The Supreme Court ruled that HHS incorrectly altered the 340B drug program, with Justice Brett Kavanaugh finding that “absent a survey of hospitals’ acquisition costs, HHS may not vary the reimbursement rates only for 340B hospitals; HHS’ 2018 and 2019 reimbursement rates for 340B hospitals were therefore unlawful.” Kavanaugh’s opinion found in favor of the American Hospital Association, which brought a suit against HHS over the changes. “When the original [changes] went into effect in 2018, CMS cut Medicare 340B reimbursements by ~30% for most outpatient drugs, leading to ~$1.6B in savings for the first year,” wrote Citi analyst Jason Cassorla in a note to investors. HHS may have to make retroactive payments to hospitals to make up for the savings, Cassorla noted.
Inflation has not yet impacted health care prices, according to new research from the Kaiser Family Foundation (KFF). The KFF study reports that in the 12 months ending in April 2022, “overall prices grew by 8.3% from the previous year, while prices for medical care increased by only 3.2%.” The authors added, “This is unusual, as health prices historically outpace prices in the rest of the economy. However, the relatively high rate of inflation seen in the rest of the economy may eventually translate to higher prices for medical care. This may lead to steeper premium increases in the coming years.” Generally speaking, according to the report, prices have grown faster for commercial insurance than public payers, a trend that held up in 2022. Though inflation is greater than it has been for a generation, its impact is likely delayed in health care because of contracting cycles. “Health prices are generally set in advance, administratively or via private insurance contracting, so there may be a delay in observable price increases,” the authors observe.
Biogen Inc. and Samsung Bioepis Co., Ltd. said on June 2 that they had launched Byooviz (ranibizumab-nuna), and the medication will be commercially available “through major distributors across the U.S.” on July 1. The drug is the first FDA-approved ophthalmology biosimilar and references Roche Group unit Genentech USA, Inc.’s Lucentis (ranibizumab). On Sept. 20, 2021, the FDA approved Byooviz for the treatment of neovascular (wet) age-related macular degeneration, macular edema following retinal vein occlusion and myopic choroidal neovascularization. The list price of the intravitreal injection is $1,130 per single use vial, which is 40% less than Lucentis’ list price.
Between 2008 and 2021, drug launch prices increased by 20% per year, according to new research published in JAMA. In 2020 and 2021, prices rose 11% each year, even after adjusting for manufacturer discounts. In addition, nearly half of all drugs launched in the last two years initially cost at least $150,000 per year. “Rising brand-name drug prices often translate to payers restricting access, raising premiums, or imposing unaffordable out-of-pocket costs for patients,” the study’s authors observed.
An opinion article published in the New England Journal of Medicine argued that the 340B drug program creates “perverse incentives” for preexposure prophylaxis (PrEP) medications that prevent HIV infection by encouraging safety-net clinics to prescribe the most expensive PrEP treatments. The article observes that “insurers reimburse 340B clinics for medications at an amount close to their list price; the difference between the list price and the discounted 340B price results in revenue — known as the ‘340B spread’ — that clinics can allocate toward other health services. The higher the drug’s price, the bigger the spread….The high cost of PrEP medications has made 340B central to the ability of some safety-net clinics…to provide HIV-prevention and other services....Brand-name oral medications for PrEP, Descovy and Truvada… produc[e] a spread of as much as $1,600 per patient per month. That revenue can fund...important services provided by 340B clinics.” That results in “costs to the health care system that far exceed the clinical benefits.”
Health care consulting firm Avalere Health has been sold to Fishawack Health, by previous owner Inovalon Health. In a letter to clients disclosing the deal, Avalere President Elizabeth Carpenter said that Avalere would “retain our logo and brand,” and “your client teams will remain the same and there will be no change to your current business relationship with Avalere. Everyone you know and love from Avalere is joining Fishawack, including all of our practice leadership.”
A new report by the Government Accountability Office (GAO) found that little information is available about the role that short-term health plans played during the COVID-19 pandemic — and that state regulators are not watching the industry closely. Short-term health plans are not required to meet all the standard benefits mandated by the Affordable Care Act. Per the report, “GAO found that limited and inconsistent data hinder understanding of the role short-term plans played during the COVID-19 pandemic for those who lost [employer-sponsored insurance], such as whether they were used by consumers as temporary coverage or as a longer-term alternative to ACA-compliant plans….State officials in the five states with plan sales were not able to report on the role of short-term plans for consumers, as none of them collected data on the duration of short-term plan coverage.”
CVS Health Corp.’s Aetna won a new group Medicare Advantage contract to serve retirees covered by Connecticut’s state health plan. Connecticut Comptroller Natalie Braswell on June 1 said the state selected Aetna after a competitive bidding process and that the new contract will save an estimated $400 million over the next three years. Beginning Jan. 1, 2023, Aetna will serve some 57,000 Medicare-eligible retirees and dependents enrolled in the state’s MA plan. Connecticut first adopted an MA plan for retirees in 2018.
After CMS imposed a historic increase to Medicare Part B premiums partly due to cost considerations around Alzheimer’s disease treatment Aduhelm, the agency on May 27 said it will not make a midyear change but will likely lower the Part B premium in 2023. Upon raising the standard monthly premium by $21.60 to $170.10 for 2022, the agency in November said it considered “[a]dditional contingency reserves due to the uncertainty regarding the potential use” of Aduhelm, which was approved in July 2021 and priced at $56,000 per year. After Aduhelm makers Biogen and Eisai, Co., Ltd., cut that price in half starting Jan. 1, HHS Secretary Xavier Becerra instructed CMS to reassess the Part B premium. Meanwhile, the FDA issued a National Coverage Determination stating that Medicare will cover Aduhelm only for patients enrolled in randomized, controlled clinical trials conducted either through the FDA or the National Institutes of Health. CMS recommended incorporating the savings realized from this year’s lower-than-anticipated spending into the 2023 Part B premium determination.
While health insurers have made gains in consumer satisfaction in recent years, that progress stalled over the last year, according to a new report from J.D. Power & Associates. “Overall satisfaction has increased…during the past five years, but there is no change in 2022 from 2021, due in part to declines in satisfaction in customer service and dissatisfaction with coverage options and desired network providers,” a J.D. Power press release said. The report said that the health plans that members call “responsive” and “innovative” received the best satisfaction scores. Members also critiqued long hold times at call centers and have found decreasing satisfaction from electronic contact tools like texting and mobile apps. The highest scores for health plans, which were separated by region, were awarded to Kaiser Permanente, Humana Inc., Anthem, Inc., Geisinger Health Plan and several Blue Cross Blue Shield affiliates.
Alvaro Bedoya’s confirmation as a commissioner of the Federal Trade Commission gave new hope to organizations urging the FTC to investigate PBMs. The Senate confirmed Bedoya, a Biden administration nominee, on May 11. Prior to Bedoya’s confirmation, an effort to investigate PBMs stalled when the agency’s existing four commissioners deadlocked along party lines in a Feb. 17 meeting over whether to start such a probe. Instead, the commission on Feb. 24 issued a public request for information (RFI) regarding “the ways that practices by large, vertically integrated Pharmacy Benefit Managers’ (PBMs) are affecting drug affordability and access.”
Meanwhile, Sens. Chuck Grassley (R-Iowa) and Maria Cantwell (D-Wash.) on May 24 introduced legislation that they said would empower the FTC “to increase drug pricing transparency and hold pharmacy benefit managers (PBMs) accountable for unfair and deceptive practices that drive up the costs of prescription drugs at the expense of consumers.” According to the two legislators, the Pharmacy Benefit Manager Transparency Act “would ban deceptive unfair pricing schemes; prohibit arbitrary claw backs of payments made to pharmacies; and require PBMs to report to the FTC how much money they make through spread pricing and pharmacy fees.”
Biden administration officials confirmed that they would extend the COVID-19 public health emergency (PHE) past July 15, when it is currently set to expire, according to press reports, though HHS Sec. Xavier Becerra has not yet issued an official proclamation to that effect. The administration has promised states that it will give them at least 60 days’ notice before the end of the emergency, in part to assist state officials as they restart Medicaid eligibility redeterminations. The PHE also allows for certain flexibilities in areas including telehealth practice. According to news reports, the PHE is likely to be extended until at least Oct. 13.
Nationally, commercial health plans pay 224% more than Medicare rates for services at hospitals, according to new research from the RAND Corp. The study is the latest in a series on hospital prices; the last installment came in 2018. Relative prices vary widely from state to state, with some states’ plans reimbursing below 175% of Medicare rates and some seeing rates of 310% or higher. The study also found that “a large portion of price variation is explained by hospital market power.”
Humana Inc. on May 16 said it had established a second joint venture with Welsh, Carson, Anderson & Stowe (WCAS) to further expand its value-based primary care clinics. (Hg Capital Partners and WCAS share control of MMIT, the parent of AIS Health.) The new JV will provide up to $1.2 billion of additional capital for the development of approximately 100 new CenterWell Senior Primary Care Clinics between 2023 and 2025, said Humana. The expansion follows an earlier JV that is currently deploying up to $800 million of capital to open 67 clinics by early 2023 and support their ongoing operations, added the insurer. WCAS will have majority ownership of the JV, while Humana will own a minority stake.