacks on the pharmacy benefits manager (PBM) industry. In its latest investigation, the newspaper tells us that PBMs took payments from opioid manufacturers in return for not restricting the flow of pills. PBMs collected billions while tens of thousands overdosed and died from the prescription painkillers. Among the drug manufacturer payors was Purdue Pharma and the disgraced Sackler Family.

Slowly but surely the roles of various drug channel stakeholders have come to light, from drug makers to wholesalers to PBMs to pharmacies. It is a national tragedy stoked by greed. All of the corruption needs to come to light and violators civilly and criminally held to account.

The report is sure to turn up the heat even more on PBMs on Capitol Hill.

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#nyt #opioids #branddrugmakers #pbms

https://www.nytimes.com/2024/12/17/business/pharmacy-benefit-managers-opioids.html

CR and Healthcare Policy Bill Updates

Capitol Hill lawmakers are inching toward a continuing resolution (CR) that needs to be adopted by the end of the week. At the same time, Congress looks like it has agreed to a critical bill to extend certain healthcare programs set to expire at year’s end. Telehealth extensions will be for two years, while the hospital at home program will get a five-year extension. Medicare docs will get a 2.5% hike in 2025 vs. a 2.8% cut. At least a dozen other healthcare areas get fixes or increases under the bill.

In a bombshell, there are major offsets to pay for increases, including major pharmacy benefits manager (PBM) reforms.

• A “delinking” policy to require that Part D Plan sponsors delink PBM compensation from the price of the drug.
• Prohibition on PBM “spread pricing” in Medicaid.
• Medicare Part D transparency requirements for PBMs and Medicare Part D.
• Private Insurance PBM reforms.

Reports also suggest that Medicare Advantage (MA) prior authorization reforms are or may be included. These could include some or all of the provisions in the Improving Seniors’ Timely Access to Care Act.

The PBM trade lobby, the Pharmaceutical Care Management Association (PCMA), issued a vociferous response to reports, arguing the changes will increase costs to the government, employers, and consumers. Specifically, it says the delinking reform would increase premiums in Part D by $13 billion and will benefit drug companies.

In other news, an interesting article on the state of traditional PBMs and those dedicated to transparency. President-elect Trump declared last week he would support reform of PBMs. Major companies with PBMs saw their stocks drop on the declaration.

Additional articles: https://thehill.com/business/budget/5042654-government-funding-deal-progress/ and https://insidehealthpolicy.com/daily-news/lawmakers-close-health-package-includes-two-year-telehealth-extension and https://www.fiercehealthcare.com/payers/pbm-lobby-punches-back-end-year-package and https://insidehealthpolicy.com/daily-news/pbm-lobby-blasts-reported-inclusion-delinking-private-market-transparency-policies and https://www.fiercehealthcare.com/payers/2025-outlook-alternative-pbms-look-heap-pressure-industry-titans and https://www.modernhealthcare.com/politics-policy/cvs-unitedhealth-cigna-shares-pbms-donald-trump-middlemen

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#crs #governmentshutdown #healthcare #pbms #drugpricing #hospitalathome #telehealth #medicareadvantage #partd #pdp #medicaid #physicians #rates #trump

https://www.fiercehealthcare.com/regulatory/two-year-extension-telehealth-likely-negotiations-crest-congress

UnitedHealth CEO Admits Frustration Is Understandable

UnitedHealth Group CEO Andrew Witty published an opinion piece in The New York Times today where he acknowledged the rage that has surfaced in the aftermath of the death of his deputy. Witty said health plans play a role in the issues. Witty stated: “We know the health system does not work as well as it should, and we understand people’s frustrations with it.”

Oscar Health CEO Mark Bertolini, who once ran Aetna before its merger with CVS Health, also said that anger at the healthcare system is “justified.” Bertolini says he would eliminate employer-sponsored insurance because employers have little leverage. He thinks that migrating to individual coverage would be better. Oscar is focused on the individual market.

While I understand Witty’s statement in light of what occurred, I think insurers are an actor in a very dysfunctional system. Health plans alone are not the culprits. See my blog here: https://www.healthcarelabyrinth.com/i-am-shocked-by-the-vitriol-post-unitedhealthcare-executives-assassination/

In other news, Pro Publica obtained a UnitedHealthcare playbook that seeks to limit the coverage of autism.

Additional articles: https://www.modernhealthcare.com/insurance/unitedhealth-group-andrew-witty-brian-thompson-nyt-op-ed  and https://thehill.com/policy/healthcare/5039515-oscar-health-ceo-employer-healthcare-unitedhealthcare-shooting/?tbref=hp and https://thehill.com/policy/healthcare/5039630-unitedhealth-ceo-defends-healthcare/ and https://www.fiercehealthcare.com/payers/unitedhealth-strategically-limiting-access-critical-treatment-kids-autism

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#unitedhealthcare #oscar #tragedy

https://www.fiercehealthcare.com/payers/unitedhealth-group-ceo-acknowledges-outpouring-frustration-healthcare

Centene Earnings Guidance Released For 2025

Centene released its earnings guidance for 2025 at its investor day. Centene says revenue will be between $166.5 billion and $169.5 billion. It says utilization will continue to be elevated and its medical loss ratio (MLR) will be between 88.4% and 89%.

Centene reaffirmed that it expects to bring in between $143.5 billion and $144.5 billion in premium and service revenue for 2024. Its MLR will be between 88.3% and 88.5% for this year.

Centene expects to lose $250 million on Medicare Advantage (MA) this year but intends to break even by 2027. It also lost 20% of its MA enrollment during the 2025 enrollment season that just concluded.

Centene will gain $200 million in additional MA Star Ratings bonus payments in 2026 after the Centers for Medicare and Medicaid Services (CMS) revised its ratings.

Additional articles: https://www.modernhealthcare.com/insurance/centene-medicare-advantage-ratings-investor-sarah-london and https://www.beckerspayer.com/policy-updates/centenes-predictions-for-trump-administration-policy-3-things-to-know.html

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#centene #medicareadvantage #medicaid #managedcare

https://www.fiercehealthcare.com/payers/centene-expects-earn-least-1665b-revenue-2025

Bipartisan Bills Seek PBM Divestitures From Health Plans

More evidence that some kind of pharmacy benefits manager (PBM) reform is coming on Capitol Hill: Democratic and Republican lawmakers now have bills to have health plans divest their PBMs. In the Senate, the bill is co-led by a very unlikely pair – liberal Sen. Elizabeth Warren, D-MA, and conservative Sen. Josh Hawley, R-MO. In the House, a companion bill is sponsored by Rep. Jake Auchincloss, D-MA. and Diana Harshbarger, R-TN. Hawley is among those anti-corporate welfare Republicans who are getting more active on healthcare issues.

The Patients Before Monopolies Act of 2024 would require insurers to sell off their PBMs within three years. The bill also would prohibit corporations that own PBMs or health plans from also owning pharmacies.

Other PBM reform proposals continue to gain bipartisan momentum. Some changes could come in the end-of-year stop-gap bill or sometime in 2025.

Additional articles: https://www.modernhealthcare.com/politics-policy/pbm-act-cvs-unitedhealth-cigna-elizabeth-warren-josh-hawley and https://www.healthcaredive.com/news/pbm-act-force-pharmacy-sales-introduced-unitedhealth-cigna-cvs/735233/ and https://thehill.com/policy/healthcare/5035450-bipartisan-lawmakers-want-to-force-health-insurers-pbms-to-sell-off-pharmacies/

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#pbms #healthplans #drugpricing

https://www.fiercehealthcare.com/payers/warren-hawley-introduce-bill-requiring-insurers-offload-pbm-businesses