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New Alzheimer’s Drug Spending Will Leap In Medicare

The Centers for Medicare & Medicaid Services (CMS) says spending on the new Alzheimer’s drug Leqembi will leap well over estimates. CMS estimates that per member per month spending on Leqembi will rise from $1.67 in 2024 to $4.67 in 2025. This will bring spending across all Medicare to $3.5 billion in 2025. This threatens to add demonstrably to Medicare troubles and will hike Part B premiums.

#drugpricing

https://www.fiercehealthcare.com/regulatory/report-cms-projects-spending-leqembi-will-hit-35b-next-year

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Community Health Centers Suffering From Medicaid Disenrollment

A new study of patients at community health centers are reporting major Medicaid disenrollments, which impacts the level of care that can be provided to these individuals.  Community health centers largely serve those in low-income areas.

It also finds that about 75% of people who have lost Medicaid coverage are still disenrolled. Further, 32% have chronic conditions, 24% are children, 12% were adults older than 65 years of age and 12% had disabilities.

#medicaid redeterminations #primarycare

https://www.fiercehealthcare.com/payers/one-year-after-unwinding-community-health-centers-struggle-medicaid-reenrollment

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CMS Cuts Off Broker Access To SSNs

Kudos for Kaiser Health News’ articles and focus on fraudulent switching in the Exchanges by untrustworthy agents.  The trend has caused a lot of misery for enrollees.  One problem was the access by agents and brokers to full social security numbers (SSNs).  As of today, that has been cut off by the Centers for Medicare and Medicaid Services (CMS) in the federal Marketplace.  Henry Kaiser is smiling from heaven.

#kff #khn #fwa #exchanges #aca

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Study Finds Enrollees Like Zero-Premium Benefit Of MA

A Harvard and Inovalon study finds that enrollees in Medicare Advantage (MA) with zero-dollar premiums are three times more likely to be minorities than white. They also are more likely to be urban. Researchers note that MA is not monolithic and that different benefit offerings appeals to enrollees. The same researchers have found that MA enrollees have fewer hospitalizations, yet more social determinant barriers. More are in Health Maintenance Organization (HMO) products which has lower costs.

I would note that MedPAC and other critical organizations simply spend too little time on these types of stats.  I would also say that these kind of advantages for low and fixed income seniors will be ruined by poor rate hikes and terrible prior authorization rules that have just been finalized. It is a real shame.

#medicareadvantage

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CMS Allows Absolute Biosimilar Substitution In Part D

Medicare Part D plans can now immediately substitute all FDA-approved biosimilars even if they are not deemed interchangeable by the drug approval agency, under the 2025 Medicare Advantage (MA) and Part D rule finalized by the Centers for Medicare and Medicaid Servies (CMS). Interchangeability is an extra step that drug makers take to substitute for brand biologics. The new rule will allow Part D plans to treat formulary substitutions of any biosimilars as maintenance changes as was allowed earlier just for interchangeables.

The Biden administration has pushed for biosimilar adoption in many ways and this is yet another. This should begin to mean lower biologic costs for Medicare members.

(Article may require a subscription.)

#biosimilars #drugpricing #medicareadvantage #partd #medicare

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CVS Executive Pushes Back On Cuban And PBM Transparency Narrative

CVS Caremark President David Joyner wrote and op-ed for Fortune to explain the innovation and transparency his pharmacy benefits manager (PBM) is engaged in.  It seeks to counter some of the press Mark Cuban is getting.  I will note that leadership at CVS Health overall is on a path of reform and innovation.

#cvshealth #pbms #transparency

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Private Equity’s Role In Healthcare Takes Center Stage At Hearing

Democrat members of the Senate HELP Committee staged a hearing on the role of corporate greed in healthcare.  Of particular concern was the role of private equity firm monies and whether dollars are diverted out from healthcare to corporate margins.  PE firms have big investments in both hospitals and provider groups.

Additional article: https://www.fiercehealthcare.com/regulatory/steward-healthcares-struggles-full-display-clinicians-policy-researchers-tell-senators

#privateequityfirms #healthcare

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Scrutiny Of Private Equity Healthcare Investments Expand

Private equity investments are already being broadly looked at by Congress and regulators.  Now, the Senate Homeland Security and Governmental Affairs Committee is seeking information on private equity’s role in emergency physician staffing firms that are leaving hospital emergency departments unprepared.

Letters were sent to Apollo Global Management, the Blackstone Group and KKR — three of the nation’s largest private-equity firms — and four emergency medicine staffing companies owned by the firms.  It is estimated at least 40% of hospital emergency departments are overseen by staffing companies that are owned by private-equity firms.

Additional article: https://www.fiercehealthcare.com/providers/senator-probes-private-equity-physician-staffing-firms-emergency-care-cost-cutting

#privateequityfirms #healthcare

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New GLP-1 Survey Says Growth Is Explosive

A new survey from Virta Health backs up the bleak cost picture. It says that 43% of health plan leaders are predicting 100% or more growth in GLP-1s for weight loss and obesity in 2024. More than half say GLP-1s will be a top 3 drug in 2024 in terms of spending. One fifth say they will be their most expensive drug class this year. Executives believe the media is misrepresenting GLP-1s and that lifestyle programs should be tried first. At the same time, a Vitra Health-linked study comes to a different conclusion on what occurs after stopping GLP-1s.  It says those who stop taking GLP-1s can avoid negative effects on glycemia and body weight if they are properly engaged in their healthcare, including proper nutrition.

See my blog today on the subject: https://www.healthcarelabyrinth.com/whats-all-the-clamor-over-glp-1s-for-weight-loss/

#weightlossdrugs #drugpricing

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NBA Player Robert Horry’s Healthcare Adventures Are Proof We Need Affordable Universal Coverage

Touching story on NBA great Robert Horry’s healthcare adventures with his daughter, who lived with a genetic disorder and died in her 18th year.  It is a testament to why we need affordable universal access to healthcare.  Horry is now with a company promoting Individual Coverage Health Reimbursement Arrangements (ICHRA), which allows businesses to cover portions of healthcare premiums and allows employees to privately procure insurance (usually on the Exchange). To me, it is one of the few positive healthcare developments from the Trump administration.

#ichra #obamacare #aca #exchanges

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