Within Innovative Oncology Space, Companies Need to Address Oncologists’ Needs

The oncology space is undergoing a tremendous amount of innovation, as novel new products and practices become available. But those treatments can do only so much good if oncologists aren’t using them. Biopharma companies have an opportunity to differentiate themselves from their competitors by addressing oncologists’ specific needs, industry experts tell AIS Health, a division of MMIT.

When it comes to drug information, oncologists not only want to understand a product’s efficacy, “but also how to efficiently and effectively diagnose the patient and get that patient to the right targeted drug or combination using the patient’s genetics and the genetics of the tumor,” such as BRCA1 mutation-positive in breast cancer, explains Kristen Pothier, principal at KPMG U.S. Healthcare and life sciences deal advisory and strategy leader.

Stop-Loss Market May Be Hot Opportunity for Health Insurers

While it’s become common knowledge in the health insurance sector that employer-sponsored coverage isn’t a major growth market, stop-loss insurance is bucking that trend. And with Blue Cross Blue Shield plans in particular not taking as much market share as they could, stop-loss could present attractive opportunities to health care-focused insurance carriers, experts say.

As it applies to health coverage, stop-loss insurance is typically paired with an administrative services only (ASO) contract, in which an employer pays its workers’ health care claims and hires an insurer to process those claims and perform other administrative functions. By adding stop-loss coverage, a self-funded employer is able to have that policy cover any “high-dollar” claim above a certain threshold, called an attachment point, thus minimizing the employer’s risk.


Drug Pricing Remains Hot Topic, but Legislation Addressing It Has Stalled

While drug prices continue to be an issue of concern to many Americans, whether it can get any legislative traction issue remains unclear. So what might happen on the issue in 2022?

Dea Belazi, Pharm.D., M.P.H., president and CEO of AscellaHealth: Pharmaceutical drug pricing continues to be a contentious policy issue. Recent data has branded drug list prices growing annually by more than 9% over the last decade, which is much higher than gross domestic product (GDP) growth. However, a RAND study found that prices for unbranded generic drugs...are slightly lower in the United States than in most other nations. Additionally, patients’ out-of-pocket costs for specialty drugs have increased faster than GDP growth over the same period — 2.8% vs. 2.3%. Furthermore, the current White House administration and Congress have declared that reining in Medicare prescription drug costs to help older adults and people with disabilities is a top priority. This will put drug pricing in the crosshairs of elected officials, advocacy groups and patients.…

ICER Draft Report Deems Four COVID Drugs Reasonably Priced

The manufacturers of four treatments aimed at easing the disease burden of mild-to-moderate COVID-19 received good news recently when the Institute for Clinical and Economic Review (ICER) determined in a draft report that their prices are “reasonably aligned with patient benefits.”

Each of the treatments — molnupiravir, Paxlovid and fluvoxamine, which are delivered orally, and the IV-administered sotrovimab — have been shown in clinical trials to greatly reduce the risk of hospitalization or death in comparison to placebo treatments, according to a draft evidence report released Feb. 3 by ICER.

Lower MA, Individual Enrollment Estimates Dim Cigna 4Q Earnings

Although Cigna Corp. ended 2021 with earnings that exceeded Wall Street expectations, the company also reported continued struggles with elevated medical costs last year. Further, the insurer disclosed that it expects less Medicare Advantage growth than it originally anticipated in 2022 and a decline in individual/family plan enrollment.

For the fourth quarter of 2021, Cigna reported adjusted earnings per share (EPS) of $4.77, beating the consensus estimate of $4.50. Cigna’s full-year adjusted EPS was $20.47, reflecting year-over-year growth of 11% that the company said was largely driven by the Evernorth health services segment.


News Briefs: CMS Proposes 8% Pay Hike for Medicare Advantage Plans

CMS on Feb. 2 released the 2023 preliminary rate notice for Medicare Advantage plans, giving plans an average pay boost of about 8%. To arrive at an expected average change in revenue of 7.98% for 2023, CMS factored in an effective growth rate of 4.75%, which is based largely on an anticipated rise in fee-for-service Medicare costs, according to a CMS fact sheet on the subject.

Medicare Part B beneficiaries will be able to acquire over-the-counter COVID-19 tests free of charge at participating pharmacies and retailers “starting in early spring,” according to CMS. Per a CMS fact sheet, beneficiaries will not need to apply for reimbursement to get the tests: “Eligible pharmacies and other entities that are participating in this initiative to allow Medicare beneficiaries to pick up tests at no cost at the point of sale and without needing to be reimbursed.” AHIP CEO Matt Eyles applauded the move. “This is a commendable model and the right path — for Medicare-eligible people and for all Americans — to ensure equitable access, swift treatment, and an effective response to the virus,” he said in a statement.


News Briefs: CMS Says It Found a Way to Cover Medicare Beneficiaries’ At-Home COVID Tests

CMS on Feb. 3 said it is working on an initiative to enable Medicare coverage of over-the-counter (OTC) COVID tests in early spring. The administration in January issued guidance requiring group and individual health plans to reimburse members for up to eight at-home COVID tests per month without cost sharing. Sen. Debbie Stabenow (D-Mich.) and 18 other senators on Jan. 24 wrote to HHS Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure urging them to extend the same access to Medicare enrollees. And in a bipartisan letter issued Jan. 20, House representatives made a similar request. Despite several issues that complicated CMS’s efforts to cover the tests, the agency said it has “identified a pathway that will expand access to free over-the-counter testing for Medicare beneficiaries.”

Anthem Reports Solid End to 2021, Offers Initial Look at 2022

Health insurer Anthem, Inc., reported solid fourth-quarter results on Jan. 26, with some numbers in line with expectations and others hitting above or below expectations. The company also indicated it’s bracing for medical costs to rise above normal levels this year amid the ongoing COVID-19 crisis — though perhaps not as much as in 2021.

Anthem reported $5.14 in adjusted earnings per share (EPS) for the quarter, beating the consensus of $5.11. “EPS appears to be aided by better-than-expected investment income to the tune of $0.42, which grew $23% [year over year],” Jefferies analyst David Windley wrote in a Jan. 26 note to investors.


Ivermectin for COVID Costs Insurers Millions Despite Lack of Clinical Evidence

Insurers have paid millions of dollars to cover the cost of anti-parasitic drug ivermectin as a COVID-19 treatment even though there is no evidence that it’s actually effective against the disease, according to a new JAMA study. By analyzing claims from December 2020 through March 2021, the researchers found that patients with private insurance spent, on average, $22.48 per ivermectin prescription with insurers reimbursing an average of $35.75, for a total cost of $58.23. Patients with Medicare Advantage spent an average of $13.78, while their health plans reimbursed $39.13, for a total average cost of $52.91 per script. The study also estimated that health plans paid $2.5 million for COVID-related ivermectin prescriptions just in the week of Aug. 13, 2021; extrapolating that over the course of a year, such spending could add up to $129.7 million.

UnitedHealth Downplays Cost of Omicron, At-Home Tests

For health insurers, the new year has ushered in a mandate to cover at-home COVID-19 tests and a highly transmissible coronavirus variant that is making it clear the pandemic is far from over. During its recent conference call to discuss fourth-quarter 2021 financial results, UnitedHealth Group explained how its massive, integrated health care enterprise is responding to both challenges.

The Biden administration on Jan. 10 unveiled new guidance specifying that all group and individual health plans must reimburse members for eight free over-the-counter COVID tests per month without cost sharing. The administration also said it would allow insurers to cap test costs at $12 each if insurers set up in-network agreements with pharmacies/retail stores that allow members to access free tests directly, without filing for reimbursement.