In what’s being called one of the first instances of a group using the Affordable Care Act to contest an insurer’s benefit package, a women’s advocacy group says that a beneficiary should not have to pay for a dependent’s pregnancy costs. The Wall Street Journal on June 4 reports, “The complaints are rooted in a health law provision requiring employers to allow workers to keep dependents up to 26 years old” on coverage plans.... The Supreme Court ruled last year that states could opt out of Medicaid expansion, and so far 14 have done so, according to a report in the June issue of Health Affairs. This saves the government about $8.4 billion a year, but ensures that 3.6 million more people will be without insurance. The states not participating, though, are likely to see an increase in spending in the short run because they’ll have to spend more on uncompensated care.... CareFirst BlueCross BlueShield’s foray into the world of patient-centered medical homes has paid off handsomely. The health plan, with 3.4 million covered lives in Maryland, Washington, D.C., and northern Virginia, reports that it saved $98 million last year with its patient-centered medical home. It saved $38 million in 2011. Some experts worry that medical home savings will dwindle over time as doctors run out of obviously wasteful methods to eliminate. Most of CareFirst’s savings came from lower drug spending, less use of emergency departments, and fewer hospital admissions.... COPD hits women hardest, a report by the American Lung Association reaffirms. Women are 37% more likely to have COPD then men. About 7 million women are known to suffer from the disease, and millions more have it but have not been diagnosed.... We spend $200 billion each year, mostly in unneeded hospitalizations and doctor visits, thanks to the improper use of prescription drugs, according to a study by IMS Health’s Institute for Healthcare Informatics. The study, released June 19, says too many patients take the incorrect drug or dose. There is often inadequate oversight when patients are taking more than one medication. The study also cites the misuse of antibiotics. The authors say that financial incentives included in the ACA for better care coordination may help reduce the amount of waste.... Men are much more likely to develop health care related infections than are women, according to a study in the Journal of General Internal Medicine. Men have a 60% higher risk of developing bloodstream and surgical site infections.
House Republicans come out with their ACA alternative. A continuous coverage surcharge replaces the individual mandate. But where’s the CBO score?
The biosimilar segment of the pharmaceutical industry is on fire. Some 700 biosimilars are at some stage of development, and more than 660 companies are involved in some way in the biosimilars land rush. Still, only a handful may get on the market in the next few years.
No one knows how much of an effect biosimilars will have on oncology expenditures. Pricing and market share are in a large, opaque “to be determined” cloud. But there’s certainly potential for a major impact that could lower oncology expenditures by millions, if not billions.
The future of biosimilars in this country is nothing if not uncertain. Most immediately, the U.S. Supreme Court is hearing a case that will determine the timing of the 180-day waiting period before a biosimilar can go on the market. But there are larger and longer-term issues at play as well.
While coupons help individual consumers, they are also having a major impact on the insurance industry and anyone responsible for paying health care bills. Insurers and pharmacy benefit managers complain that they foil formularies and other pricing strategies designed to steer consumers to less-expensive drugs.
The hard truth is that telehealth’s future—its size, its contours—will depend a lot on what payers will be willing to pay for. Currently, commercial plans cover only a limited number of services. In addition, research suggests that there may be quality and utilization problems.
Insurers should consider covering new drug-delivery devices that can improve outcomes while lowering disease-specific pharmacy and long-term overall health care costs. Managing these devices in the pharmacy benefit will consolidate volume-based purchasing and capitalize on PBM strategies for improving adherence.
Basaglar is coming on the scene during tumultuous times for insulin products. Manufacturers are under attack for price hikes. There are allegations of backroom rebate deals. And a class-action lawsuit has been brought on behalf of uninsured patients, charging insulin makers with setting artificially high prices.
Evaluating the quality of telemedicine care is about as easy as evaluating the quality of health care, period, and researchers are still ironing out the methodological kinks. That may be one reason research results are all over the place. This article involved reviewing nine such studies, and the findings are a mixed bag.
The results can be tragic. Patients with addictions are unlikely to wait the hours or days it takes health insurers to approve the medications they need. Insurers are changing their practices, but not without some outside pressure.