The PBM unit of the health giant CVS decided that any new drug exceeding $100,000 per quality-adjusted life year (QALY) may be excluded from the formularies that are maintained by its clients. Patient groups (with the backing of pharma) say that the measure is discriminatory.
CMS has broadened the services that Medicare Advantage plans can provide—services that may reduce expensive treatments and injuries. Insurers continue to see the market as a business opportunity. Critics see a slow-motion privatization of Medicare.
Because it enables both the security and sharing of data, blockchain seems ideally suited to health care. Next year, the pieces may come together for it to finally get some real traction in the sector.
We’ll see what happens to the administration’s Part B proposal. Congress is not likely to take bold action, partly because drugmakers are a strong influence on both parties. That leaves the FDA and Administrator Scott Gottlieb, MD, as major players in efforts to rein in drug prices.
PBMs and insurers are getting rolled into single entities with clout over the supply chain and benefit design. Any major changes in how they operate may wait as they spend 2019 figuring out how to mesh.
Starting a health plan is difficult and success is certainly not guaranteed. Of three 2014 start-up health plans in New York City, Health Republic closed in 2015 and CareConnect closed on New Year’s Eve 2017. Only Oscar remains, and it racked up cumulative losses of $235 million from 2014 to 2016.