Prescription Drug Rebates On The Rise

Trump administration to eliminate safe harbors for drug rebates to PBMs |  Fierce HealthcareSource: Axios, by Tina Reed

Prescription drug rebates from drugmakers to commercial health plans are steadily increasing, a study published in JAMA Health Forum shows.

Why it matters: This is all part of a system in which drugmakers negotiate to get their product on the formularies of middlemen known as pharmacy benefit managers and health plans.

  • * “While drug rebates can reduce plans’ net costs, rebates do not reduce patients’ cost sharing,” the authors write.

This can ultimately “incentivize drug manufacturers to inflate list prices and PBMs to distort drug formularies to favor high list price and high-rebate therapies,” the authors write.

What they’re saying: This is also an equity issue, particularly for patients buying individual plans.

  • * “We have the sick people paying more than their fair share for the drug and the rebate goes back to the plan to reduce premiums for the healthy,” said Ge Bai, a professor of accounting at Johns Hopkins Carey Business School who was one of the authors of the study.

What to watch: Trump era rules to block rebates for Medicare stalled under the Biden administration.

  • * But the issue has been gaining attention on Capitol Hill, with a bipartisan group of lawmakers pushing to outlaw rebates as part of legislation that would cap the price of insulin, FierceHealthcare wrote.

Specialty Drug Costs Continue To Vex Employer-Sponsored Health Plans

 

Specialty drug costs continue to vex employer-sponsored health plans |  BenefitsPRO

Source: BenefitsPRO, by Scott Wooldridge

new report from Pharmaceutical Strategies Group finds that specialty drugs continue to be a top focus for plan sponsors, in part because they tend to be very expensive.

The drugs tend to also be highly complex and require special handling or administration, the report noted. At the same time, the drugs can have great value: extending life for some patients and keeping them productive and relatively healthy, even when conditions are not cured outright.

Related: ‘Super spenders’ accrued $2.1 billion in specialty drugs costs 

“Today, advances in drug therapy allow many patients living with conditions treated by specialty drugs to live decades longer than in the past,” the report said. “As a result, today, many specialty drugs are being used as long-term, chronic therapy for a significant portion of patients.”

Very high costs lead to an “appetite for disruption”

The report noted, as many other sources have, the financial burden that specialty drugs present, both to plans and to enrollees. “Patients who use specialty drugs often have additional health care costs such as non-specialty drugs, doctor’s office visits, outpatient hospital visits, and lab testing to monitor their condition, among others,” the study said. “The monthly total cost of care for a member who uses at least one specialty drug averages $4,846 for the plan and $574 for the member. Annualizing these costs equate to average plan costs of $58,157, and average member costs of $6,894, using the monthly average. These costs are in addition to health care premiums and deductible costs.”

To address high costs, plan sponsors are trying a variety of approaches, the report said, including the use of prior authorization, step therapy, and quantity limits as management strategies. More than 50% of employers use at least one strategy to increase the use of biosimilar drugs. And 8% of plans are currently using alternative funding models, while 31% are exploring their use.

An eye on utilization—but complexity remains a problem

Plan sponsors also are putting a premium on appropriate utilization. This is by far the top priority of plan sponsors, the report found: 37% said reducing inappropriate utilization of specialty drugs was a top goal. The next-highest goal was reducing patient out-of-pocket costs (18%), followed by improving specialty drug adherence and persistency (15%).

The report also stressed the importance of reporting on a plan’s drug spend: “Timely, accurate, and actionable reporting is key to measuring how a plan is doing in specialty drug benefit management,” the report said. “When done well, reporting can highlight areas of opportunity to improve clinical and financial outcomes.”

Among the barriers to reporting is the fact that patients with these conditions often see multiple doctors at multiple facilities. In addition, a single patient’s prescriptions often cannot be filled all at one facility, adding to the complexity.

PSG officials said there was a range of reporting for different areas of specialty drug utilization: “More than 80% of plan sponsors have access to reporting on their total health care costs,” said Tracy Spencer, senior vice president and practice leader of employer groups, labor, and health systems at PSG. “However, clinical outcomes of adherence, persistency and clinical efficacy were reported less often (71% and 31%, respectively). The impact of specialty medications on employee productivity had the lowest reporting rate at 23%.”

5 Predictions For Employee Benefits In 2022 And Beyond

5 predictions for employee benefits in 2022 and beyond | BenefitsPRO

Source: BenefitsPRO, by Becky Seefeldt

The pandemic and the Great Resignation have created a perfect storm for employers. Employers need to be forward-thinking regarding employee benefits because this crucial feature can make or break a company. As people are less likely to stay at their current positions, they’re also much less interested in applying with any company that doesn’t offer them benefits such as health care or vacation time.

Related: 10 recruiting trends for the years ahead

The future of benefits is uncertain, but there are five predictions for where they’re headed in the next few years that could help employers adjust their current package.

1. A push to improve HSAs

There’s a chance that some common-sense changes could be made to health savings accounts (HSAs). These adjustments will allow those who are eligible for Medicare or Tricare benefits the ability to contribute towards their own HSAs. There’s also interest in revisiting how we define what a “qualified high-deductible plan” entails so as not only to accommodate more Americans but also do away with any unnecessary restrictions altogether.

The solution to this problem is not one-size-fits-all. Some would like the requirement taken away altogether, while others are open to compromise. This may include modifying how high-deductible plans should work so that anyone, even those with limited benefits, can contribute towards an HSA. With these changes, individuals will be able to prepare themselves better because they can use their HSA as needed now or put money away for the future.

2. A convergence of health plan options

For roughly the past 20 years, premiums have been increasing. The average premiums for family coverage have increased from $7,000 in 2001 to more than $22,000 by 2021. Deductibles have also risen, with the average deductible for a PPO rising from $201 in 2001 to nearly $1,700 in 2021. The average deductible is so high that it’s beginning to meet the criteria for a high-deductible health plan. PPOs (and all plans) have been increasing their deductibles, which may indicate convergence between health care and savings options.

The best option for employees can be to utilize these new and improved tools. Some people hesitate to move into a high-deductible health plan because of the name: “high-deductibles.” But, this is an excellent option for certain employees who want more control over their expenses and savings rates if something happens unexpectedly. The contribution and eligibility for an HSA can be adjusted by making a few changes to the PPO design. This way, employees will save more money since they’ll have access to managing their medical expenses, which benefits employers, too!

3. Increased or improved price transparency

Increased or improved price transparency has been on the table for about two decades; however, there is more reason than ever to expect forward progress in this area. First is the No Surprises Act, which protects consumers from being surprised by unexpectedly high bills. This includes air ambulance claims, emergency services, and even non-emergency medical treatments that are billed as out-of-network when performed at an in-network facility. This act establishes limits on what can reasonably be charged and provides dispute resolution between plans and out-of-network providers.

Next, the Transparency in Coverage Act requires plan providers, including employers with group coverage or individuals purchasing their own plan to be transparent about prices and out-of-pocket costs. The start date for this act has been pushed back to July 1, 2022.

4. A move to strengthen health and wellness

When it comes to health and wellness, there are several options available. Help employees identify and address health risks before they result in costly medical procedures. As an employer, you can provide them with more comprehensive management and assistance using digital programs, online counseling services, etc.

Another option is utilizing a “specialty account” that caters to unique needs. This type of pre-tax savings plan has been gaining traction with employers who want to help their employees save money on afterschool programs, fitness classes, or even scooters for commuting purposes.

5. An increase in targeted benefits communications

The final prediction is regarding an increase in targeted benefits communications. With targeted communications on the rise, this trend is just getting started. We live in a world where personalization is everything, and benefits should be no exception. Benefits have traditionally been a data dump that occurs every few weeks in which employees are overwhelmed by the sheer volume of information. As employees continue to demand more from their employers both digitally and physically, companies must find ways to elevate their offerings. Consumers want personalized everything — from meals at home or takeout to how much information is given about them when they buy something. Why should employee benefit plans be any different?

While the future of benefits is uncertain, employers should be proactive in preparing for changes. Employers need to be forward-thinking regarding employee benefits and stay up-to-date on the latest industry trends. These five predictions offer a glimpse into what could be ahead, so it’s essential to start thinking about how they may impact your organization and employees.

Becky Seefeldt is vice president of strategy at Benefit Resource LLC (BRI), a leading provider of dedicated pre-tax account administration and COBRA services nationwide.

Trump Era Rule That Expanded Duration Of Short-Term Health Plans In Democrats’ Crosshairs

Trump era rule that expanded duration of short-term health plans in  Democrats' crosshairs | Fierce Healthcare

Source: Fierce Healthcare, by Robert King

Democratic lawmakers and advocacy groups are making a push to convince the Biden administration to nix a controversial Trump-era rule that expanded the duration of short-term health plans.

 

A collection of more than 40 House Democrats wrote to Department Health and Human Services (HHS) Secretary Xavier Becerra earlier this week calling for the agency to pull the rule. The action comes after more than 20 advocacy groups wrote to Becerra back in January asking for the rule to be nixed or modified.

“Junk plans pose clear risks to consumers, undermine the strength of the Affordable Care Act and are incompatible with the goal of making affordable, high-quality health insurance accessible to all Americans,” the letter, led by Rep. Cindy Axne, D-Iowa, told Becerra.

Advocates say urgency has been rising to get the administration to reverse the rule, which was finalized in 2018 and lengthened the duration of short-term plans from three months to a year.

A major concern is the potential end of the COVID-19 public health emergency (PHE), which was extended until July. Once the PHE goes away, states will be able to disenroll ineligible Medicaid beneficiaries and extra COBRA subsidies will go away.

“The second that the PHE is allowed to end all of those people are suddenly uninsured and the worry is that if we don’t do something now a lot of those people continue to stay uninsured or will buy a short-term plan that doesn’t meet their needs,” said Caitlin Donovan, senior director of the National Patient Advocate Foundation, one of the groups pressing the administration to act.

 

Donovan said she was confident the rule will eventually be rescinded, as it has not been popular.

The Trump administration finalized the regulation in 2018 for short-term limited duration plans that can bypass requirements under the Affordable Care Act (ACA) to cover preexisting conditions and essential health benefits. The rule said that the 12-month plans can be renewed for up to 36 months.

HHS at the time said the plans were necessary to give consumers options as premiums on the ACA’s exchanges were too high. However, the insurance industry and consumer advocates charged the plans offer skimpy coverage and can deceive consumers that they are getting more robust benefits.

“Individuals that unwittingly purchase a short-term plan that are later diagnosed with a chronic or acute condition may find themselves seriously uninsured as short-term plans typically exclude coverage of key services such as prescription drugs and mental health services, among others,” the letter, led by the National Patient Advocate Foundation and more than 20 other groups, said.

 

The letter has proposed several changes to the initial 2018 rule, chief among them to restore the original three-month limit for the plans.

Other recommended changes include:

  • * Halting sales of short-term plans during the ACA open enrollment. Advocates pointed to studies that indicate the plans can be “aggressively and deceptively marketed to consumers.”
  • * Limit sales of plans via internet and phones to help clamp down on deceptive marketing tactics.
  • * Improve disclosure of the types of risks associated with short-term health plans, including by telling the consumer the plan is not comprehensive.

The Biden administration has been in favor of getting rid of the rule or making changes, referencing it in the latest Unified Agenda that outlines regulatory priorities for the coming year.

So far, HHS has not released any regulations on the issue, and the Centers for Medicare & Medicaid Services did not return a request for comment as of press time.

Hospital Prices For Health Plans Vary Widely Across The U.S., Study Finds

U.S. Health Care Prices Are All Over the Map, New Study Finds

Source: Modern Healthcare, by Mari Devereaux

How Medicare Advantage Plans Can Increase Consumer Satisfaction

Medicare Advantage plans are more likely to achieve high satisfaction scores when they offer a consistent product message and brand experience and have control over the delivery of care, according to a J.D. Power study. Members frequently choose a plan they understand and find easy to work with. The study measures member satisfaction with Medicare Advantage plans based on six factors in order of importance: coverage and benefits (26%); customer service (20%); provider choice (15%); cost (14%); information and communication (13%); and claims processing (13%).

Improving communications with enrollees is one of the greatest opportunities for health plans to improve member satisfaction. It’s the only factor in the study that has not seen a significant improvement in member satisfaction. Valerie Monet, director of the insurance practice at J.D. Power, said that many plans have multiple product design features and come with technical manuals that are 20 pages or longer. Expecting members to be experts on these services and benefits is a losing battle for the plan and the member. Members expect their plan to provide guidance, ranging from assistance in selecting a doctor to helping them understand prescription costs.

Forty-eight percent of members agree strongly that their health plan is a trusted partner in their health and wellness, which increases satisfaction by 166 points. Satisfaction is 136 points higher among the 89% of members who completely understand how to find a doctor under the plan. Satisfaction is 110 points higher among the 88% of members who say their doctor spends the right amount of time with them.

Members expect immediate attention or advice when they call their health plan provider. Forty-one percent of those who called their plan had to give the same information more than once to get their issue resolved. Only 35% of members said that customer service provided all of the information they needed on the costs of prescription medications. Ninety-one percent of customers who are delighted with their Medicare Advantage plan (satisfaction scores of 901 or higher), say they will definitely renew their policy, and 89% will definitely recommend their plan to family and friends. Loyalty drops to 71% and advocacy to 66% among members who are pleased with their plan (scores of 751-900). Plans garnered the following member-satisfaction scores:

  • Kaiser Permanente 851
  • Highmark 791
  • Humana 782
  • UnitedHealthcare 775
  • Cigna 774
  • Aetna 773
  • Anthem 765
  • Health Net 756
  • WellCare 742

In 2016, members reported an average increase of $117 in annual premiums to $1,497. They also have more out-of-pocket expenses. On average, member deductibles are $1,705 in 2016, a $310 jump from 2015. Satisfaction is 136 points higher when members completely understand their out-of-pocket costs. Monet said that members are more satisfied and see the value of their plan when they have a better understanding of how much they are paying and what the costs cover.” For more information visit http://www.jdpower.com/resource/us-medicare-advantage-study.

Health Plan Offer Rates Since the ACA

A study by the Employee Benefits Research Institute (EBRI) reveals that large employers have had steady health insurance offer rates since passage of the ACA. In fact, 99% of employers with 1,000 or more workers offer heath insurance as do 93% to 95% of employers with 100 to 999 workers. However, offer rates have been falling since 2009 for employers with fewer than 10 workers, from 36% in 2008 to 23% in 2015. Offer rates for employers with 10 to 24 workers went from 66% in 2008 to 49% in 2015. Offer rates for employers with 25 to 99 workers went from 81% in 2008 to 74% in 2015.

Consumer-Driven Health Plans Gain Ground

Thirteen percent of the privately insured U.S. population was enrolled in a consumer-driven health plan (CDHP) in 2015, according to a report by the Employee Benefits Research Institute. Sixty-three percent of those enrolled in CDHPs had an HSA; 13% had an HRA, and 24% had the option of an HSA-eligible health plan, but had not opened an HSA.

Covered California Rates Jump 13% in 2017

Covered California Rising costs

Covered California’s premiums jumped 13.2% for 2017, up from about a 4% increase in each of the past two years. However, most consumers will see a much smaller increase or pay less next year if they switch to another plan. California executive director Peter Lee said, “Shopping will be more important this year…Almost 80% of our consumers will be able to pay less than they are paying now, or see their rates go up by no more than 5% if they shop and buy the lowest-cost plan at their same benefit level.”

While premiums will rise, the subsidies will rise as well. About 90% of Covered California enrollees get help to pay for their premiums. The average subsidy covers roughly 77% of the consumer’s monthly premium. “Even though the average rate increase is larger this year than the Past two years, the three-year average increase is 7% – substantially better than rate trends before the Affordable Care Act was enacted,” Lee said.

Covered CaliforniaPremium increases 2014-2015 2015-2016 2016-2017 3-year average
Average weighted increase 4.2% 4% 13.2% 7%
Lowest price Bronze plan 4.4% 3.3% 3.9% 3.9%
Lowest priced Silver plan 4.8% 1.5% 8.1% 4.8%
Second lowest priced Silver plan 2.6% 1.8% 8.1% 4.1%
If a consumer switches to the lowest priced plan in the same tier -4.5% -1.2%

 

Lee said the average rate increase reflects the following factors:

  • A one-year adjustment due to the end of the reinsurance funding mechanism in the Affordable Care Act. The provision was designed to moderate rate increases during the first three years when exchanges were being established. The American Academy of Actuaries estimates that this will add 4% to 7% to premiums for 2017.
  • Special enrollment by some consumers who sign up only after they become sick or need care, which has had a significant effect on rates for two insurance plans.
  • The rising cost of health care, especially for specialty drugs.
  • Pent-up demand for health care among those who were uninsured before the Affordable Care Act.

Lee said, “Covered California is working to address some of these issues on multiple fronts. The exchange is aggressively marketing to attract healthy consumers year-round, and is working to ensure special enrollment is available only to those who meet qualifying circumstances. It is also sampling the special enrollment population to better understand how to make any further improvements needed.”

Covered California is reducing the number of services that are subject to a consumer’s deductible. Starting in 2017, consumers in Silver 70 plans will save as much as $55 on an urgent care visit and $10 on a primary care visit. Consumers in Silver, Gold, and Platinum plans will pay a flat copay for emergency room visits without having to satisfy a deductible, which could save them thousands of dollars.

These improvements build on features already in place that ensure most outpatient services in Silver, Gold and Platinum plans are not subject to a deductible, including primary care visits, specialist visits, lab tests, X-rays and imaging. Some Enhanced Silver plans have little or no deductible and very low copays, such as $3 for an office visit. Consumers in Covered California’s most affordable Bronze plans can see their doctor or a specialist three times before the visits are subject to the deductible.

The contract with health insurers for 2017 ensures that consumers select or are provisionally assigned a primary care physician. Below are the companies selected for the 2017 exchange:

  • Anthem Blue Cross of California
  • Molina Healthcare
  • Blue Shield of California
  • Oscar Health Plan of California
  • Chinese Community Health Plan
  • Sharp Health Plan
  • Health Net
  • Valley Health Plan
  • Kaiser Permanente
  • Western Health Advantage
  • A. Care Health Plan

The following carriers are increasing their coverage areas in 2017:

  • Oscar will be entering the market in San Francisco, Santa Clara, and San Mateo counties.
  • Molina will expand into Orange County.
  • Kaiser will be available in Santa Cruz County.

With the expansion of carriers, 93% of consumers will be able to choose from three or more carriers, and all will have at least two to select from. In addition, more than 93% of hospitals in California will be available through at least one Covered California health insurance company in 2017, and 74% will be available in three or more plans. Rate details by pricing regions can be found in Covered California’s Health Insurance Companies and Plan Rates for 2017, posted online at: http://coveredca.com/news/pdfs/CoveredCA-2017-rate-booklet.pdf.

Manufacturing Leads Adoption of High-Deductible Health Plans

Manufacturing

A survey by Benefitfocus reveals distinct differences in benefit offerings among manufacturing, education, and health care industries. Manufacturing leads the adoption of high-deductible health plans (HDHPs), education favors traditional plans (PPOs, HMOs, etc.) and the health care industry offers the most voluntary benefits. Manufacturing is the only industry of the three, in which more companies offer a combination of HDHPs with traditional plans than traditional plans only (48% to 46%). Manufacturing employees selected an HDHP over a traditional plan 46% of the time. The findings suggest that manufacturing employers have an opportunity to encourage employees to participate in health savings accounts (HSAs) or flexible spending accounts (FSAs) to cover higher out-of-pocket costs associated with HDHPs. Only 23% of education employers offer at least one HDHP. Traditional health plans dominate the mix of benefits. HMOs made up 44% of employee enrollments, which suggests an opportunity to offer a wider range of lower cost benefit options for a multi-generational workforce.

Employees in the health care industry face high deductibles regardless of plan selection, but are better equipped to cover unexpected medical costs with voluntary benefits (including critical illness, accident, and hospital-indemnity insurance). Health care employers offered gap products at the highest rate of the three industries at 12 percentage points above the average. Nearly half of health care workers selected a voluntary plan when given the choice.

Last Updated 06/29/2022

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