January 5, 2024

FDA Approves Florida Drug Importation

The Food and Drug Administration (FDA) has approved Florida to import prescription drugs from Canada via bulk purchasing. This would mean Florida residents would have access to Canadian wholesale prices, which are far lower than in the United States. Brand drug makers immediately attacked the waiver as reckless and claimed it could endanger health. Nonsense. Canada is a developed country with a great safety record. The waiver also has strict quality control measures in it. This is yet another stunt by Big Pharma to maintain its high prices in the United States. It likely will sue to stop it. Canada, too, could disrupt the plan if it results in shortages there. Although the targeted drugs right now look like they are in reasonable supply, look out for a “manufactured” crisis to emerge.

This is a feather in the cap of presidential candidate and Fl. Gov. Ron DeSantis, who has been pressing the Biden administration for the waiver. Biden will surely tout this during his run. Donald Trump too, as he passed the original rules to allow states to do this. Florida sued the federal government when its application stalled.

Florida says residents could save $150 million annually, but Florida will start very slowly, with a few classes of drugs and government programs now. Other states have pending applications and others could submit as well. So, broad relief will take time and the program would have to grow in Florida and other states. Many currently import drugs individually through Canadian pharmacies and it is technically illegal. But with Medicare drug price negotiations, this is yet another way to solve a huge affordability crisis in America over time.

2024 Formularies Show More Biosimilars But Will It Always Mean The Lowest Price?

More news on better penetration of biosimilars. This is good news overall, but watch for some weird impacts as well. As I have discussed in a recent blog, PBMs tend to play games by keeping some brands on the formulary at the expense of generics due to rebates. The same happens with brands vs. biosimilars.

Even with greater adoption of biosimilars on formularies, other behind-the-scenes arrangements (akin to rebates) motivate PBMs in different ways. That can leave consumers scratching their heads. It could lead to potential differences in prices and cost-sharing based on the PBM their health plan has and what brands and generics/biosimilars are on the formulary. In the end, PBMs may end up with a better net price, but consumers may not always benefit. So, we still don’t have transparency even with the positive steps. Mark Cuban’s Cost Plus Drugs is the most transparent entity and seems to get the best deals for patients. So, be cautiously optimistic by the development.

#drugpricing #biosimilars

Link to Article

Elevance Health Sues CMS Over Star Ratings

Elevance Health and its state-based subsidiaries are suing the Centers for Medicare and Medicaid Services (CMS) over the Star program. Elevance wants new technical changes surrounding calculations undone and Star scores recalculated with new quality bonuses. Elevance says CMS violated the Administrative Procedure Act when promulgating rules for the Star program. The decision could rest on whether there was a technical error that deleted a key section of a rule at one point in time. Courts have been much more active in ruling against regulatory rulemaking of late. Elevance is battling low Star scores for 2024, which impacts revenue greatly for its 2M Medicare Advantage (MA) lives.

(Article may require a subscription.)

#stars #elevancehealth #medicareadvantage

Link to Article

Aetna Reporting Great MA Enrollment

CVS Health is reporting great Atena Medicare Advantage (MA) growth for 2024. It says it may add as many as 800,000 lives, a one-fourth increase over Q3 enrollment. It would be an even bigger gain year-over-year. It is riding high on strong 2024 Star scores that turned around from a disappointing 2023. Bigger plans United and Humana are tempering expectations. Overall, the projections were that the industry would continue to see lower enrollment gains year-over-year.

(Article may require a subscription.)

#aetna #cvsaetna #cvshealth #medicareadvantage #stars

Link to Article

ACHP Urges Finalization of Strong MA Rule

The Alliance of Community Health Plans (ACHP) should be commended for its work leading up to the announcement of the 2025 Medicare Advantage and Part D rule. The organization has been pressing for a number of reforms that were included in the proposed rule. It is now asking the Centers for Medicare and Medicaid Services (CMS) to finalize proposals for standardized broker payments and overall reform of broker compensation. Marketing reforms were a key part of their recommendations.

(Article may require a subscription.)

#ahcp #medicareadvantage #partd #cms

Link to Article

NH Declines To Make Medicaid Expansion Permanent

The NH House rejected legislation that would have permanently continued the state’s expanded Medicaid program, which provides nearly 57,000 low-income residents health insurance. The program will remain in place for the next seven years.

#aca #medicaid #nh

Link to Article

Other States Could Expand Medicaid – Emphasis On Could

There are ten states that have not enacted Medicaid expansion under the Affordable Care Act to 133% of the federal poverty limit. The Kaiser Family Foundation says 3.5 million uninsured adults would become eligible if all states expanded Medicaid. This article offers some hope that some states might finally change their minds on expansion. But the odds are not necessarily great.

#aca #medicaid

Link to Article

More Bad Press on Medicare Advantage Marketing

I think the advocates and Sen. Richard Blumenthal, D-CT, are largely wrong here. Opponents seem simply anti-prior authorization and opposed any limits on networks. But marketing has been abused the past few years (largely by third party marketing firms) and special needs plans can be especially tricky. United and the industry are taking a hit here and it will mean more investigations on Capitol Hill.

#medicareadvantage #united #marketing

Link to Article

— Marc S. Ryan