Data & Analytics

In 2021, almost all commercial, Medicare Advantage and Medicaid health plans covered at least one immediate-release buprenorphine, a medication for treating opioid use disorder (OUD), according to a recent Health Affairs study. Also, since 2017, fewer health plans have been requiring prior authorization and quantity limits for those medications.

However, fewer than half of commercial formularies and one-fifth of MA formularies covered extended-release buprenorphine products in 2021. Comparatively, 82.8% of Medicaid formularies covered such medications, and the share of Medicaid formularies without prior authorization requirements increased from 6.8% in 2018 to 63.3% in 2021.

A review of market access for cervical cancer treatments shows that under the pharmacy benefit, about 33% of the lives under commercial formularies are covered with utilization management restrictions. Around 65% of the lives under Medicare formularies are not covered for at least one of the drugs.

The Congressional Budget Office estimated that in 2023, 248 million people who are younger than 65 will have health insurance coverage, with over 57% covered through employment-based health plans. As COVID-era policies expire over the next decade, employment-based coverage will grow to 159 million and remain the largest source of insurance.

The coverage patterns vary significantly by income. People with income less than 150% of the federal poverty level are more likely to be uninsured or covered through Medicaid or the Children’s Health Insurance Program, while those with higher income are predominantly insured through employer-sponsored coverage.

By the end of the third year of the COVID-19 pandemic, health services utilization had returned to their pre-pandemic levels overall, but some shifts have occurred. That’s just one of the findings of the IQVIA Institute for Human Data Science’s The Use of Medicines in the U.S. 2023: Usage and Spending Trends and Outlook to 2027 recently released report. And while spending on medications will continue to grow, driven by new oncology drugs, traditional areas of growth such as immunology and diabetes will instead help to slow that growth.

Since the beginning of the COVID-19 pandemic, the institute has tracked patient visits, including both telehealth and in-person ones; screening and diagnostic tests; elective procedures; and new prescriptions for its IQVIA Health Services Utilization Index. Speaking at a May 18 webinar on the report’s findings, Michael Kleinrock, research director for the IQVIA Institute for Human Data Science, explained that overall, those services have returned to 100% of pre-pandemic levels as of the fourth quarter of 2022. However, some shifts among the four elements have occurred.

A review of market access for atopic dermatitis treatments shows that under the pharmacy benefit, about 43% of the lives under commercial formularies are covered with utilization management restrictions. Around 25% of the lives under health exchange formularies are not covered for at least one of the drugs.

It is getting harder and harder for health care providers to get claims approved and get paid on time by commercial health insurance plans, according to a new report from Crowe, a company that provides revenue cycle intelligence for providers. One of the report’s authors says that it’s difficult to parse what exactly is driving the trend, but she pointed out that Crowe’s data indicates many initially denied claims eventually get resolved — suggesting insurers are aiming to “hold on to the money a little bit longer.”

Commercial payers reimburse providers at higher rates than Medicare or Medicaid, which usually leads organizations to prefer a payer mix that skews more toward the privately insured, the Crowe report noted. Yet that comes with a downside: The firm found that compared to government payers, private insurers “take the longest to pay, require providers to jump through more administrative hoops to get paid,” such as prior authorization, and “delay payments to providers via claim denials at a higher frequency.”

More than 1 in 5 adults without access to a vehicle or public transportation missed or skipped a health care visit in the previous year, according to a recent Urban Institute study.

Using June 2022 data from the Urban Institute’s Health Reform Monitoring Survey, the researchers found that overall, about 5% of non-elderly adults reported forgoing medical care due to transportation barriers in the previous year. The experience was more common among Black and Hispanic/Latinx adults, individuals from low-income families, people with disabilities and those using public insurance.

Primary care practitioners are working through dramatic change in the business of their profession: More PCPs than ever are working under capitation or risk-based reimbursement arrangements. That trend accelerated as physician employment increased during the worst years of the COVID-19 pandemic, with many doctors selling their independent practices to private equity, insurers or hospital systems.

Although risk-based reimbursement is well established in government books of business, the commercial market is adopting risk-based primary care payment using lessons learned in Medicare Advantage and Medicaid managed care. The transition to commercial risk-based compensation was the subject of a May 23 panel convened by the Primary Care Collaborative, a primary care policy group.

A review of market access for treatments for adults with narcolepsy shows that under the pharmacy benefit, about 55% of the lives under commercial formularies are covered with utilization management restrictions. Around 11% of the lives under Medicare formularies are not covered for at least one of the drugs.

The higher the market share of the leading insurer in a state, the lower the negotiated prices were that the insurer paid to hospitals, according to a new study published in Health Affairs, which used market concentration data from 2019 and payer-specific negotiated prices from 1,446 acute care hospitals as of the end of 2021.

The level of insurer market concentration varied significantly across the nation. In states like Alabama and Alaska, the dominant insurers held a near-monopoly position with market share over 71%, while the leading health plans in states like New York and Wisconsin faced a more competitive environment. The study found that market leaders in the most concentrated markets paid 15% less to hospitals than those in the least concentrated markets.