Democrats Winning Key House Leadership Jobs Have Taken Millions From Pharma

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Source: Kaiser Health News

Three of the lawmakers who will lead the House next year as Congress focuses on skyrocketing drug costs are among the biggest recipients of campaign contributions from the pharmaceutical industry, a new KHN analysis shows.

On Wednesday, House Democrats selected Rep. Steny Hoyer of Maryland to serve as the next majority leader and Rep. James Clyburn of South Carolina as majority whip, making them the No. 2 and No. 3 most powerful Democrats as their party regains control of the House in January.

Both lawmakers have received more than $1 million from pharmaceutical company political action committees in the past decade. Just four members of Congress hold that distinction, including Rep. Kevin McCarthy of California, whom Republicans chose as the next House minority leader earlier this month.

Adding Rep. Nancy Pelosi, the California Democrat expected to be the next speaker, the three-person House Democratic leadership team has collected more than $2.3 million total in campaign contributions from drugmakers since the 2007-08 election cycle, according to KHN’s database.

High drug prices surfaced as a major campaign issue in 2018. With almost half of Americans saying they were worried about prescription drug costs last summer, many Democrats told voters they’d tackle the issue in the next Congress. But the large amount of money going to key Democrats, and Republicans, raises questions about whether Congress will take on the pharmaceutical industry.

In the past decade, members of Congress from both parties have received about $81 million from 68 pharma PACs run by employees of companies that make drugs and industry trade groups.

Brendan Fischer, who directs federal reform programs at the nonpartisan Campaign Legal Center, said drugmakers, like other wealthy industries, “shower money” on congressional leaders who are mulling legislation that could affect the pharmaceutical industry.

“Both Democrats and Republicans have discussed taking action on prescription drug prices, and drug companies likely expect that big contributions will help them maintain access to, and influence over, powerful lawmakers,” he said.

McCarthy, who has close ties to President Donald Trump, has received more than $1.08 million from drugmaker PACs since 2007. According to the latest data, which runs through September, he received about $250,000 this election cycle.

The fourth lawmaker to top $1 million is Sen. Richard Burr, a North Carolina Republican who serves on both the Senate Committee on Health, Education, Labor and Pensions and the Senate Committee on Finance. North Carolina is also home to a number of research universities and drugmakers’ headquarters.

While campaign contributions may seem tantalizing as a metric for influence, industries are not necessarily buying votes with their cash. More likely, they are buying access — a sizable donation from a drugmaker’s PAC may increase the chances its lobbyists get a meeting with an influential lawmaker, for example.

Clyburn, who like Hoyer has served as a top Democratic leader since 2007, has received more from drugmaker PACs over the past decade than any other member of Congress — more than $1.09 million. During the 2018 election cycle, he received at least $170,000, despite trouncing his Republican opponent in his safely Democratic district.

A party leader and the highest-ranking African-American in Congress, Clyburn has had ties to the pharmaceutical industry over the years. In 2013, he was a featured speaker at a conference hosted by PhRMA, the industry’s leading trade group. The conference was held at the James E. Clyburn Research Centerat the Medical University of South Carolina, a hub for biopharmaceutical research.

This fall, Hoyer topped the million-dollar mark in drugmaker PAC contributions over the past decade, collecting more than $1.02 million since 2007 and more than $128,000 this election cycle.

“Mr. Hoyer’s positions on legislation are based on what is in the best interest of his constituents and the American people, and he has made it clear the new Congress will tackle rising health care and prescription drug costs,” said Mariel Saez, a Hoyer spokeswoman.

Clyburn, McCarthy and Pelosi’s offices did not respond to requests for comment.

Pelosi, in contrast to her deputies, has received nearly $193,000 total from drugmaker PACs the past decade. In the month before the midterm elections, she intensified her calls for action to control drug prices, saying on Election Day that she believed Democrats could find “common ground” with Trump on addressing the problem.

Senior committee members also tend to draw huge sums from the industries they oversee. Rep. Frank Pallone of New Jersey, the Democrat who is expected to chair the House Committee on Energy and Commerce, received nearly $169,000 this election cycle from drugmaker PACs, according to KHN’s database. Since 2007, he has collected more than $840,000.

Similarly, Rep. Greg Walden, the Oregon Republican who is finishing his term as chair of the committee, received $302,300, the most of any member this election cycle in contributions from drugmaker PACs.

By contrast, Rep. Elijah Cummings — the Maryland Democrat who is expected to head the House Committee on Oversight and Government Reform — has attracted minimal drugmaker cash, receiving just $18,500 since the 2007-08 election cycle. He has made it clear that he intends to target pharmaceutical companies next year as he investigates climbing drug costs.

Amazon Private Label Healthcare Offerings Grow

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Source: Healthcare Dive

It remains to be seen how disruptive Amazon will be in the prescriptions space now that it has its own online pharmacy. The company snagged PillPack, which focuses on delivering individualized rolls of presorted medicines to people who manage multiple daily medications.  

It now looks like Amazon is revving up for expansion of PillPack, Jeffries says, citing a new prescribing license in Washington state and licenses pending in Indiana and New Mexico. The pharmacy also has postings for pharmacy technicians and packaging and shipping jobs at its Phoenix distribution center.

“We feel that the strategic significance of the WA Rx license is especially intriguing, suggesting that AMZN is possibly laying the groundwork to leverage the PillPack asset with its own employees before rolling out a full nationwide offering,” Jefferies says.

Amazon is steadily pushing further into healthcare, planting its footprint in a range of product and service areas.

Amazon Web Services, the company’s cloud business, announced last week that three of its most popular services — Amazon Translate, Amazon Comprehend and Amazon Transcribe — are now HIPAA-eligible. That brings to six the number of HIPAA-eligible AWS machine learning services in its catalog of offerings. The other three are Amazon Polly, Amazon SageMaker and Amazon Rekognition.

The eCommerce giant has also secured a patent for a feature that would enable Alexa, Amazon’s voice-activated technology, to detect when a user is feeling ill and recommend an OTC remedy for them to try.

And last month, Amazon announced it would begin selling glucose monitors and blood pressure cuffs direct to consumers via a partnership with Arcadia Group. The devices and supporting apps will be marketed under the “Choice” label and can be purchased without prior authorization.

Amazon also formed a company with J.P. Morgan Chase and Berkshire Hathaway to redesign how healthcare is delivered to their U.S. employees.

In Health Insurance Wastelands, Rosier Options Crop Up For 2019

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Source: Kaiser Health News

In recent years, places such as Memphis and Phoenix had withered into health insurance wastelands as insurers fled and premiums skyrocketed in the insurance marketplaces set up by the Affordable Care Act. But today, as in many parts of the country, these two cities are experiencing something unprecedented: Premiums are sinking and choices are sprouting.

In the newly competitive market in Memphis, the cheapest midlevel “silver” plan for next year will cost $498 a month for a 40-year-old, a 17 percent decrease. Four insurers are selling policies in Phoenix, which then-presidential candidate Donald Trump highlighted in 2016 as proof of “the madness of Obamacare” as all but one insurer left the region.

Janice Johnson, a 63-year-old retiree in Arizona’s Maricopa County, which includes Phoenix, said her premium for a high-deductible bronze plan will be $207 instead of $270 because she is switching carriers.

“When you’re on a fixed income, that makes a difference,” said Johnson, who receives a government subsidy to help cover her premium. “I’ll know more than a year from now if I’m going to stick with this company, but I’m going to give them a chance, and I’m pretty excited by that.”

Across all 50 states, premiums for the average “benchmark” silver plan, which the government uses to set subsidies, are dropping nearly 1 percent. And more than half of the counties that use the federal healthcare.gov exchange are experiencing an average 10 percent price decrease for their cheapest plan.

In most places, the declines are not enough to erase the price hikes that have accrued since the creation in 2014 of the health care exchanges for people who don’t get insurance through an employer or the government.

Instead, experts said, next year’s price cuts help to correct the huge increases that jittery insurers set for 2018 plans to protect themselves from anticipated Republican assaults on the markets. Although Congress came up one vote shy of repealing the law, Trump and Republicans in Congress did strip away structural underpinnings that pushed customers to buy plans and helped insurers pay for some of their low-income customers’ copayments and deductibles. Insurers responded with 32 percent average increases.

“Insurers overshot last year,” said Chris Sloan, a director at Avalere, a health care consulting company in Washington, D.C. “We are nowhere close to erasing that increase. This is still a really expensive market with poor benefits when it comes to deductibles and cost.”

For 2019, the average benchmark silver premium will be 75 percent higher than it was in 2014, according to data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

When Republicans failed to kill the health law last year, they inadvertently may have made it stronger. Insurers banked hefty profits this year, and new companies are moving in.

All these factors were especially influential in Tennessee, where the average benchmark premium is dropping 26 percent, according to a government analysis. That is more than in any other state.

In 2018, 78 of 95 Tennessee counties had just one insurer. That monopoly allowed the insurer to set the prices of its plans without fear of competition, said David Anderson, a researcher at the Duke-Margolis Center for Health Policy in Durham, N.C. “They were massively overpriced,” he said.

But for the coming year, 49 Tennessee counties will have more than one insurer, with a few — like Shelby County, where Memphis is located — having four companies competing. There, Cigna dropped the price of its lowest-cost silver plan by 15 percent. Nonetheless, it was underbid by Ambetter of Tennessee, which is owned by the managed-care insurer Centene Corp.

“We’re finally at the point where the market is stabilized,” said Bobby Huffaker, the CEO of American Exchange, an insurance brokerage firm based in Tennessee. “From the beginning, every underwriter, and the people who were the architects, they knew it would take several years for the market to mature.”

Still, the cheapest Memphis silver premium is nearly three times what it was in 2014, the first year of the marketplaces. A family of four with 40-year-old parents will be paying $19,119 for all of next year unless they qualify for a government subsidy.

“The unsubsidized are leaving,” said Sabrina Corlette, a professor at Georgetown University’s Health Policy Institute. “They are finding these premiums unaffordable.”

The landscape in Phoenix is greatly improved from when Trump visited after the federal government announced a 116 percent premium increase for 2017, as the number of insurers dropped from eight to one.

But now, three new insurers are entering Maricopa County. Ambetter, the only insurer this year, dropped its lowest price for a silver plan for next year by 12 percent and still offers the cheapest such plan.

Ambetter’s plan is still 114 percent above the least expensive silver plan in the first year of the exchanges. And none of the insurers are offering as broad and flexible a choice of doctors and hospitals as consumers had back then, said Michael Malasnik, a local broker.

Since the start of the exchanges, he said, insurers have “raised their rates by multiples, and they’ve figured out you have to be a very narrow network.”

Each plan for 2019 contains trade-offs. He said only Bright Health’s plan includes Phoenix Children’s Hospital. Ambetter’s plan includes the most popular hospital and doctor groups, but they are not as conveniently located for people living in the southeastern corner of the county, making other insurers’ plans appealing.

“Geography is the name of the game this year,” Malasnik said.

Theresa Flood, a preschool teacher who lives outside Phoenix, said none of the plans she considered accepted her doctors, who include a specialist for her spine problems — she has had four surgeries — and a neurologist who monitors a cyst and benign tumor in her brain.

“I have to establish care with a whole new spine doctor and establish care with a whole new neurologist if I want to follow up on these things,” Flood, 59, said. “You’re going from established care to who in the heck am I going to see?”

The plan she chose would have been too expensive except that she and her husband, John, a pastor, qualified for a $1,263-a-month subsidy that will drop the cost to $207 a month. That bronze plan from Ambetter carries a $6,550-per-person deductible, so she expects she’ll still have to pay for her doctors on her own unless she needs extensive medical attention.

“It’s gone from being able to have a plan that you could sort of afford and got some benefit from, to putting up with what you can afford and hoping nothing happens that you actually have to use your insurance,” she said. “At this point, I’ll take what I can get.”

Trump Administration Invites Health Care Industry to Help Rewrite Ban on Kickbacks

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Source: New York Times

The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.

The goal is to open pathways for doctors and hospitals to work together to improve care and save money. The challenge will be to accomplish that without also increasing the risk of fraud.

With its request for advice, the administration has touched off a lobbying frenzy. Health care providers of all types are urging officials to waive or roll back the requirements of federal fraud and abuse laws so they can join forces and coordinate care, sharing cost reductions and profits in ways that would not otherwise be allowed.

From hundreds of letters sent to the government by health care executives and lobbyists in the last few weeks, some themes emerge: Federal laws prevent insurers from rewarding Medicare patients who lose weight or take medicines as prescribed. And they create legal risks for any arrangement in which a hospital pays a bonus to doctors for cutting costs or achieving clinical goals.

The existing rules are aimed at preventing improper influence over choices of doctors, hospitals and prescription drugs for Medicare and Medicaid beneficiaries. The two programs cover more than 100 million Americans and account for more than one-third of all health spending, so even small changes in law enforcement priorities can have big implications.

Federal health officials are reviewing the proposals for what they call a “regulatory sprint to coordinated care” even as the Justice Department and other law enforcement agencies crack down on health care fraud, continually exposing schemes to bilk government health programs.

“The administration is inviting companies in the health care industry to write a ‘get out of jail free card’ for themselves, which they can use if they are investigated or prosecuted,” said James J. Pepper, a lawyer outside Philadelphia who has represented many whistle-blowers in the industry.

Federal laws make it a crime to offer or pay any “remuneration” in return for the referral of Medicare or Medicaid patients, and they limit doctors’ ability to refer patients to medical businesses in which the doctors have a financial interest, a practice known as self-referral.

These laws “impose undue burdens on physicians and serve as obstacles to coordinated care,” said Dr. James L. Madara, the chief executive of the American Medical Association. The laws, he said, were enacted decades ago “in a fee-for-service world that paid for services on a piecemeal basis.”

Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, said the laws stifle “many innocuous or beneficial arrangements” that could provide patients with better care at lower cost.

Hospitals often say they want to reward doctors who meet certain goals for improving the health of patients, reducing the length of hospital stays and preventing readmissions. But federal courts have held that the anti-kickback statute can be violated if even one purpose of the remuneration is to induce referrals or generate business for the hospital.

The premise of the kickback and self-referral laws is that health care providers should make medical decisions based on the needs of patients, not on the financial interests of doctors or other providers.

Health care providers can be fined if they offer financial incentives to Medicare or Medicaid patients to use their services or products. Drug companies have been found to violate the law when they give kickbacks to pharmacies in return for recommending their drugs to patients. Hospitals can also be fined if they make payments to a doctor “as an inducement to reduce or limit services” provided to a Medicare or Medicaid beneficiary.

Doctors, hospitals and drug companies are urging the Trump administration to provide broad legal protection — a “safe harbor” — for arrangements that promote coordinated, “value-based care.” In soliciting advice, the Trump administration said it wanted to hear about the possible need for “a new exception to the physician self-referral law” and “exceptions to the definition of remuneration.”

Almost every week the Justice Department files another case against health care providers. Many of the cases were brought to the government’s attention by people who say they saw the bad behavior while working in the industry.

“Good providers can work within the existing rules,” said Joel M. Androphy, a Houston lawyer who has handled many health care fraud cases. “The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”

But the laws are complex, and the stakes are high. A health care provider who violates the anti-kickback or self-referral law may face business-crippling fines under the False Claims Act and can be excluded from Medicare and Medicaid, a penalty tantamount to a professional death sentence for some providers.

Federal law generally prevents insurers and health care providers from offering free or discounted goods and services to Medicare and Medicaid patients if the gifts are likely to influence a patient’s choice of a particular provider. Hospital executives say the law creates potential problems when they want to offer social services, free meals, transportation vouchers or housing assistance to patients in the community.

Likewise, drug companies say they want to provide financial assistance to Medicare patients who cannot afford their share of the bill for expensive medicines.

AstraZeneca, the drug company, said that older Americans with drug coverage under Part D of Medicare “often face prohibitively high cost-sharing amounts for their medicines,” but that drug manufacturers cannot help them pay these costs. For this reason, it said, the government should provide legal protection for arrangements that link the cost of a drug to its value for patients.

Even as health care providers complain about the broad reach of the anti-kickback statute, the Justice Department is aggressively pursuing violations.

A Texas hospital administrator was convicted in October for his role in submitting false claims to Medicare for the treatment of people with severe mental illness. Evidence at the trial showed that he and others had paid kickbacks to “patient recruiters” who sent Medicare patients to the hospital.

The owner of a Florida pharmacy pleaded guilty last month for his role in a scheme to pay kickbacks to Medicare beneficiaries in exchange for their promise to fill prescriptions at his pharmacy.

The Justice Department in April accused Insys Therapeutics of paying kickbacks to induce doctors to prescribe its powerful opioid painkiller for their patients. The company said in August that it had reached an agreement in principle to settle the case by paying the government $150 million.

The line between patient assistance and marketing tactics is sometimes vague.

This month, the inspector general of the Department of Health and Human Services refused to approve a proposal by a drug company to give hospitals free vials of an expensive drug to treat a disorder that causes seizures in young children. The inspector general said this arrangement could encourage doctors to continue prescribing the drug for patients outside the hospital, driving up costs for consumers, Medicare, Medicaid and commercial insurance.

Trump Administration Looks to Give Private Medicare Plans Negotiating Power on Drugs

Trump administration looks to give private Medicare plans negotiating power on drugs

Source: The Hill

Insurers that participate in Medicare’s prescription drug program would be able to exclude certain drugs if prices rise faster than inflation as part of a new proposal from the Trump administration.

The proposal, announced Monday, is aimed at lowering prescription drug costs for seniors by giving Medicare plans leverage in price negotiations.

Currently, private Medicare health plans are required to cover all or “substantially all” drug in six “protected” classes, such as HIV treatments, antidepressants and cancer drugs, regardless of cost.

This gives pharmaceutical companies little incentive to make the drugs affordable, administration officials said.

“The lack of any ability for Part D plans to manage drugs in the protected classes has allowed the pharmaceutical industry to command high prices on protected class drugs in Part D, without patients getting a good deal,” Centers for Medicare and Medicaid Services Administrator Seema Verma said in a statement.

Under the proposal, health plans would be allowed to exclude protected drugs with price increases that are greater than inflation, as well as certain new drug formulations that are not a “significant innovation” over the original product.

The proposal could save taxpayers $692 million over a decade, officials said.

“By bringing the latest tools from the private sector to Medicare Part D, we can save money for taxpayers and seniors, improve access to expensive drugs many seniors need, and expand their choice of plans,” Health and Human Services Secretary Alex Azar wrote in a Monday blog post.

The proposal would also allow private Medicare plans to use two controversial policies called prior authorization and step therapy — requiring patients try cheaper drugs before turning to more expensive ones, regardless of what their doctor prescribes.

The proposal is sure to elicit significant pushback from the pharmaceutical industry. Patient advocacy groups were quick to argue such policies would restrict seniors’ access to medicine.

“Step therapy is unheard of in the treatment of HIV due to the danger of developing resistance to an entire class of drugs and potential side effects,” the AIDS Institute said in a statement. “The Medicare Part D Program is working well for people living with HIV, and there is no reason to take these draconian actions.”

The American Cancer Society’s advocacy arm also expressed concern with the proposal.

“The proposals aim to save the Medicare program money, but in their current form could actually have the inverse effect, raising costs in other parts of the program and likely resulting in tremendous cost-shifting to patients,” said Chris Hansen, president of ACS’s Cancer Action Network

Administration officials pushed back on the argument of access, saying patients will be “in the driver’s seat.”

“[I]t’s important to remember that if seniors don’t like a plan that takes advantage of these new flexibilities, they are in the driver’s seat. They have the option to choose a different plan that better meets their needs. These new tools will only become as common as beneficiaries want them to be,” Azar said in the blog post.

A Drug Maker Boosted the Price of Its Opioid-Overdose Antidote by 600 percent, and Taxpayers Suffered

Image result for A Drug Maker Boosted the Price of Its Opioid-Overdose Antidote by 600 percent, and Taxpayers Suffered images

Source: STAT

In order to capitalize on the opioid crisis, a small company that sells a version of naloxone, a decades-old drug that is widely used to reverse the effect of opioid and heroin overdoses, raised the price of its product by more than 600 percent between 2014 and 2017, which cost the federal government more than $142 million, according to a lengthy report from a Senate subcommittee.

Central to its strategy, Kaleo circumvented the traditional pharmaceutical market by subsidizing patients who were given its Evzio opioid antidote device, instead of contracting with pharmacy benefit managers and insurers. In doing so, the company used a controversial scheme to provide Evzio at no cost to patients, but counted on private and public insurers to pay an ever-rising wholesale, or list, price.

“Kaléo’s more than 600 percent price increase of EVZIO not only exploits a country in the middle of an opioid crisis, but also American taxpayers who fund government-run health care programs designed to be a safety net for our country’s elderly and most vulnerable,” the Senate Permanent Subcommittee on Investigations alleged.

Evzio is an auto-injector device that provides verbal instructions that talk the user through using the product on an overdose victim. Kaleo began selling the device in July 2014 at $575 per unit, but since then, has regularly boosted the price, which is $4,100. However, a lower-cost alternative known as Narcan is available for $125 which, the committee noted, also includes two doses.

For its part, Kaleo did not deny the pricing moves, but argued its product has saved more than 5,500 lives and that the company is working with “stakeholders” to provide Evzio at a lower cost. The drug maker also derided “negative attention” to what it called a “complex story.” The Senate report,  which is worth reading, was given in advance to “60 Minutes,” which broadcast a critical segment on its Sunday night program.

The report arrives as the U.S. struggles to contain the number of overdoses and deaths attributed to opioids, which the Centers for Disease Control and Prevention pegged at more than 49,000 in 2017. A growing number of city, county, and state governments, meanwhile, have sued opioid makers for underplaying the addictive risks of their painkillers and encouraging unnecessary prescribing.

Products such as Evzio have been among the tools increasingly used by law enforcement and government agencies in recent years to blunt the costly impact of the opioid crisis. But at the same time, there have been growing complaints about rising price tags. Amphastar Pharmaceutical was first probed three years ago and Kaleo, in particular, has been in the crosshairs more recently.

Kaleo landed there thanks to a tactic that has generated confusion and, in some quarters, dismay. After dramatically raising the list price, Kaleo sales reps encouraged physician offices to sign prior authorization paperwork for Evzio prescriptions, which indicated the device was medically necessary. This move triggered insurance coverage without first requiring patients to try a cheaper option.

In reality, patients received Evzio at no cost regardless of whether they had commercial insurance coverage. How so? Kaleo paid for prescriptions not covered by commercial health plans, including any associated fees. And for patients with commercial insurance coverage, the company paid any associated copays.

At the same time, Kaleo ended contracts with pharmacy benefit managers and health plans for both commercial and Medicare Part D drug coverage. This meant Kaleo no longer paid administrative fees as well as rebates that reduced the cost of Evzio. And the company stopped participating in Medicaid. As a result of these moves, both Medicare and Medicaid began paying more for the device.

The Senate committee found that Medicare was paying an average of $3,522 for each Evzio unit and Medicaid was paying an average of $2,412. Meanwhile, commercial health insurers were only paying an average of $367, which meant that government health care programs were subsidizing usage. It is worth noting that lawmakers have probed Kaleo over pricing tactics for its Auvi-Q allergic reaction device, an EpiPen rival.

The model has been used before. In fact, Kaleo hired two consultants, including Todd Smith, who had previously run two drug makers that relied on this strategy, Horizon Pharma and Novum Pharma. He and his partner were paid $10.2 million over a two-year period for advising Kaleo.

Five years ago, when Smith ran Horizon, the drug maker bought the rights to the Vimovo painkiller and on the first day the deal closed, raised the price for 60 tablets by 587 percent, to $959.00. After yet another huge price hike, the company maintained there would always be a “limited financial impact on the patient,” and that about 97 percent of Vimovo patients would not pay out-of-pocket costs.

Smith later moved to Novum Pharma which, two years ago, gained notice for huge price hikes on skin gels. The company blamed middlemen for passing on extra costs to patients, and claimed that patients do not actually pay much for its products. In fact, Novum insisted people with commercial insurance paid nothing for its gels, even when their insurance does not provide coverage.

As for Kaleo, a spokeswoman sent us this: “We believe two facts are critical to the Evzio story. First, we have received voluntary reports from recipients of donated product that Evzio has saved more than 5,500 lives since we launched the product in 2014. Second, we have never turned an annual profit on the sale of Evzio. Patients, not profits, have driven our actions.

“We believe patients and physicians should have meaningful choices. There is no doubt, the complexity of our health care system has had unintended negative implications for everyone involved, but most importantly, for patients. To this end, we explored viable paths within the current healthcare system to make Evzio available to patients in a responsible, meaningful and affordable way.

“We agree changes need to be made. We believe all patients should have the right to innovative products at reasonable prices. We are actively working with stakeholders in the health care system, including insurers, policymakers, and government officials, to provide Evzio at a lower cost while ensuring patients and their loved ones have access to this life-saving drug.”

The Senate subcommittee, meanwhile, offered several suggestions. This topped the list: The Centers for Medicare & Medicaid Services should review the use of medical necessity formulary exceptions to prevent companies from inappropriately influencing prescribing.

From Rising Drug Prices to Mobile Clinics, 8 Key Healthcare Trends to Watch

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Source: Employee Benefit Adviser

Access to high-quality healthcare was a recurring theme last week at the National Alliance of Healthcare Purchaser Coalitions’ annual conference in Washington, D.C.

Leading physicians and industry experts shared opinions on healthcare delivery, wellness and healthcare waste — and what employees and employers can expect coming down the pipeline.

Poor health is having a big impact on employers

The health of U.S. adults has only grown worse the past few decades, as chronic conditions have become much more rampant and have driven up healthcare costs for employers, said Bruce Sherman, chief medical officer at the National Alliance of Healthcare Purchaser Coalitions.Not only that, but unhealthy employees also cost employers by way of presentism and absenteeism, as well as other business impacts such as increased customer complaints and delayed work or deliveries, he added.

Getting employee input on care is vital

As more data becomes available to employers, finding and putting in place high quality programs for employees, and communicating its value, can be tough.“Employees do not realize there is a difference in healthcare quality,” said Lisa Woods, Walmart’s senior director of healthcare benefits. “How do we, as employers, get our employees to realize there is a difference? One thing we’re working toward is rising the tide. We have our associates, when they see good care, come back and tell us.”

Meanwhile, she said, Walmart is working on piloting different healthcare programs like centers of excellence — specialized programs within healthcare institutions that supply exceptionally high concentrations of expertise.

Employers can expect pharmacy costs to rise

“Drug prices will most likely be a conversation for the next election,” said Ezekiel Emanuel, vice provost for global initiatives and chair of the department of medical ethics and health policy at the University of Pennsylvania. “You’re going to see more activity and more talking, but no definitive actions until after the next election.”

Employers strategizing obesity programs

It’s just as important to keep your healthy people healthy as it is to address high-cost individuals, said Natalie Johnson, president of Population Health Consultants, a health and wellness consulting firm. One way to engage the workforce is to create year-over-year financial incentives for employees who maintain a healthy weight, and to provide the same incentives for obese workers who consistently lose a percentage of their weight, she said.

Employers need to provide more robust cancer-care benefits

If an employee is diagnosed with cancer, employers need to help them navigate their benefits, said Alan Balch, CEO of the National Patient Advocate Foundation.When a patient first gets a cancer diagnosis, they’ll need education on the benefits their employer provides, including if they provide a secondary cancer policy, he said.

Meanwhile, employers also need to help their employees navigate the cost of cancer care. “There are financial factors to consider in the period between confirming the diagnosis and before treatment begins,” he said. “Between out-of-pocket costs, loss of income from work disruption and travel costs, the employee’s world is going to be turned upside down financially. They’ll need help navigating through the field.”

Wellness tech can decrease healthcare costs

Milt Ezzard, vice president of global benefits for entertainment and gaming company Activision Blizzard, said he’s been investing in new wellness technologies like sleep aids and diabetes management programs. The moves are having a significant impact on his workforce — and on the company’s bottom line.“We’ve ridden this wave of new entrants in the market in a lot of cases for things that make sense,” he said. “Innovative partners are very affordable when compared to the conventional big insurance carrier partners. They can leverage tech that is as effective as traditional [coverage] — and for less money. But it takes innovation to make that happen.”

Employers partnering with CDC’s 6|18 initiative

Christa-Marie Singleton, senior medical advisor at the CDC, put a spotlight on the agency’s 6|18 initiative — a collaboration with healthcare purchasers, payers and providers to improve health and control health costs using evidence-based interventions around six key healthcare areas: reducing tobacco use, controlling high blood pressure, preventing unintended pregnancies, controlling asthma, preventing Type-2 diabetes and improving antibiotic use.In one example, she pointed to the direct cost of asthma hitting as much as $14.7 billion, and indirect costs approaching $5 billion in lost productivity. “Asthma matters,” she said, “and is one of the conditions you should look at in your workforce.”

On- or near-site clinics provide more access to healthcare

“Most people who are employed have health insurance but aren’t connected to healthcare,” said Lisa Gish, director of clinic operations for Tri State Community Clinics, which helps employers with on-site wellness solutions. “The barriers of time and money stand in the way.”But on- or near-site health clinics are a solution, she said. “I think worksite health services bring some of the best [opportunities] to the table and raise the bar to connect people with quality healthcare.”

Major employers like AppleAmazon and Utz Quality Foods have recently turned to onsite clinics to help boost employee healthcare engagement and lower costs.

Lower Drug Prices Get an Assist From a Big Player

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Source: Bloomberg

Express Scripts Holding Co. and other pharmacy-benefit managers make money by negotiating drug prices on behalf of health-plan providers. The list prices that pharmaceutical companies set for their drugs diverge wildly from their real cost, and PBMs widen and feast on the gap, which helps make them some of the principal beneficiaries of America’s byzantine pricing system.

But on Tuesday, ahead of its acquisition by Cigna Inc. and possible regulation, Express Scripts announced a drastic departure from business as usual: a new drug list for clients that favors drugs with lower sticker prices over those that provide huge secret discounts. While unlikely to replace the current system any time soon, it’s a substantial shift for a major PBM, and an acknowledgment of tough political and business realities that could boost a nascent and positive trend in drug prices.

One of the main services PBMs provide are so-called drug formularies, or tiered lists of medicines, where drugs deemed “preferred” are much cheaper than those that are “excluded.” Preferred status on a major formulary can add millions in sales volume, and drugmakers offer huge rebates in order to secure it. The growing scale of PBMs — Express Scripts’s annual revenue has increased by $80 billion in the past decade — has contributed to an explosion in the size of rebates and the so-called gross-to-net gap between list prices and the amount that’s actually paid.

Critics contend that PBMs reap excessive profits from this arrangement, and that companies like Express Scripts have created an incentive for drugmakers to hike prices to offer higher rebates. This, in turn, has prompted regulatory scrutiny, in the form of a planned Trump administration rule.

The firm’s new formulary upends the status quo by creating a path to preferred status for drugs that have lower list prices. The strategy was enabled by drugmakers Gilead Sciences Inc. and Amgen Inc., which recently announced that they would make their pricey Hepatitis C and cholesterol medicines available at a substantially reduced list price as they try to boost sales volume in tough markets.

That new price is in line with what the drugs previously cost after rebates, so the overall cost to the system may not change much. But this is big news for people on high deductible plans as well as Medicare beneficiaries, who often have out-of-pocket expenses that are based on the full list price.

This formulary option likely won’t be broadly popular to start. List-price competition is very much still the exception, and the rebate system is firmly entrenched. Many health-plan sponsors actually like the status quo, as the rebates result in a big pile of money that they can use flexibly.

But it’s still a smart move for Express Scripts. Other drugmakers will likely follow Amgen and Gilead into a dual-class drug pricing structure if the two firms manage to boost sales volume 1 ; the new formulary from Express Scripts will make that shift easier. And if the U.S. government follows through on its plans to regulate rebates, this sort of pricing structure will likely become even more appealing.

This isn’t a panacea for high drug prices. But any step toward correcting a major health-care distortion that has a real human cost is a good one.

Incoming Dem Chairman: Medicare Negotiating Drug Prices is a Priority

Image result for Incoming Dem Chairman: Medicare Negotiating Drug Prices is a Priority images

Source: The Hill

Rep. Frank Pallone Jr. (D-N.J.), who is slated to be the next chairman of a House committee overseeing drug prices, said Wednesday that his top priorities on the issue are allowing Medicare to negotiate prices and speeding the approval of cheaper generic drugs.

Pallone, who is set to become chairman of the House Energy and Commerce Committee in January, pointed to President Trump’s support for those two policies in expressing hope for a bipartisan deal.

“I’ve always been an advocate for negotiated prices under Medicare, and as you know, President Trump says that he’s for that, so I think that’s an area where we can get agreement with the president,” Pallone told reporters.

Trump has previously expressed support for allowing Medicare to negotiate drug prices, a top Democratic priority, but has since backed off the idea. Democrats are hoping to get him back on board, and they see drug prices as an area of possible bipartisan cooperation.

Pallone also mentioned bipartisan legislation that would crack down on stalling tactics used by drug companies to prevent cheaper generic competition from entering the market. That bill is known as the Creates Act, and has been delayed all year despite support from members of both parties.

“I think you need negotiated prices under Medicare, and I think you need the Creates Act and other initiatives that will aggressively bring generics to market,” Pallone said. “There’s an area where the president agrees with me and the Democrats, so why not?”

House Democrats say drug pricing legislation will be one of their top priorities next year in the majority.

It is unclear what can come out of the GOP-controlled Senate, but Democrats are hoping that if Trump supports legislation he can help get it through the Senate.

Passing drug pricing legislation would be an uphill climb, given that pharmaceutical companies have long been a powerful force in Washington.

McConnell Says Drug Prices Are on the Agenda, Obamacare Is Off

Image result for McConnell Says Drug Prices Are on the Agenda, Obamacare Is Off images

Source: Bloomberg

Congress’s health-care priorities are likely to focus on drug prices as Obamacare repeal becomes a non-starter for a split legislature, Senate Majority Leader Mitch McConnell said Wednesday.

On changes to Obamacare, “I think it is very obvious that a Democratic House is not going to be interested in that,” McConnell said at a post-midterm elections news conference in Washington, after Democrats won control of the House of Representatives and Republicans added to their control of the Senate.

Instead, it’s more likely that the parties will find common ground on pharmaceutical costs — also a major issue for President Donald Trump.

“I can’t imagine that won’t be on the agenda,” McConnell said. House Democratic leader Nancy Pelosi, who is likely to take over as Speaker of the House when her party takes control next year, said that they “will take real, very strong legislative action” on drug prices.

Health insurance stocks rose Wednesday as investors placed bets that major changes to the health-care system are off the table, for now.

The S&P 500 Managed Care Index rose as much as 4.3 percent to an all-time high, led by a rally in insurers focused on the Medicaid program. Three states passed ballot initiatives to expand Medicaid, which covers low-income people. And Maine may move ahead with a prior expansion after the Republican governor there was defeated.

Drug stocks rose as well, with one analyst calling the risks to the sector overblown. The Nasdaq Biotechnology Index, a barometer of investor sentiment about drug prices, was up 2 percent.

“We believe this outcome will cause headline risk to drugmakers, but the Republican-controlled Senate and pharma-friendly Democrats will prevent disruptive policy change,” said Andrea Harris, an analyst with Height Securities.

Last Updated 12/05/2018

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