ERISA

The Kraft Heinz group has sued Aetna, alleging the insurer “leveraged its role as the third-party administrator or ‘TPA’ to enrich itself to Kraft Heinz’s detriment” and breached its fiduciary duties to the employer. The lawsuit contends that Aetna “(a) paid millions of dollars in provider claims that never should have been paid, (b) wrongfully retained millions of dollars in undisclosed fees, and (c) engaged in claims-processing related misconduct to the detriment of Kraft Heinz,” which contracted with the insurer to provide medical and dental benefits for the company’s employees, retirees and their family members. The firm is asking the court to force Aetna to reimburse it for losses linked to the insurer’s alleged fiduciary breach, along with any related profits.

Blue Cross Blue Shield insurers are again set to collect major payouts from the Affordable Care Act’s risk adjustment program, STAT reported based on an analysis of new federal data. The risk adjustment program transfers funds from ACA marketplace insurers that have lower-risk enrollees to those with higher-risk enrollees. STAT found that more than two dozen Blues insurers are projected to collect over $4.7 billion in risk-adjustment transfers for 2022, with Florida Blue, Health Care Service Corp. and Blue Shield of California due the largest amounts.

Plan sponsors are reporting less satisfaction with their PBMs than they have in prior years, according to a recent survey. While industry experts differ regarding what may be driving that trend, they also have plenty of ideas about what PBMs — or failing that, their regulators — can do to improve how the industry performs.

The 2022 Pharmacy Benefit Manager Customer Satisfaction Report is the 25th annual version produced by the Pharmaceutical Strategies Group (PSG), an EPIC Health LLC subsidiary. In an Oct. 19 press release unveiling the findings, the organization wrote that “there was a notable downturn in overall satisfaction levels” with PBMs in this year’s survey, “as well as in some core measures of general satisfaction such as likelihood to recommend.” Measured on a scale of one to 10, plan sponsors’ overall satisfaction with PBMs was 7.8 in 2022, down from 8.2 last year — and at the lowest level it has been since 2016.

In 2021, prescription drugs accounted for a median of 21% of large employers’ health care costs, and a full 100% of firms said they were concerned about prescription drug spending trends, according to the Business Group on Health’s 2023 Large Employers’ Health Care Strategy and Plan Design Survey.

Yet the rising cost of specialty medications — which are often covered by medical rather than pharmacy benefits — has forced companies to think differently about how to curtail drug spending, the organization found. According to the survey, specialty medications account for 56% of all pharmacy spending by polled employers.

The federal government will stop purchasing COVID-19 vaccines and therapeutics as soon as this fall, Biden administration officials said recently — meaning payers will have to procure vaccines and treatments like any other commercial pharmaceutical product. Health care experts tell AIS Health, a division of MMIT, that the move is likely to make vaccines and therapeutics less accessible and introduce dispensing costs that could drive up premiums.

The Biden administration is transitioning away from the “acute emergency phase where the U.S. government is buying the vaccines, buying the treatments, buying the diagnostic tests. We need to get out of that business over the long run,” White House Coronavirus Response Coordinator Ashish Jha, M.D., said during an Aug. 16 event organized by the U.S. Chamber of Commerce.

In 2021, prescription drugs accounted for a median of 21% of large employers’ health care costs, and a full 100% of firms said they were concerned about prescription drug spending trends, according to the Business Group on Health’s 2023 Large Employers’ Health Care Strategy and Plan Design Survey.

Yet the rising cost of specialty medications — which are often covered by medical rather than pharmacy benefits — has forced companies to think differently about how to curtail drug spending, the organization found. According to the survey, specialty medications account for 56% of all pharmacy spending by polled employers.

Morgan Health, JPMorgan Chase Co.’s health care venture arm, will invest $30 million in startup ERISA carrier Centivo Corp. The investment is part of Centivo’s Series B-1 financing round. Centivo’s strategy is based on value-based care arrangements with providers. A Morgan Health press release claimed that “among mid-size and large employers, Centivo’s typical client has saved 15 to 30 percent annually compared to traditional insurance models. In addition, members’ medical and pharmacy out-of-pocket cost has, on average, been reduced to less than $350 per person per year. These cost reductions have occurred all while increasing primary care utilization by more than 30 percent and strengthening quality through an advanced primary care-centered clinical model.” Centivo operates in 13 states. JPMorgan launched Morgan Health following the collapse of Haven, a health care joint venture with Amazon.com, Inc. and Berkshire Hathaway Inc.

More employers are looking at offering near-site or onsite health clinics to employees and their families, in a bid to improve employee retention, elevate quality of care and better manage medical and pharmacy costs. To optimize these clinic offerings, employers should incorporate high-performing providers and align incentives between patients and primary care physicians (PCPs), say experts who spoke at a recent conference held by the Business Health Care Group (BHCG) of Wisconsin.

According to Mercer’s “Health & Benefit Strategies for 2023” report (see infographic), 17% of large employers said they currently provide onsite or near-site health services to employees, while 12% are planning or considering doing so. The survey was conducted April 26 to May 13, 2022, and included 451 organizations with 500 or more employees.

More purchasers than ever are offering virtual primary care to their members and may be on the verge of launching “virtual-first” plans, according to recent surveys by benefits consultants and brokers. However, health care experts tell AIS Health, a division of MMIT, that there’s an important distinction between the availability of such options to members and actual uptake — and point out purchasers aren’t yet convinced that virtual offerings will reduce costs or improve the member experience.

Recent benefit surveys show increasing interest from employer purchasers in the availability of virtual primary care — which places a member with a telehealth primary care provider inside a traditional health benefit — and virtual-first plans, which are benefit designs that require members to use some sort of telehealth option (usually a telehealth PCP) as their primary point of contact with the health care system.