Payer

Radar On Market Access: Trump Administration’s Transparency Rules Are Part of Larger Effort

November 28, 2019

On Nov. 15, the Trump administration released two rules — one final, one proposed — outlining new price transparency requirements for hospitals and health insurers, which the industry has long warned will impede competitive rate negotiations without actually benefiting patients, AIS Health reported.

On Nov. 15, the Trump administration released two rules — one final, one proposed — outlining new price transparency requirements for hospitals and health insurers, which the industry has long warned will impede competitive rate negotiations without actually benefiting patients, AIS Health reported.

In the proposed rule, slated for publication in the Nov. 27 Federal Register, the administration would require all non-grandfathered group and individual health plans to:

  • Provide consumers with personalized out-of-pocket cost information for all covered health care items and services through an “internet-based self-service tool” and in paper form upon request, and
  • Make their negotiated rates with in-network providers and historical allowed amounts to out-of-network providers available to the public in “standardized, regularly updated machine-readable files.”

In a simultaneously issued final rule, the administration outlines transparency requirements for hospitals. It says they must make public, in a machine-readable format, all “standard charges” for items and services — which the rule defines as gross charges, payer-specific negotiated charges, de-identified minimum and maximum negotiated charges, and discounted cash prices. Plus, hospitals will have to publicly post standard charges for at least 300 “shoppable services” in a consumer-friendly format.

Previously, “standard charges” simply meant hospital chargemaster prices, explains David Kaufman, a partner at Laurus Law Group LLC and former general counsel of Blue Cross Blue Shield of Illinois. Whether CMS is allowed to expand that to include negotiated rates is “going to be the key issue” in a court challenge that hospital groups have promised to file, he tells AIS Health.

But while legal challenges could delay or even prevent one or both rules from being implemented, that doesn’t mean health care organizations have nothing to worry about, says attorney Katie Keith, a principal at Keith Policy Solutions, LLC.

“I guess if I was in the industry, I wouldn’t have my head in the sand about this,” she says. “Insurance companies, to the extent that they have not developed these tools and are not working on this and are not focused on transparency, it does seem like they’re going to want to increase focus on it, because I don’t know that every lawsuit will be successful.”

Radar On Market Access: National and Regional Players Make Dual Eligible SNP Moves

November 26, 2019

Through strategic acquisitions, product launches and geographic expansions, Medicare Advantage insurers across the U.S. are offering new Special Needs Plans (SNPs) aimed at improving the lives of members who are dually eligible for Medicare and Medicaid, AIS Health reported.

Through strategic acquisitions, product launches and geographic expansions, Medicare Advantage insurers across the U.S. are offering new Special Needs Plans (SNPs) aimed at improving the lives of members who are dually eligible for Medicare and Medicaid, AIS Health reported.

According to an analysis of the 2020 “landscape” files posted by CMS in September, Chicago health care consultancy Clear View Solutions, LLC, estimates that there are 171 net new SNP IDs, up from 60 net new plans in 2019. And 97 of those net new plans are dual eligible SNPs, compared with 47 D-SNPs that were introduced for 2019.

“I do think there is some ‘pent up energy’ from plans, and now that there is clarity with permanency and the requirements for integration, plans are ready to move forward,” Cheryl Phillips, M.D., CEO of the SNP Alliance, says in an email to AIS Health.

Phillips says plans may also be “working to better position themselves” for managed long-term services and supports, as states sharpen their focus on rebalancing their long-term care populations and shift more of the responsibility to managed care organizations.

A review of the new D-SNP offerings for 2020 indicates that larger players such as Anthem, Inc., Centene Corp., Humana Inc., Molina Healthcare, Inc. and UnitedHealthcare are leading the charge, but numerous plans have been introduced on a local level.

For instance, UCare, the largest provider of SNPs in Minnesota, said it is expanding its UCare Connect + Medicare plans to mirror the 62-county UCare Connect service area. And Priority Health is preparing to launch its first D-SNP, which will serve all 68 counties of Michigan’s lower peninsula.

MMIT Reality Check on Atopic Dermatitis (Nov 2019)

November 22, 2019

According to our recent payer coverage analysis for atopic dermatitis treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for atopic dermatitis treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for atopic dermatitis treatments shows that under the pharmacy benefit, about 26% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In March 2019, the FDA expanded the approval of Dupixent (dupilumab) to treat moderate-to-severe atopic dermatitis in people aged 12 to 17 years whose disease is not adequately controlled with topical prescription therapies or when those treatments are not advisable.

Radar On Market Access: CVS Health, Cigna Tout Benefits of PBM-Insurer Integration

November 21, 2019

Cigna Corp. and CVS Health Corp. — organizations that both recently combined a PBM and a health insurance business — are striving to prove to investors that they’re seeing valuable benefits from such vertical consolidation, AIS Health reported.

Cigna Corp. and CVS Health Corp. — organizations that both recently combined a PBM and a health insurance business — are striving to prove to investors that they’re seeing valuable benefits from such vertical consolidation, AIS Health reported.

Executives from CVS, which purchased Aetna Inc. in late 2018, during the company’s third-quarter 2019 earnings call said that having such a diversified enterprise is helping it win over PBM clients for its Caremark division.

For the 2020 PBM selling season, “our focus was to go to market with a more integrated medical-pharmacy offering,” said Karen Lynch, CVS Health executive vice president and Aetna president, according to a transcript of the call from Thomson Reuters. To that end, she noted that Caremark saw “increased traction in overall pharmacy penetration” for its employer-sponsored business, particularly among Aetna’s existing medical-benefits clients.

While CVS has won $4.9 billion in gross new business during the 2020 PBM selling season, — up from the $3.8 billion that it previously projected — “net new business is projected to be down -$6.4B overall (vs. -$7.4B previously),” due to the loss of Centene Corp.’s business and other non-renewals, Citi Research analyst Ralph Giacobbe wrote in a Nov. 6 note.

Cigna, which purchased Express Scripts Holding Co. in 2018, said a major driver of its better-than-expected quarterly financial results was the performance of its health services segment, which includes its PBM business. That book of business reported pretax operating earnings of $1.4 billion, which beat Wall Street’s consensus of $1.36 billion and far surpassed the $67 million it earned in the third quarter of 2018 — before Cigna’s purchase of Express Scripts closed.

“We were most encouraged by the PBM earnings step-up, increasing confidence [Cigna] will achieve its 2019 [earnings] target,” Jefferies analysts wrote in an Oct. 31 research note. Cigna raised its 2019 earnings per share estimate to a range of $16.80 to $17.00.

Radar On Market Access: Independent Pharmacies Push Bill to Increase Access to Part D Preferred Networks

November 19, 2019

In the Medicare Part D market in 2020, preferred cost-sharing pharmacy networks continue to be king. But because independent pharmacies often find themselves shut out of such arrangements, recently introduced legislation is seeking to change that dynamic.

In the Medicare Part D market in 2020, preferred cost-sharing pharmacy networks continue to be king. But because independent pharmacies often find themselves shut out of such arrangements, recently introduced legislation is seeking to change that dynamic.

“The Part D plans have fully adopted preferred networks over the last few years,” Adam Fein, Ph.D., president of Pembroke Consulting, Inc., and CEO of Drug Channels Institute, tells AIS Health. “The [retail] chains obviously have some different strategies but are looking for the foot traffic” that comes from offering lower cost sharing as part of a preferred network.

Meanwhile, many independent pharmacies and the pharmacy services administrative organizations (PSAOs) that represent them in negotiations with health plans are moving away from preferred Part D networks.

Fein says they “have concluded that the incremental traffic they’re going to get is not worth the profit they’re going to sacrifice.”

Ultimately, “I think the open question is, will this create access problems to preferred networks, and does CMS care?” he says.

The National Community Pharmacists Association (NCPA) isn’t counting on regulatory intervention. The organization is supporting a bill — introduced last month by U.S. Reps. Peter Welch (D-Vt.) and Morgan Griffith (R-Va.) — which would allow any pharmacy located in an underserved area to participate in a Part D preferred network as long as that pharmacy accepts the terms and conditions.

“We’re not asking for different terms and conditions, [or] higher reimbursement; we’re just asking to be able to see what the terms and conditions are to be in the preferred network and then make our best decision if we want to participate or not,” says Ronna Hauser, the president of policy and government affairs operations at NCPA.

The Pharmaceutical Care Management Association opposes the bill.

“The proposed any willing pharmacy provisions threaten the effectiveness of selective contracting with pharmacies as a tool for lowering costs,” says as statement from the PBM trade group.

MMIT Reality Check on Immune Globulin (CIDP) (Nov 2019)

November 15, 2019

According to our recent payer coverage analysis for immune globulin (CIDP) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for immune globulin (CIDP) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for immune globulin (CIDP) treatments shows that under the pharmacy benefit, almost 40% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In March 2018, the FDA gave an additional approval to Hizentra (immune globulin subcutaneous [human]) as a maintenance therapy in adults with chronic inflammatory demyelinating polyneuropathy to prevent relapse of neuromuscular disability and impairment.