As manufacturers continue to bring more advanced therapies onto the U.S. market, payers are grappling with how to afford these agents. And while the products may be life-changing for some patients, they may not have the desired outcome in others, leaving payers on the hook for an unsuccessful treatment. This has resulted in various contracting opportunities, including warranties.

While such agreements can make payers more confident in their coverage of treatments, particularly high-cost ones and products whose effectiveness or durability are uncertain, they also are beneficial for pharma companies, which are seeing utilization of their therapies.

Five insurers received the highest scores in the latest National Committee for Quality Assurance (NCQA) Health Plan Ratings, which assess plans based on patient experience and clinical quality. Two of those health plans tell AIS Health that their early adoption of value-based care models and buy-in from physicians and members are the keys to achieving their highly rated status.

The results of the annual NCQA report were published on Sept. 16 and included 1,019 commercial, Medicare and Medicaid health plans that reported Healthcare Effectiveness Data and Information Set (HEDIS) data to the NCQA, representing about 227 million people.

While plenty of telehealth and online drug dispensing companies have rolled out direct-to-consumer (DTC) offerings, two pharma manufacturers have unveiled their own digital platforms this year in a bid to streamline and simplify consumers’ experience with the U.S. health care system. Other drugmakers are likely to launch similar offerings, say industry experts, as they offer benefits to various stakeholders. Still, certain challenges exist for those stakeholders, and manufacturers will need to ensure that they take certain steps — both pre- and post-launch — to set themselves up for success while remaining compliant with various regulations.

On Aug. 27, Pfizer Inc. launched PfizerForAll, a “user-friendly digital platform designed to make access to healthcare and managing health and wellness more seamless for people across the U.S.” It is aimed at Americans with migraine, COVID-19 or flu and offers adult vaccinations for conditions such as COVID-19, flu, respiratory syncytial virus (RSV) and pneumococcal pneumonia.

People enrolled in Affordable Care Act marketplace plans had access to 40% of their local physicians in-network, on average, and those who enrolled in more expensive plans generally could access broader networks, according to a KFF analysis.

The analysis studied the percentage of physicians participating in the provider networks of Qualified Health Plans offered in the individual market in the federal and state ACA marketplaces in 2021. It found that only 4% of ACA exchange enrollees were in plans that included more than three-quarters of local doctors in-network, while 23% of enrollees were in a narrow network plan that included fewer than a quarter of the local doctors.

Most people enrolled in Affordable Care Act exchange plans had in-network access to fewer than half of clinicians in their area in 2021, according to a KFF study published on Aug. 26. Matthew Rae, the report’s lead author, tells AIS Health the number of physicians in networks varies widely even within states and counties, yet it is still difficult for consumers to compare and choose plans.

Rae adds that insurers often limit their exchange networks to keep their costs down and competitive in a crowded field, where often dozens of plans vie for enrollees. He points out that insurers seek to price their offerings based on the second-lowest cost plan in the marketplace’s silver category, which is linked to the premium tax credits that most enrollees receive. Plans that are more expensive than the second-lowest cost silver option often only get a small number of enrollees, according to Rae.

Integrated delivery networks (IDNs) are becoming an increasingly larger stakeholder within the U.S. health care system. As of January 2024, almost 80% of physicians were employees of hospitals/health systems and other corporate entities such as private-equity firms, according to an April report prepared by Avalere Health and commissioned by the Physicians Advocacy Institute. Pharma manufacturers can take steps to enhance their partnerships with these entities, said industry experts at a recent webinar.

The long-term care needs of the nation’s “silver tsunami” of 65-and-older population — a wave that began as the first of the baby boomer generation turned retirement age in 2011 — continue to elicit challenges in the broad health care buckets of spending, coverage, access to services and disparities in care. But during a recent webinar, experts discussed some promising solutions, including one health insurer’s initiative that takes a caregiver-centric approach to post-acute care.

Such pervasive problems in long-term care, an industry with a $415 billion tab in annual spending, were the primary theme of an Aug. 7 National Institute for Health Care Management (NIHCM) webinar, an event that framed the contributory elements of the country’s “long-term care crisis” — namely, underinvestment, a lagging workforce, fragmented care and an industry that often fails to take a person-centered approach.

GoodRx will offer Boehringer Ingelheim’s adalimumab-adbm, a biosimilar of AbbVie Inc.’s Humira (adalimumab), at a cash price of $550 per two-pack, revealed the companies on July 18. The price for the citrate-free biosimilar is 92% off that of its reference drug. It is available in both high-concentration and low-concentration formulations. The FDA has approved the 50 mg/mL version as interchangeable with Humira. Consumers may purchase the lower-cost tumor necrosis factor (TNF) inhibitor — which also is available as brand drug Cyltezo — at more than 70,000 retail pharmacies across the U.S.

Walmart is opening 25 new autoimmune-focused Specialty Pharmacies of the Community (SPOC) across five states, said Kevin Host, Pharm.D., senior vice president of pharmacy at Walmart Health and Wellness Pharmacy, on July 25. In October 2023, the company launched six SPOC, which are now available in nine states: Alabama, Idaho, Louisiana, New York, Oregon, Pennsylvania, Rhode Island, Texas and Wisconsin.

As the U.S. continues to grapple with drugs in short supply, a variety of strategies from onshoring production of agents to stockpiling have been proposed. A recent event by The Hill brought together a mix of stakeholders to take a closer look at the situation. Multiple factors are contributing to it, and, thus, one single solution is not going to address the situation, but numerous steps could help alleviate the current, as well as future, shortages, industry experts claimed.

Sponsored by the Healthcare Distribution Alliance, the event, titled “Keeping Pharmacy Shelves Filled: Solutions to Address Drug Shortages,” was held June 25 in Washington, D.C.

More and more plan sponsors are interested in introducing risk-based reimbursement in their contracts with health insurers. That interest has grown into a range of plan designs: On the extreme end, plan sponsors like CalPERS are introducing upside and downside risk to entire third-party administrator contracts. A more incremental approach sees health insurers offering upside risk to plan sponsors based on the health insurer’s ability to control costs for a specific condition.

UnitedHealthcare on June 26 launched such an offering, called the Level2 Assured Value Program. It’s a new payment model for an existing Type 2 diabetes management benefit design called Level2.