Data & Analytics

Small-molecule drugs and biologics may produce similar health benefits, but because small molecules tend to be priced lower than biologics, they often represent better value, according to a recent Health Affairs study. And the study authors argued those findings suggest it could be worth revising how the Medicare Drug Price Negotiation Program is set up.

The Inflation Reduction Act of 2022 requires that Medicare negotiate a Maximum Fair Price for selected small-molecule drugs nine years after they were approved by the FDA. Whereas for selected biologics, the negotiated price takes effect after 13 years.

Premiums for many stand-alone Medicare Part D Prescription Drug Plans will go up moderately in 2025, while the number of PDP options for beneficiaries will drop significantly, according to AIS Health’s analysis of the recently released CMS Medicare Advantage and Part D landscape files.

The Inflation Reduction Act, passed in 2022, ushered in a host of policy changes to the Part D benefit that will take effect in 2025: Most notably, Medicare Part D beneficiaries’ out-of-pocket drug costs will be capped at $2,000 annually and Part D plan sponsors will be responsible for 60% (up from 20%) of any costs their enrollees incur beyond that cap. As a result, the Medicare Part D national average monthly bid amount (NAMBA) is projected to increase by $115, nearly 180%, to $179.45 in 2025.

More than 25 million people lost their Medicaid or Children’s Health Insurance Program (CHIP) coverage and over 56 million had their coverage renewed during the Medicaid eligibility redetermination process, according to a KFF analysis of data released by states and CMS. Though millions have been disenrolled, nearly 10 million more people are currently enrolled in Medicaid/CHIP than at the start of the pandemic.

Starting in April 2023, states were permitted to resume disenrolling people from Medicaid who no longer qualify after a multiyear pause of routine eligibility checks during the COVID-19 public health emergency. Compared to pre-pandemic levels, total Medicaid/CHIP enrollment is now higher in all but four states: Colorado, Montana, Arkansas and Tennessee. Missouri and North Carolina saw Medicaid/CHIP enrollment growth of more than 50%, as of May 2024.

Lobbying spending by the health care industry has increased steadily over the past decade, reaching $129.3 million in 2023, according to data compiled by OpenSecrets. Among the major health plans and industry organizations, Blue Cross Blue Shield plans, AHIP, The Cigna Group and UnitedHealth Group spent the most during the 2023-2024 period, with BCBS plans spending more than $43 million from 2023 through the second quarter of 2024.

Since 2016, the health services/HMOs industry, which traditionally gives more to Republicans, has shifted to distribute more campaign funds to Democratic lawmakers. With the 2024 presidential election around the corner, around 57.3% of funds were donated to Democrats in the 2023-2024 election cycle. Among the top 20 lawmakers who received the most contributions from the industry during this election cycle, 11 are Democrats. Kamala Harris, who is running for president after President Joe Biden dropped out and endorsed her, topped the list and received over $2,347,000. Former President Donald Trump, the Republican presidential nominee, received $638,421.

In recent years, commercial health plans have increasingly opted to place both biosimilars and their reference biologics on preferred tiers in their formularies, according to a recent Health Affairs study.

The researchers analyzed coverage and market share for seven biologics — also known as “originator products” — and 20 corresponding biosimilars from the Tufts Medical Center Specialty Drug Evidence and Coverage Database and the IQVIA Longitudinal Access and Adjudicated Data Set from August 2017 to August 2022. The study categorized the payers’ coverage policies as:

Here’s how major U.S. health insurers performed financially in the second quarter of 2024. Health Plan Weekly subscribers can access more health plan financial data — including year-over-year comparisons of leading health plans’ net income, premium revenue, medical loss ratios and net margins. Just email support@aishealth.com to request spreadsheets for current and past quarters.

In the first quarter of 2024, annual growth in health care spending exceeded the levels seen before the COVID-19 pandemic. Yet hospital inpatient admissions, on a per capita basis, remained lower than pre-pandemic levels, reflecting a shift to outpatient centers, according to a recent Peterson-KFF Health System Tracker analysis.

As many elective hospitalizations were canceled or delayed at the beginning of the pandemic, health care spending dipped in late 2019 and early 2020. Shortly after that, year-over-year growth in health services spending rebounded to pre-pandemic levels and remained high, with double-digit growth since early 2023. Nursing and residential care facilities spending saw year-over-year growth ranging from 10.0% to 13.4% since the beginning of 2023.

CareFirst BlueCross BlueShield, one of the largest insurers in the mid-Atlantic region, recently announced its involvement in a program for early stage technology companies looking to develop artificial intelligence (AI) products for the health care sector. A CareFirst executive tells AIS Health that the payer hopes to learn more about what is happening in the AI space for potential use within the company. One expert, however, says insurers for the most part are still contemplating how to implement AI in their workflows while also being cognizant of its potential flaws.

CareFirst is partnering with Johns Hopkins University for the TechStars AI Health accelerator that will take place in March 2025 in Baltimore. TechStars is a company that invests in and provides guidance and money to startup companies in several industries. The firm hosts numerous so-called accelerators, which are months-long programs where founders of young companies meet with experienced industry leaders and investors. TechStars invests $120,000 in the companies it chooses for the accelerators in exchange for a 6% to 9% equity stake. Most accelerators receive hundreds of applicants, of which TechStars usually selects 20 or fewer to participate.

In 2023, the federal government received more than three times as many surprise billing payment disputes it received in 2022, and provider groups continued to win the vast majority of cases while reaping higher payment amounts, according to new CMS data.

The No Surprises Act (NSA), passed in 2021, banned the practice of billing patients for the difference between what their insurer pays and what a provider charges when patients unknowingly receive care from an out-of-network provider. The law also established a Federal Independent Dispute Resolution (IDR) process that out-of-network providers and insurers can use to determine the OON rate that providers should receive if the two parties fail in their own attempts to negotiate.

Children and adolescents were much more likely to access necessary mental and behavioral health (MBH) services if they lived in states that mandate insurance coverage for mental health care, according to a recent study published in JAMA Network Open.

The study is based on responses from almost 30,000 caregivers of kids and adolescents ages 6 to 17 years with mental and behavioral health conditions in the National Survey of Children’s Health and State Mental Health Insurance Laws Dataset (SMHILD) from 2016 to 2019. The comprehensiveness of state MBH insurance laws was defined by the SMHILD score and categorized as 0 to 2, 3, 4, and 5 to 7.