July 10, 2024

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


Brand New Interoperability Rule Published

Even though major new interoperability requirements have yet to go into effect, the nation’s healthcare interoperability regulator, the Office of the National Coordinator (ONC) within the Department of Health and Human Services (HHS) issued fresh new interoperability standards for data-sharing. Among other things, the rule helps implement HHS prior authorization (PA) mandates as well as updates required US Core Data for Interoperability (USCDI) standards to version 4. It also has certification standards for electronic PA. 

Additional article: https://insidehealthpolicy.com/daily-news/hhs-releases-proposed-interoperability-health-data-rule

(Some articles may require a subscription.)

#onc #hhs #interoperability


Medicare FFS Rate Proposals Creating Huge Provider Concerns

For federal fiscal year 2025, the Centers for Medicare and Medicaid Services (CMS) announced a 2.9% decrease for Medicare physicians and a 2.6% increase for hospital outpatient and ambulatory surgery centers (ASCs).  Both proposal met with criticism from providers are inadequate.  Physicians especially are in need of a permanent solution that recognizes their financial needs.

Additional articles: https://www.modernhealthcare.com/policy/policy/doctors-medicare-pay-cut-cms-2025 and https://www.fiercehealthcare.com/providers/cms-floats-26-annual-outpatient-asc-pay-increase-new-obstetrics-conditions-participation and https://www.modernhealthcare.com/policy/outpatient-hospitals-medicare-pay-cms-2025  and https://www.healthcaredive.com/news/medicare-proposed-outpatient-payment-rates-2025/720945/

(Some articles may require a subscription.)

#medicare #rates #providers


More On Court Staying Agent Compensation Reform In MA

New articles on a federal court staying implementation of agent-broker compensation reform in Medicare Advantage (MA). It creates unknowns for the 2025 enrollment even as a great deal of churn is anticipated due to the reining of benefits.

Additional article: https://www.modernhealthcare.com/insurance/medicare-advantage-marketing-ruling-2025-open-enrollment

(Some articles may require a subscription.)

#marketing #tpmos #brokers #medicareadvantage #cms


House GOP Proposes Even More Regulatory Restrictions Post Chevron Precedent Repeal

 A group of GOP members in the House are proposing even more restrictions on agency rulemaking post the Supreme Court’s decision to strike the Chevron precedent. Among other changes, their bill would limit agency regulation to what authority is explicitly delegated by Congress.

(Article may require a subscription.)

#chevron #supremecourt #regulations


CMS Says More Prior Authorization Restrictions Coming

CMS says it will issue a new rule to streamline the prior authorization of certain drugs in Medicare Advantage (MA) and the Exchanges. The rule could come in November.  This after two huge rules that chill the ability of MA plans to save medical expense. More bad news would come on the benefits front if the rule is issued.

(Article may require a subscription.)

#priorauthorization #medicare #exchanges #healthplans #managedcare


— Marc S. Ryan

Leave a Reply

Your email address will not be published. Required fields are marked *

Available Now