March 14, 2024

Change Pharmacy Network Back On

While insurtechs overall have struggled, at least three – Alignment Healthcare, Devoted Health, and Clover Health – appear to be doing well.  Clover Health had an adjusted EBITDA loss of $19.1 million in the fourth quarter and a full-year loss of $44.7 million last year.  This is significantly better than in 2022. Its medical loss ratio (MLR) is projected to be just 81.2% for 2024. It expects adjusted EBITDA profit up to $20 million. Since it began, it, too, amassed a sizeable membership.

#clover #insurtechs

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Federal Appeals Court Deals Drug Makers A Blow On 340B

A federal appellate court said that a state law could be reconciled with the federal 340B drug discount program. Drug makers are fighting to rein in the discounts they give to various pharmacies and hospitals. 

While I find Big Pharma’s constant lawsuits defending their unreasonable pricing system distasteful, the 340B is in desperate need of reform to ensure that discounts really go to support access for everyone. Some studies show that it is essentially a margin tool for some providers, especially hospitals.

#340b #branddrugmakers #providers #hospitals

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PBM Reform May Be Back From The Dead

Senate Finance Committee Chair Ron Wyden, D-OR, and Ranking Member Mike Crapo, R-ID, want to attach some elements of PBM reform on a must-pass bill to keep the government open.  This came after pressure from various advocate and provider lobbies when it was not included in other bills. There is a long way of convincing to go. The House had passed a more comprehensive bill, but would likely go along.

Additional articles: https://insidehealthpolicy.com/daily-news/senate-finance-leaders-seek-quick-passage-pbm-reforms\ and https://insidehealthpolicy.com/inside-drug-pricing-daily-news/cbo-scores-ec-pbm-bill-after-suggesting-delinking-could-save-less

(Articles may require a subscription.)

#pbms #drugpricing

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New HHS Artificial Intelligence Task Force Being Created

A new Health and Human Services (HHS) artificial intelligence task force will oversee “assurance, monitoring, risk-management practices” around AI in healthcare.  The task force comes from a directive in a recent Biden executive order. The task force will cover many agencies within HHS.

#ai #healthcare

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Excellent Blog On GLP-1 Weight-Loss Drugs

I highly recommend reading this excellent blog on GLP-1 weight-loss drugs.  Among the conclusions I find in here are the following:

  • Almost 70% of patients stopped GLP-1 treatment less than one year after starting
  • Almost two-thirds of lost weight was gained back when switched to a placebo. It points to the need for lifetime use to be effective.
  • The drug works best with lifestyle changes.
  • There are suspected unknown long-term effects of the drug. Some studies already show some impacts, including pancreatitis for those with diabetes. Note that dosages for pure weight-loss seem to be higher.
  • There are limitations in existing published studies and the public is not getting the full picture.
  • A cautious approach on GLP-1 is needed and widespread adoption is premature.
  • Fundamental questions remain about who should take them and at what doses. Long-term health impacts could be more concerning than actual costs.

By the way, none of this seems to matter to brand drug makers. They are not particularly worried about real long-term effects of drugs. They want to pass their tests and get to market to earn money. They will deal with the impacts later. The Food and Drug Administration (FDA) is little better. It has a broken system and a revolving door, which has meant a lack of true oversight and thorough testing of many drugs.

In addition, a STAT article finds that the Food and Drug Administration’s (FDA) approval of Wegovy for the reduction of risk of major heart complications for those with heart disease and who are overweight or obese could open the door to major spending on weight-loss drugs in Medicare. Medicare is prohibited by law from covering medications for obesity treatment alone. 

STAT article on Wegovy: https://www.statnews.com/2024/03/14/medicare-wegovy-fda-label-ruling-heart-health-benefits/

(Some articles may require a subscription.)


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Health Plan Lobby Pushes Back On Request For Prior Auth Flexibility In Light Of Change Cyber Attack

Health plan trade group AHIP is pushing back on a federal government request to hit pause on prior authorizations. While the health plan’s position may seem unpopular, it is justified – especially in light of the drubbing it is taking on the new Medicare prior authorization rule.

(Article may require a subscription.) 

#priorauthorization #healthplans 

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Excellent FDA Proposals On Generic Competition

The Food and Drug Administration has some excellent legislative proposals that would promote greater generic competition. These include:

  • Amending exclusivity provisions
  • Establishing a safe harbor for skinny labeling
  • Requiring full ingredient disclosure for drugs
  • Closing patent litigation loopholes
  • Easing requirements for generic drug-device combination products
  • Enhancing the availability of generic animal drugs
  • Eliminating the statutory distinction between biosimilars and interchangeable drugs
  • Unrestricted biosimilar substitution. A Medicare proposal would do the same for Part D

Proposals here: https://insidehealthpolicy.com/fda-releases-budget-justification-legislative-proposals

(Articles may require a subscription.)

#fda #generics #drugpricing

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Tough Going For Brand Drug Makers

Brand drug makers have seen a series of setbacks in federal courts over their claims against the Inflation Reduction Act’s Medicare drug price negotiations. A New Jersey federal judge is not making it easier for them. The judge appears skeptical of many of the drug makers’ claims of unconstitutionality. Arguments were largely centered on claims the negotiations violate the takings clause of the fifth amendment.

(Article may require a subscription.)

#ira #drugpricing #branddrugmakers

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EHealth Finds High Satisfaction With Medicare Advantage

An eHealth survey of its customers and the general public found that 93% of Medicare Advantage (MA) enrollees are “satisfied” or “very satisfied” with their plan choice. Ninety-six percent of participants reported that they enrolled in MA because it helped them with coverage gaps; 97% believe the government should preserve access.

EHealth survey here: https://news.ehealthinsurance.com/_ir/68/20242/Spotlight_on_Medicare_Advantage_Agent_Satisfaction.pdf

EHealth also had a great report on MA statistics and figures for 2024: https://news.ehealthinsurance.com/_ir/68/20242/eHealth_Medicare_Index_Report_2024.pdf

Also, a very balanced Commonwealth primer on Medicare Advantage: https://www.commonwealthfund.org/publications/explainer/2024/jan/medicare-advantage-policy-primer#:~:text=The%20average%20premium%20for%20a,%2450%20or%20more%20per%20month.

#medicareadvantage #coverage

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— Marc S. Ryan

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