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June 21, 2024

Mixed Bag Court Decision On Preventive Services Mandate

A Federal Appeals Court issued a mixed-bag ruling on whether free preventive services will continue in the Affordable Care Act (ACA).  It upheld a lower court ruling finding that the government could not compel a Christian-based business to cover certain services that violate its religious beliefs.  At the same time, it struck down the lower court’s bar on enforcement of preventive services nationwide and returned the future of the preventive services mandate back to a lower court.

Additional article: https://thehill.com/policy/healthcare/4733629-obamacare-preventive-care-mandate-to-stay-in-place-after-court-ruling/

#aca #obamacare #exchanges #healthcare #coverage #healthcarereform

https://www.fiercehealthcare.com/payers/mixed-bag-fifth-circuit-rules-aca-preventive-services-legal-case

AI PA Tech Startup Receives Huge Health Plan Backing

Humata Health, a prior authorization startup, closed a $25 million funding round, gaining backing from prominent health plan concerns. Blue Venture Funds (a capital fund associated with the majority of Blue Cross Blue Shield plans), United’s Optum Ventures, and Highmark (a PA Blue) Ventures all backed the concern. This shows the commitment of health plans to the responsible use of AI in healthcare.

(Article may require a subscription.)

#ai #healthcare #priorauthorization

https://www.modernhealthcare.com/digital-health/top-funding-humata-health-talkiatry-prior-authorization

CBO Scores Could Favor Passage Of Bills To Usher In Generics And Biosimilars

A series of new Congressional Budget Office (CBO) scores that say passage could save the federal budget considerably would appear to help the prospects of passing bills that rein in brand drug maker practices that stop generic and biosimilar introduction and adoption. These include patent reforms, better competition, barring pay-for-delay deals, and reining in lawsuits. This is a very good thing.

(Article may require a subscription.)

#drugpricing #branddrugmakers #biosimilars

https://insidehealthpolicy.com/daily-news/new-cbo-scores-may-boost-chances-drug-patent-bills-year-end-spending-package

Unfair NYT Article Riles PBM Industry

A brand-new New York Times article on PBM practices has again riled pharmacy benefit managers (PBMs).  The PBMs argue the NYT cherry picks scenarios to attack their industry.  I am a supporter of PBMs in general.  They do bring value to the drug channel, including sensible formulary and prior authorization services.  At the same time, there is no question we need some reform of PBMs, including transparent arrangements, barring certain unseemly deals with brand drug makers, and banning spread pricing. 

That said, the NYT articles do appear unfair, are selective in what they feature, and largely give brand drug makers a free pass. I also agree that the NYT is being spoon fed by the PhRMA. Part of the PhRMA agenda is to blame PBMs for all the flaws of the drug supply channel, principally the high prices of brand drug makers.  The article does just that. Sloppy journalism for sure.

(The article at the bottom link is the NYT not behind a pay wall. The second additional article is the PBM trade group’s response.

Additional articles:

https://www.nytimes.com/2024/06/21/business/prescription-drug-costs-pbm.html and https://www.pcmanet.org/press-releases/pcma-statement-on-biased-and-incomplete-article-in-the-new-york-times/06/21/2024/

(Some articles may require a subscription.)

#drugpricing #branddrugmakers #pbms #transparency

https://sg.news.yahoo.com/opaque-industry-secretly-inflating-prices-121357450.html

KFF Survey Shows Eligibility Reforms Despite Huge Medicaid Losses

The Kaiser Family Foundation (KFF) survey of state Medicaid directors shows that states have made a number of eligibility and enrollment reforms despite the huge losses (23 million) since the re-introduction of redeterminations in March 2023. Reforms include expansion of eligibility for key groups (children and pregnant mothers), automation and streamlining renewal processes, automatic enrollment in children’s health insurance programs (CHIP),  and additional outreach.

Additional articles: https://www.kff.org/medicaid/press-release/states-adopted-changes-to-expand-medicaid-eligibility-and-streamline-renewal-processes-that-will-continue-beyond-the-unwinding-though-challenges-remain/  and https://www.kff.org/medicaid/issue-brief/medicaid-eligibility-and-enrollment-policies-for-seniors-and-people-with-disabilities-non-magi-during-the-unwinding/ and https://www.healthcaredive.com/news/medicaid-redeterminations-states-lessons-learned-kff-survey/719489/

#medicaid #redeterminations #coverage

https://www.kff.org/medicaid/report/a-look-at-medicaid-and-chip-eligibility-enrollment-and-renewal-policies-during-the-unwinding-of-continuous-enrollment-and-beyond/

— Marc S. Ryan

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