Infographics

Preventable Hospitalizations Are More Common Among Black Medicaid Enrollees

Black Medicaid enrollees were more likely to be hospitalized for preventable reasons than white enrollees, regardless of whether they were enrolled in the Supplemental Security Income (SSI) program, according to an Urban Institute study.

Using data from CMS, the analysis studied preventable hospitalization rates across 21 states and among Medicaid enrollees ages 19 to 64 for the three most common types of preventable conditions: asthma/chronic obstructive pulmonary disease (COPD), diabetes, and heart failure. For all three conditions, preventable hospitalization rates were significantly higher for people enrolled in Medicaid through the SSI program — meaning they have a qualifying disability — compared with those who enrolled through other pathways.

0 Comments

Study: Medicare Advantage Members Are More Likely to Use Biosimilars

Biosimilar uptake is higher for Medicare Advantage beneficiaries than their traditional Medicare (TM) counterparts, with MA members up to 2.3 times more likely to be prescribed a biosimilar, according to new research published in JAMA Health Forum. The FDA has approved 45 biosimilars so far, with more approvals expected this year.

Researchers from CMS, the FDA and policy research firm Acumen LLC studied claims and encounter data to calculate market share for 20 biosimilars across seven product categories. Biosimilar uptake was higher for MA members in every category but bevacizumab, the generic name for Genentech’s targeted cancer therapy Avastin. Avastin currently has four biosimilars available, with a fifth approved last month.

0 Comments

What Was in MedPAC’s Controversial MA Status Report?

Tensions were unusually high at a Jan. 12 meeting of the Medicare Payment Advisory Commission (MedPAC), which is preparing its annual March report to Congress on the state of Medicare Advantage, among other things. While the routine discussion of the commission’s January status report hit several familiar notes — MA is becoming increasingly popular in an industry plagued by consolidation, excessive coding is driving up program costs, and quality bonus payments don’t reflect high quality care — one commissioner called out the group’s perceived lack of neutrality as the industry prepared for CMS’s 2025 Advance Notice.

MedPAC projects that in 2024, the government will pay $88 billion more than it would pay if MA members were instead beneficiaries of fee-for-service (FFS) Medicare, continuing a trend that has proliferated in recent years. These overpayments, MedPAC analysts outlined for the commission, are driven by MA plans’ enrollment of a largely healthy risk pool, which is then subject to “coding intensity” (i.e., the higher coding patterns due to financial incentives that don’t exist in FFS Medicare).

0 Comments

National Health Care Spending Growth Returned to Pre-COVID Levels in 2022

Total U.S. health care spending increased by 4.1% in 2022, hitting $4.5 trillion, according to CMS. The growth rate appeared to return to the average annual rate of the 2010s, while the share of the gross domestic product (GDP) devoted to health care (17.3%) also fell to pre-pandemic levels.

The rise in overall health care expenditures reflected faster growth in spending for administration costs, retail prescription drugs and long-term services from 2021 to 2022, which was offset by a decline in federal public health spending, according to an analysis by KFF. As the pandemic entered its third year, public health spending dropped by $33 billion compared to 2020.

0 Comments

On Roe v. Wade Anniversary, Here’s a Closer Look at U.S. Abortion Access

The Biden administration announced new measures to protect reproductive health care accessibility on the 51st anniversary of the Roe v. Wade ruling, which found that the U.S. Constitution protects the right to have an abortion. HHS, alongside the Labor and Treasury departments, released new guidance that instructs health insurers on how to comply with the Affordable Care Act’s requirements to cover contraception at no cost. For hospitals and provider associations, HHS and CMS launched new efforts to increase awareness about access to emergency medical care — including abortion services — required under the Emergency Medical Treatment and Labor Act.

A year and a half after the Supreme Court’s decision in Dobbs v. Jackson Women's Health Organization — which reversed Roe v. Wade — access to abortion is uneven across the nation. As of January 2024, 14 states have made abortion illegal. Among the states without bans, the majority have at least one restriction on the books, such as limiting abortion access to just those who are early in pregnancy and imposing mandatory waiting periods. Arizona, North Carolina and Wisconsin, for example, currently have six abortion-limiting regulations in place, according to a KFF analysis.

0 Comments

Employers Increasingly Opt for Self-Funded Health Plans

The share of employer-sponsored health insurance (ESI) enrollees who are in self-funded plans — meaning the employer, rather than an insurer, collects premiums and bears responsibility for paying claims — increased to 60% in 2021 from 55% in 2015, according to a recent Health Affairs study.

Based on 2015 and 2021 Clarivate Interstudy enrollment data, researchers found that in 80.5% of U.S. counties in 2021, the majority of ESI enrollees were in self-funded health plans. Over the years, 78.2% of counties saw growth in the share of ESI enrollees in a self-funded plan. Generally, that growth was concentrated in states with a lower percentage of self-funded plan enrollees in 2015.

0 Comments

Commercial Payers Wrestle With Managing Weight Loss Drug Coverage

With the launch of a new website, Eli Lilly and Co. recently became the first pharmaceutical company to offer weight loss medications though a telehealth provider. The platform — LillyDirect — comes less than two months after Lilly’s weight loss drug Zepbound (tirzepatide) gained FDA approval and joined fellow glucagon-like peptide 1 (GLP-1) agonists from Novo Nordisk A/S, Wegovy (semaglutide) and Saxenda (liraglutide), in the burgeoning obesity drug market.

The weight loss medication market is currently dominated by Wegovy, a once-weekly injectable drug. The FDA initially approved semaglutide for Type 2 diabetes under the brand name Ozempic, but the agency expanded the indications to include weight management three years ago. Pharmacy formularies that cover more than half of commercial-plan enrollees categorize Wegovy as “preferred” or “preferred with utilization management restrictions,” — such as prior authorization and/or step therapy — according to MMIT Analytics. (MMIT is the parent company of AIS Health.)

0 Comments

Drug Utilization Is Down in Medicaid, but Spending Continues to Climb

Medicaid drug spending shows no signs of slowing despite a drop in prescriptions, according to new research from KFF. Net spending on prescription drugs grew 47% to $43.8 billion from fiscal year (FY) 2017 to 2022. The average Medicaid enrollee had 11.4 prescriptions in FY 2017, with a net spend of $39 per prescription. In FY 2022, the number of prescriptions per enrollee dropped to 9.4, while net spending per prescription rose to $58.

Meanwhile, Medicaid enrollment climbed to historic levels amid the COVID-19 pandemic, reaching 96.3 million lives in June 2023, according AIS’s Directory of Health Plans (DHP). With the end of the COVID-era continuous enrollment provision, states are now in the middle of a lengthy — and sometimes controversialunwinding process. Yet utilization (the overall number of prescriptions) stayed under 2017 levels despite the enrollment boom. That could be because the number of days supplied per prescription has increased, with 90-day supplies becoming more common, in addition to lower utilization overall.

0 Comments

Study: Medicare Advantage Members Are More Likely to Use Biosimilars

Biosimilar uptake is higher for Medicare Advantage beneficiaries than their traditional Medicare (TM) counterparts, with MA members up to 2.3 times more likely to be prescribed a biosimilar, according to new research published in JAMA Health Forum. The FDA has approved 45 biosimilars so far, with more approvals expected this year.

Researchers from CMS, the FDA and policy research firm Acumen LLC studied claims and encounter data to calculate market share for 20 biosimilars across seven product categories. Biosimilar uptake was higher for MA members in every category but bevacizumab, the generic name for Genentech’s targeted cancer therapy Avastin. Avastin currently has four biosimilars available, with a fifth approved last month.

0 Comments

ACA Marketplaces Continue to See Record-Breaking Enrollment

Over 20 million people have enrolled in Affordable Care Act marketplace coverage since the start of the 2024 open enrollment period (OEP), reaching a record for the third consecutive year, according to CMS. Over 3.7 million people who have signed up for ACA plans are new enrollees this year.

More than 15.5 million people have enrolled through HealthCare.gov in the 32 states that use that platform, and another 4.8 million have enrolled across 18 states and the District of Columbia, which use their own marketplaces.

After adjusting enrollment figures to account for the fact that there is one fewer day included in the 2024 OEP data compared to last year’s report, an ACAsignups.net analysis showed that every state except Maine and the District of Columbia saw membership growth in 2024, ranging from 2.8% in Hawaii to 78.8% in West Virginia. A total of 10 states reported signup surges of more than 50%.

0 Comments