Do Wellness Programs Actually Help People Manage Chronic Conditions?

Forty-four percent of consumers enrolled in wellness programs have a diagnosed chronic condition, according to a HealthMine report. But just 14% say that their wellness program helps them manage their disease. Only 29% say their wellness program offers a disease management program. Only 11% participate in disease management through their wellness program. And just 6% have connected a disease management application/tool to their wellness program. Bryce Williams, CEO and president of HealthMine says, “Health plans and wellness programs need to have real time analytics that guide each member on health actions. We are loaded with health data including lab results, insurance claims and more, but we are not analyzing the data or offering recommendations consistently enough. Programs that do will close gaps in care, thus helping members manage their chronic conditions and minimize costly co-morbidities and utilization.”

Expensive Drugs Are Becoming More Accessible Under Exchange Plans

ACA exchange plans are making some drugs more accessible to patients in 2016. Plans are less likely to place all drugs for conditions, such as HIV, cancer, and multiple sclerosis (MS) in a class on the highest cost-sharing tier, according to a report by Avalere. The study looked at Silver plans across 20 classes of medications. In five medication classes, some plans all drugs on the highest tier including drugs to treat HIV, cancer, and MS. However, fewer exchange plans are doing so in 2016 than in the prior two years.

As in prior years, the anti-angiogenics class, used to treat cancer, was most often subject to universal placement on the specialty tier. Half of all Silver plans placed all covered drugs in this class on the specialty tier in 2016. Nearly one-third of Silver plans place all covered MS drugs on the specialty tier as well, though this rate is down 14% from 2015. The sharpest decline is for molecular target inhibitors at 18%. For these three classes, 2016 reversed the sharp increase in this tiering structure.

Since the launch of exchanges in 2014, patient groups and policymakers have considered how formulary designs could affect patients’ ability to access medications. At the same time, plans strive to offer innovative benefit designs with low premiums. CMS has issued guidance discouraging plans from placing all drugs for a condition on the highest tier without regarding the cost of the medication. The federal government has not yet created a tool for regulators to evaluate benefit designs in this regard. California passed legislation preventing plans from placing all drugs for a condition on the highest formulary tier beginning in 2017

The Cost Implications of Private Exchanges

Private exchanges could encourage employees to select less-generous plans, according to a report by Rand. This could expose employees to higher out-of-pocket costs, but premium contributions would drop substantially, so net spending would decrease. On the other hand, employee spending may increase if employers decrease their health insurance contributions when moving to private exchanges. Most employers can avoid the ACA’s Cadillac tax by reducing the generosity of their plans, regardless of whether they move to a private exchange. There is not  enough evidence yet to determine whether private exchanges will become prominent and how they will affect employers and their employees.

Workers who choose less-generous plans could risk higher out-of-pocket costs. But their net spending would drop because premiums would drop substantially. Average employee spending could increase if employers lower their health insurance contributions when moving to private exchanges. Private exchanges are unlikely to significantly affect the ACA’s Small Business Health Options Program (SHOP) Marketplaces.

What Consumers Are Saying About Obamacare and Cancer Coverage

When consumers talk about Obamacare online, cancer is the most frequently discussed health condition, according to a report by Treato. Online, consumers discuss cancer 2.5 times more often than any other health condition. When discussing cancer, the leading topics are breast, lung, and colon cancers. Online discussions about Obamacare generally skew negative among cancer patients, but those who are positive express extreme gratitude. Twenty percent of patients and caregivers on cancer forums express gratitude and 48% have various criticisms about Obamacare.

Conversations about the downside of Obamacare’s cancer coverage generally fall into two categories: dissatisfaction with coverage and frustration with the lack of plan options. Consumers discuss the challenges of deciphering insurance rules to get the coverage they want, and confusion about subsidies, exclusions, inclusions, and co-pays.

Consumers are also complaining that certain groups are gaining more from Obamacare. The strongest criticisms are about women having access to more preventative screenings and more coverage for conditions, such as for breast cancer, and the poor getting free coverage. Consumers are also critical of other health conditions getting less coverage than cancer.

Consumers complain about losing good private insurance plans because of Obamacare and paying more out-of-pocket for cancer treatment. Many say that Medicare and Medicaid are simpler to access and easier to understand. Those who like Obamacare cite preventative screenings, coverage of pre-existing conditions, removal of lifetime limits on coverage, and the affordability of coverage

How the Affordable Care Act Challenges Insurers

In the past year, the Affordable Care Act (ACA) has had a more pronounced effect on large and small health insurance carriers, according to an A.M. Best report. The fact that the enrollment population continues to be older and riskier, is having a bigger negative financial effect than anticipated.

Publicly traded companies fared well, reporting an increase in earnings through Sept. 30, 2015. The ACA health insurer fee has affected insurers’ earnings. It was $11.3 billion in 2015 and is a similar amount for 2016. Since the fee is not tax-deductible, it has a greater effect on net income. Many insurers have compensated for the fee through premiums. Since some government-funded programs are more sensitive to premium increases, carriers have not been able to consistently pass the fee along in rates.

To alleviate the growing financial pressure, health insurers are looking at initiatives to control the cost of care, such as disease management programs and better care coordination. As a result, there has been increased collaboration with providers that can benefit all parties involved, including the patient.

Merger and acquisition activity accelerated in 2015 with several large transactions announced during the year. The desire for further diversification is driving the mergers and acquisitions among insurance companies and other health-related businesses. A.M. Best’s outlook for the U.S. health insurance sector was recently revised to negative from stable, largely due to earnings and capitalization pressures as a result of the ACA. The industry pressures are expected to continue to hurt earnings. The lower earnings and growth in premiums from increased membership will result in lower levels of risk-adjusted capitalization.

The merger and acquisition activity will bring additional earnings pressure to the bigger carriers since they will need to service higher debt loads. Since many of these pressures will not subside in the near term, A.M. Best says that there could be more negative rating actions on health insurers.

The report also explores other trends, such as how health insurers are viewing cyber risk, changing consumer demands, emerging member-focused insurers, rising pharmaceutical costs, and 2015 rating trends

Maintaining Reliable Provider Directories for Health Plan Shoppers

A new report by the California HealthCare Foundation examines how Colorado, Maryland, New York, and Washington overcame obstacles to develop well-functioning provider directories. The goal of the report is to inform California policymakers and stakeholders as they seek to improve consumer access to accurate provider network information. The following are key findings:

  • An environment for shared accountability can be fostered through incentives, policy alignment, and enforcement of regulatory and contractual requirements.
  • Uniform data standards and accompanying guidance ensures that data are usable, especially when they come from disparate sources.
  • Provider directories should engage and inform consumers with diverse language needs and educational levels as they enroll in coverage and seek care.

Report: Employer-sponsored health plans hold steady

Most people who enrolled in a health insurance plan through an Affordable Care Act exchange were previously uninsured and were not employees of companies dropping health plans, according to new Census Bureau data. Fewer middle-income Americans took advantage of the marketplace than did people with low incomes, and the uninsured rate dropped by a higher percentage in states that expanded Medicaid eligibility, the data show. The New York Times (free-article access for SmartBrief readers) (9/16), Bloomberg (9/16)

Consumers Face Obstacles in Understanding Prescription Coverage

Consumers Face Obstacles in Understanding Prescription Coverage
Consumers find it frustrating and time consuming to get information about their prescription drug benefits, according to a report by the California HealthCare Foundation (CHFC). CHFC surveyed consumers as well as agents and enrollment counselors. Publicly posted formularies are hard to navigate. They often feature arcane terminology, provide incomplete and inaccurate information, and are not available in languages other than English.

Many consumers don’t think of checking whether their medications are covered before selecting a health plan. But those who seek this information have a hard time finding it. Participants say that prescription benefit information is not prominent on plan websites or on the Covered California website. Many participants say that it took multiple clicks to locate a company’s formulary, if they were able to find it. Most were unable to find all the information they wanted, and resorted to calling each plan under consideration to check whether their drugs were covered and get details on their financial responsibility.

In general, consumers are not familiar with many of the terms used routinely in prescription benefit information, such as “formulary,” “prescription drug tier,” “co-insurance,” and “preferred drug” versus “non-preferred” drug. Consumers want materials that are written in more common, accessible language. The following are more key findings:

  • Consumers have little awareness of how to request medications that are not on a plan’s formulary.
  • When shopping for health insurance, drug benefits take a backseat. Consumers base their health plan choices on monthly premiums, physician access, and out-of-pocket costs, such as deductibles and copays for physician office visits.
  • Consumers have often assumed that their drugs would be covered so they didn’t double-check their availability or potential cost.
  • Neither agents nor counselors routinely help clients conduct drug benefit searches. Agents in the study say that it is too time-consuming to be profitable while counselors say they have limited familiarity with the process.
  • Study participants reviewed online formulary search tools. The Colorado Health Plan Finder tool is well-received among consumers and agents because it offers filters to refine plan options. Shoppers can view only plans that cover their drugs. It also displays the copays. Participants said that it allowed them to figure out what they would be spending monthly on prescriptions.
  • Information throughout the Covered California website was consolidated into a table to clarify relationships among prescription coverage and metal tier options. Agents say that having the information presented this way is useful when explaining drug costs to clients. Consumers are split on whether they could understand all elements of the table.

Respondents offered the following suggestions:

  •  Have an online tool with drug cost and coverage information, by plan. An interactive Internet formulary search tool would allow consumers to input drug names. Results would include details, such as cost and tier placement for each plan.
  •  Health plan websites should consolidate drug benefit information under a clearly labeled tab that’s easy to find with a minimum number of clicks.
  • A formulary should specify whether it is for individual or group plans or those included or excluded from Covered California.
  • Consumer education should address the differences among formulary designs. There should be particular attention to educating consumers on how to appeal medication denials and seek redress of other prescription drug coverage issues. Enrollment counselors want additional education on prescription benefits.
  • Use the term “prescription drug list” instead of “formulary.”
  • Drug categories should include understandable terms like “high blood pressure” instead of “hypertension.” Other suggestions are to standardize formulary terms and abbreviations to make comparisons less confusing.
  • Display copay information with tier placement, the cost of monthly prescriptions, the difference between branded drugs and generics, information on step therapy, the appeals process, and a list of pharmacies.

Doctors Say That the Affordable Care Act Increases Healthcare Costs

Sixty-one percent of doctors say that complying with the ACA has increased their overhead costs, according to a report by Jackson Healthcare. Sixty percent say they do more administrative work due to the law, resulting in less time with patients. The law is also costing patients more, doctors say. Fifty-one percent of patients are delaying routine screenings because of the cost of high-deductible plans associated with the ACA. Richard L. Jackson, chairman and CEO of Jackson Healthcare said, “The ACA had good intentions, but failed to solve the major problem with healthcare – reducing costs. If we don’t do something about costs…,we are just rearranging deck chairs on the Titanic.”

Twenty-three percent of doctors say they are retiring, thinking of retiring or becoming part-time in 2015. Ninety percent attribute that decision to the ACA. Sixty-seven percent of doctors accept insurance plans sold in the exchange. Such plans are known to pay less than traditional insurance and in line with Medicaid, according to the survey.

AARP Report Reiterates Need for Fair Generic Drug Reimbursements

National Community Pharmacists Association (NCPA) CEO B. Douglas Hoey, RPh, MBA issued the following statement in response to a new report by AARP on rising generic drug costs in 2013:

“This new report…underscores the need for action by Congress to support patient access to essential medications. Moreover, a 2015 survey of 700 community pharmacists concluded that this situation has only become worse since 2013…

Patient access to these medications is threatened by more than their rising cost. Independent community pharmacies are absorbing unsustainable losses of $100 or more on these prescriptions because insurance middlemen known as pharmacy benefit managers (PBMs) may wait months to raise reimbursement rates to pharmacies to cover the higher costs.

This buy high, sell low situation threatens the viability of independent community pharmacies, which provide care in many underserved rural and inner city areas without other convenient pharmacy options. Already some pharmacies can no longer stock certain medications for patients because the reimbursement rates are so far below the cost of acquiring and dispensing them. Because of the lack of transparency, PBMs may be profiteering during…by charging health plans much higher rates than they reimburse the pharmacies.

We encourage lawmakers to cosponsor H.R. 244. This bipartisan legislation would ensure that federal health plan intermediaries, such as PBMs, update reimbursement rates for rising generic drug costs to keep pace with market conditions. It would codify and expand upon a requirement that Medicare has adopted for the 2016 plan year.”

Last Updated 10/28/2020

Arch Apple Financial Services | Individual & Family Health Plans, Affordable Care California, Group Medical Insurance, California Health Insurance Exchange Marketplace, Medicare Supplements, HMO & PPO Health Care Plans, Long Term Care & Disability Insurance, Life Insurance, Dental Insurance, Vision Insurance, Employee Benefits, Affordable Care Act Assistance, Health Benefits Exchange, Buy Health Insurance, Health Care Reform Plans, Insurance Agency, Westminster, Costa Mesa, Huntington Beach, Fountain Valley, Irvine, Santa Ana, Tustin, Aliso Viejo, Laguna Hills, Laguna Beach, Laguna Woods, Long Beach, Orange, Tustin Foothills, Seal Beach, Anaheim, Newport Beach, Yorba Linda, Placentia, Brea, La Habra, Orange County CA

12312 Pentagon Street - Garden Grove, CA 92841-3327 - Tel: 714.638.0853 - 800.731.2590
Email:
Jay@ArchApple.com
Copyright @ 2015 - Website Design and Search Engine Optimization by Blitz Mogul