A new behavioral health venture that sprung from an innovative Horizon Blue Cross Blue Shield of New Jersey initiative is focused on embedding its integrated approach within other health plans and provider groups. NovaWell, a Horizon affiliate that launched Nov. 14, is offering a suite of technology-forward solutions aimed at tackling the country’s ongoing mental health crisis. Jolted into the public consciousness by the COVID-19 pandemic, the crisis is characterized by rising rates of anxiety and depression amid a shortage of trained professionals.

Backed by more than five years of testing and program design aimed at addressing the behavioral health needs of Horizon’s members, the NovaWell suite brings an integrated care management approach supported by network-enhancing solutions to a wider audience. Two of the company’s four core offerings, a fully integrated clinical model called NovaClinical and a network solution known as NovaNetwork, are positioned to bolster health plans, Suzanne Kunis, president and CEO of NovaWell, tells AIS Health, a division of MMIT.

Plan sponsors’ overall satisfaction with their PBMs was 7.8 on a 1-10 scale in 2022, down from 8.2 last year, according to Pharmaceutical Strategies Group’s 2022 Pharmacy Benefit Manager Customer Satisfaction Report. The report was based on surveys completed by 236 individuals representing employers, unions/Taft Hartley plans, health plans and health systems that covered an estimated 76 million lives. Respondents reported a lower likelihood to recommend their PBM to a colleague or to renew their contract without issuing a competitive request for proposal this year, highlighting costs as the primary driver to leave the PBM.

Among core PBM services, satisfaction was highest for “offering competitive traditional drug discounts” and “meeting financial guarantees.” As clinical and cost management programs play a key role in reducing overall costs, 82% of respondents reported using utilization management, while only 8% used gene therapy financial protection programs.

Plan sponsors are reporting less satisfaction with their PBMs than they have in prior years, according to a recent survey. While industry experts differ regarding what may be driving that trend, they also have plenty of ideas about what PBMs — or failing that, their regulators — can do to improve how the industry performs.

The 2022 Pharmacy Benefit Manager Customer Satisfaction Report is the 25th annual version produced by the Pharmaceutical Strategies Group (PSG), an EPIC Health LLC subsidiary. In an Oct. 19 press release unveiling the findings, the organization wrote that “there was a notable downturn in overall satisfaction levels” with PBMs in this year’s survey, “as well as in some core measures of general satisfaction such as likelihood to recommend.” Measured on a scale of one to 10, plan sponsors’ overall satisfaction with PBMs was 7.8 in 2022, down from 8.2 last year — and at the lowest level it has been since 2016.

As researchers gain growing insight into the mechanics of what makes diseases tick, more and more genetic tests are coming onto the market to help make sure the right patient gets the right drug at the right time. While these diagnostics can help inform diagnosis and treatment for patients, the sheer volume of these tests may be overwhelming payers in their coverage decisions. Stakeholders should work together to help establish the clinical utility that payers need to make coverage decisions on these diagnostics, industry experts say.

Daryl Pritchard, Ph.D., senior vice president of science policy at the Personalized Medicine Coalition (PMC), describes the landscape of coverage for genetic testing as “uneven. Payers are increasingly considering coverage and reimbursement of genetic testing products and services.” However, he tells AIS Health, a division of MMIT, “there remain significant challenges in establishing coverage policies and payment rates for diagnostic tests that reflect the value of their care. As a result, many newer novel diagnostics are under-reimbursed or not covered at all. Such practices ultimately restrict patient access to some needed tests and to optimal care. Coverage and reimbursement policies vary widely among different payers, and decision-making processes are often inconsistent and not transparent.”

The average annual premium for employer-sponsored health insurance in 2022 was $7,911 for single coverage and $22,463 for family coverage, similar to the average premiums last year, according to the Kaiser Family Foundation 2022 Employer Health Benefits Survey. On average, employees contributed 17% toward single coverage premiums and 28% toward family coverage premiums. Among employees at small firms, 33% of them chose a plan where the employer paid the entire premium for single coverage, compared with only 6% at large firms. Meanwhile, 31% of small firm workers were in a plan that required them to contribute more than half of the premium for family coverage.

More than 30% of rural hospitals nationwide could close soon, according to a new report from the Center for Healthcare Quality & Payment Reform (CHQPR). Health care experts tell AIS Health, a division of MMIT, that closures could have dire effects on rural communities, but health insurers may be able to spearhead changes in care delivery and payment models to help keep rural health care viable.

According to the CHQPR report, 631 rural hospitals are at risk of closure in the “near future,” with over 200 of those at “immediate risk” of closing. In “almost half” of states, 25% of rural hospitals are at risk of closure, and in 10 states, 40% or more are at risk. Hawaii (75%), Connecticut (67%) and Alabama (60%) have the highest proportion of hospitals at risk of closure. Texas (50%) is the most populous state to have at least half of its rural hospitals at risk. This precarious state of affairs follows 112 rural hospital closures between 2010 and July 2019, per HHS. Rural obstetric care is in particularly poor shape. Researchers from the University of Minnesota found that 165 rural obstetric units closed between 2004 and 2014, “leaving over half of rural counties without obstetric services,” as HHS put it.

Since June, manufacturers of the three FDA-approved poly (ADP-ribose) polymerase (PARP) inhibitors have withdrawn their indications in the later line treatment setting for ovarian cancer. Payers should be reviewing their utilization management criteria to make sure they are covering the drugs in the appropriate setting, advises one industry expert.

In a Form 8-K filed with the U.S. Securities and Exchange Commission on June 16, Clovis Oncology, Inc. said it was voluntarily withdrawing the FDA approval for Rubraca (rucaparib) for the treatment of BRCA-mutated ovarian cancer after at least two chemotherapies based on overall survival (OS) data from the ARIEL4 clinical trial. The company also disclosed that it had requested withdrawal of that indication in Europe. The drug’s indications for the maintenance treatment of adults with recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer who are in a complete or partial response to platinum-based chemotherapy and for the treatment of adults with a deleterious BRCA mutation-associated metastatic castration-resistant prostate cancer (mCRPC) who have been treated with androgen receptor-directed therapy and a taxane-based chemotherapy, the latter of which has accelerated approval, remain on its label.

Since the FDA’s approval of the first biosimilar — Zarxio (filgrastim-sndz) from Sandoz, a division of Novartis Pharmaceuticals Corp. — on March 6, 2015, the agency has approved almost 40 more agents via the 351(k) pathway established under the Biologics Price Competition and Innovation Act (BPCIA), itself part of the Affordable Care Act (ACA). Although not all of those agents have launched yet, and almost all of the ones that have are all professionally administered, industry experts say they expect to see more competition in the space, depending on interchangeability status, provider uptake and the impact of the Inflation Reduction Act.

The average premium for an average employer-sponsored plan didn't go up much in 2022, according to the Kaiser Family Foundation's annual survey of plan sponsors. Managed care insiders tell AIS Health, a division of MMIT, that even though prices are nearly certain to go up for plan sponsors in 2023, the era of cost-shifting to employees may be drawing to a close as firms struggle to retain low-wage workers who are feeling the pressure of inflation.

KFF found that the average annual premium for employer-sponsored health coverage is $7,911 for single coverage and $22,463 for family coverage this year, which are “similar to the average premiums in 2021.” While those costs remained stable between 2021 and 2022, the average premium for family coverage has increased 20% over the last five years and 43% over the last 10 years. The survey also found that premiums for workers at small and large firms are similar (KFF defines large firms as having a workforce of at least 200 people).

In late October, the House of Representatives’ Committee on Oversight and Reform published a report that takes aim at managed care companies’ coverage of birth control products. Health policy experts say that while enforcement of the Affordable Care Act’s contraceptive coverage mandate has always been challenging, the new report comes as the Biden administration signals it is getting increasingly serious about cracking down on noncompliance. The insurers/PBMs mentioned in the report and the industry's main trade group, meanwhile, contend that they are in fact providing adequate coverage of contraceptives.