Benefit Management

West Coast Public Sector Plan Sponsors Will Coordinate More Closely Through Purchaser Group

The Purchaser Business Group on Health (PBGH) for the first time has created a public purchaser advisory committee. The decision, part of the purchaser group’s newly announced five-year plan, is meant to align the needs of its public members and integrate them with private purchasers.

PBGH is a nonprofit coalition representing nearly 40 public and private purchasers that collectively spend $350 billion annually on health care services. While the group’s members include major corporations such as Apple, Inc., Microsoft Corp. and the Walt Disney Co., PBGH is different from other purchasing organizations in that it also represents public purchasers, according to Elizabeth Mitchell, PBGH’s chief president and chief executive officer.


Private Plans in Michigan Stall Under CPC+ Model

A primary care reform model in Michigan failed to deliver intended cost savings and quality improvements among two private payers, casting doubt on whether current value-based model designs in the primary care space have the muscle to exert real benefits.

A study published in the September issue of Health Affairs analyzed the spending and quality results of two large insurers in Michigan that offered a payment reform model designed after the federal Comprehensive Primary Care Plus (CPC+) program. The results were muted: Among the private payers involved, the CPC+ model failed to reduce total spending; the results indicate that, when accounting for care management fees, spending actually rose under the CPC+ program. On the quality side, performance remained unchanged between CPC+ and non-CPC+ participants.


Armed With Transparency Data, Purchaser Groups Focus on Rising Prices

Amid growing medical cost trend and broad fears of inflation, two major purchaser groups have unveiled initiatives to coordinate plan sponsors in an effort to lower health care prices. Managed care experts tell AIS Health, a division of MMIT, that purchasers’ frustration with high prices are valid, but they don’t expect prices to come down any time soon with inflation and other macroeconomic trends set to wash over the health care sector.

The National Alliance of Healthcare Purchaser Coalitions (NAHPC) recently released a “playbook” white paper for regional purchaser groups and employers seeking to rein in price increases. The term purchaser coalition refers to a number of regional nonprofits across the country that are composed of the region’s largest employers; those groups comprise NAHPC’s membership. NAHPC’s largest member, the Purchaser Business Group on Health (PBGH), also rolled out a new plan to manage costs.


Holistic Approach to Prior Authorization for Genetic Testing Is Key in Making Sure People Get Right Tests, Best Care in Timely Manner

Genetic testing is becoming a greater part of health care, as providers can take advantage of it to help inform patients’ diagnosis and treatment. Multiple tests are now available, and many health plans are covering their costs if certain criteria are met. But that’s a tall order with more than 77,000 genetic tests available and new tests constantly coming to market.

Many payers have prior authorization for genetic tests: An AHIP industry survey conducted between September and December 2019 found that genetic testing was the third most common treatment for prior authorization behind specialty drugs and high-tech imaging.

U.S. Sees First Ophthalmologic Biosimilar Launch in Crowded, High-Cost Space

The U.S. market recently welcomed the first ophthalmologic biosimilar onto the market: Samsung Bioepis Co., Ltd. and Biogen Inc.’s Byooviz (ranibizumab-nuna), which references Roche Group unit Genentech USA, Inc.’s Lucentis (ranibizumab). While the agent is entering what is becoming a fairly crowded space, it will offer a cost-effective option for payers, say industry sources.

On Sept. 20, 2021, the FDA approved Byooviz for the treatment of neovascular (wet) age-related macular degeneration (AMD), macular edema following retinal vein occlusion (RVO) and myopic choroidal neovascularization (mCNV). Under an agreement with Genentech, Samsung Bioepis and Biogen were not able to market the vascular endothelial growth factor (VEGF) inhibitor in the U.S. until June 2022. Biogen Inc. and Samsung Bioepis Co., Ltd. said on June 2 that they had launched Byooviz, and the medication became commercially available on July 1. The list price of the intravitreal injection is $1,130 per single use vial, which is 40% less than Lucentis’ list price.

Florida Blue, Prime Post Encouraging Results of Opioid Intervention Pilot

After the Centers for Disease Control and Prevention reported alarming increases in the number of opioid-related deaths in the U.S., HHS in 2017 declared the opioid crisis a public health emergency. Insurers across the country have responded with initiatives to address opioid overuse and misuse among their member populations, including Medicare Advantage enrollees. And CMS has deployed numerous strategies to ensure the appropriate use of pain treatments among Medicare, Medicaid and CHIP beneficiaries, including requiring that all Medicare Part D sponsors adopt drug management programs by 2022. Yet opioid overuse continues to be a concern for MA and Part D organizations.

UnitedHealth Eyes No Out-of-Pocket Costs for Certain Drugs; Other Large Payers May Follow Suit

UnitedHealth Group announced on July 15 that it would eliminate out-of-pocket costs for insulin and a few other medications for beneficiaries enrolled in fully insured plans. The managed care organization expects to implement the changes starting as early as Jan. 1, 2023, pending regulatory approval.

Health and drug policy experts who spoke with AIS Health, a division of MMIT, applauded UnitedHealth’s decision, and noted it would benefit patients who struggle to pay for medications and increase adherence. They also said the move could help United financially, as members are more likely to stay out of the hospital and have better long-term health, but they said it could lead to higher premiums for employers and employees. UnitedHealth did not respond to AIS Health’s request for comment on how the company would foot the bill for implementing the zero cost-share policy.

New Drug Benefit Design Report Shows Increasing Emphasis on Member Experience

In 2022, the majority of plan sponsors used a drug benefit consultant while designing their drug benefit programs, according to Pharmaceutical Strategies Group’s 2022 “Trends in Drug Benefit Design Report,” sponsored by Rx Savings Solutions. The report, which is based on surveys of 153 individuals representing employers, union/Taft-Hartley plans and health plans that covered an estimated 35.1 million lives, also revealed an increasing focus on member satisfaction.

Payers, Government Are Increasing Focus on Health Inequities

Health insurers, states and the federal government are beginning to take more seriously health inequities, according to experts who spoke with AIS Health, a division of MMIT, as the issue becomes a hot topic due to the health and financial costs caused by disparities in health care access and outcomes.

Health inequities related to race, socioeconomic status and sex/gender account for $320 billion in annual health care spending for five high-cost diseases, according to a Deloitte report released on June 22. Deloitte actuaries project that could increase to $1 trillion by 2040 and lead to an average $2,000 increase in health spending per person in the U.S. if those issues are not addressed. The researchers examined the costs of health inequities related to the treatment — or lack thereof — of breast cancer, diabetes, colorectal cancer, asthma and coronary heart disease.


Employers Focus on Affordability, Access in 2023 Benefit Design, Mercer Reports

Over 70% of employers with 500 or more employees are planning to enhance their benefit programs in 2023, with increasing emphasis on health care affordability, work and life balance and women’s reproductive health, according to Mercer’s “Health & Benefit Strategies for 2023 Report.” The report, which is based on surveys of 708 organizations with a focus on the 451 large employers, also found that health benefit strategies are becoming less about reducing health care costs but more about supporting the emotional, physical, social and financial well-being of employees.