Radar on Market Access

Radar On Market Access: Trump’s International Drug Pricing Order Is Still Missing; Rebate Order Draws Fire

September 16, 2020

A promised executive order that would tie drug prices to their costs in other countries has yet to emerge, although President Donald Trump has promoted the order as part of his re-election campaign. Meanwhile, payers and PBMs are continuing to push back against three executive orders the Trump administration issued in July with the intention of lowering drug prices, one of which would overhaul the Medicare Part D prescription drug rebate system, AIS Health reported.

“I think the purpose of these executive orders is to give the president some talking points going into the debates,” says Avalere Health founder Dan Mendelson. He adds that, regardless of their purpose, the orders will not make a difference in the real world any time soon.

A promised executive order that would tie drug prices to their costs in other countries has yet to emerge, although President Donald Trump has promoted the order as part of his re-election campaign. Meanwhile, payers and PBMs are continuing to push back against three executive orders the Trump administration issued in July with the intention of lowering drug prices, one of which would overhaul the Medicare Part D prescription drug rebate system, AIS Health reported.

“I think the purpose of these executive orders is to give the president some talking points going into the debates,” says Avalere Health founder Dan Mendelson. He adds that, regardless of their purpose, the orders will not make a difference in the real world any time soon.

Administration officials indicated during the rollout of the executive orders on July 24 that the international pricing order would be released within 30 days of the debut of the other three drug pricing orders. Yet the deadline passed and the administration at press time had not released the promised order.

Meanwhile, the executive orders that actually have been released are being criticized from stakeholders across health care. The order that would remove safe harbor protections from the Anti-Kickback Statute for prescription drug rebates in Medicare Part D has been panned even by conservatives.

Alex Brill, a resident fellow at the American Enterprise Institute (AEI), penned a white paper sponsored by PBM trade group Pharmaceutical Care Management Association (PCMA) that concluded the executive order would “restrict an important tool for providing savings to the federal government and Medicare Part D beneficiaries. Moreover, net drug costs and drug company revenues would rise significantly if the Medicare Part D safe harbor for rebates is eliminated.”

Mendelson says that the pharmaceutical industry is beginning to realize that it will have to change its business model one way or another.

“The pharmaceutical industry is facing a real pivot point where there are going to have to be more innovative ways to price for these products,” Mendelson observes. “…it’s really important that the industry start to figure out ways to engage positively with payers. And the government is the biggest payer.”

Radar On Market Access: Amazon Moves Further Into Health Care Data, Sharp Deal Shows

September 10, 2020

Health care industry insiders say that Amazon.com Inc.’s Aug. 27 deal to provide Halo fitness trackers to Sharp HealthCare indicates the retail and tech giant will make big bets on clinical and actuarial data analytics, AIS Health reported.

Sharp Chief Information and Innovation Officer Michael Reagin says that Amazon will provide the San Diego-based integrated plan and provider with about 500 of the wearable fitness trackers.

Health care industry insiders say that Amazon.com Inc.’s Aug. 27 deal to provide Halo fitness trackers to Sharp HealthCare indicates the retail and tech giant will make big bets on clinical and actuarial data analytics, AIS Health reported.

Sharp Chief Information and Innovation Officer Michael Reagin says that Amazon will provide the San Diego-based integrated plan and provider with about 500 of the wearable fitness trackers.

Sharp will use the devices in two pilot programs, Reagin says. The company will give “about 100” Halos to clinicians, who will wear them in order to track staff performance and prevent burnout. Reagin says the Halo’s much-discussed voice monitoring technology is an essential element of the clinician-focused effort.

The rest of the devices will go to Sharp Health Plan members for remote monitoring purposes.

Michael Abrams, co-founder and managing partner of health care consultancy Numerof & Associates, says that member engagement will be essential to the pilot program’s success. He says that remote monitoring can be stifled if patients don’t fully buy in.

Since the Halo will continually monitor members without any action in their part, Abrams is optimistic that the program will enjoy better adherence than other remote monitoring efforts.

“If plans can get member adoption and perseverance, this could be a great tool for seeing high-level, aggregated community trends and identifying specific interventions,” says Rajshri Ravi, the head of product and technology at ConsejoSano. “Population health management is all about data: the more, the better. It depends on how they use the data. Propensity modeling could predict member behavior and offer insights to increase retention.”

Friso van Reesema, a senior account executive for Eliza, Elli and Essette Solutions, says that Amazon is uniquely well-positioned to offer health plans technology and services that will process that data.

“In the next three years, we’’re going to see some really exciting artificial intelligence and improvement of these platforms that are leveraging these devices to power the platform and be able to roll out exciting algorithms, whether they’re retrospective, prospective, prescriptive,” van Reesema says.

He adds that the deal is likely an attempt by the tech giant to start training its AIs on population health models using data gathered from the Halo pilot.

Radar On Market Access: Some COVID Cost-Sharing Waivers Would Expire Soon

September 8, 2020

Although federal relief legislation tied to the pandemic required health insurers to waive cost sharing for COVID-19 testing, not treatment, many plans opted to do both anyway. In fact, a recent analysis from the Kaiser Family Foundation (KFF) found that 80% of enrollees in the individual and fully insured group insurance markets were in plans that voluntarily waived out-of-pocket costs for COVID-19 at some point during the pandemic, AIS Health reported.

Yet according to the Peterson-KFF Health System Tracker analysis, published Aug. 20, 20% of individual and fully insured group plan enrollees are in plans where a cost-sharing waiver for COVID-19 treatment has already expired, and another 16% are in plans where the waiver is scheduled to expire by the end of September.

Although federal relief legislation tied to the pandemic required health insurers to waive cost sharing for COVID-19 testing, not treatment, many plans opted to do both anyway. In fact, a recent analysis from the Kaiser Family Foundation (KFF) found that 80% of enrollees in the individual and fully insured group insurance markets were in plans that voluntarily waived out-of-pocket costs for COVID-19 at some point during the pandemic, AIS Health reported.

Yet according to the Peterson-KFF Health System Tracker analysis, published Aug. 20, 20% of individual and fully insured group plan enrollees are in plans where a cost-sharing waiver for COVID-19 treatment has already expired, and another 16% are in plans where the waiver is scheduled to expire by the end of September.

Daniel McDermott, a KFF research associate and co-author of the analysis, says that the calculus could change for some insurers as the pandemic wears on.

“Among the insurers who have pushed back their expiration date or extended it, a lot of them had initially set expiration deadlines in early spring — so around May — only to push those back as that date approached,” he says. “So I think it would be reasonable to expect that as some of these fall expiration dates approach, some insurers might take the opportunity to re-evaluate…and make a decision about whether to push back that expiration date again.”

Among enrollees in individual and fully insured group health insurance, 15% were in plans where the expiration date of the COVID-19 treatment cost-sharing waiver was either unspecified or set to end when the public health emergency does, observed the KFF analysis.

Meanwhile, KFF’s more recent report also found that 11% of individual market enrollees and 27% of fully insured group market enrollees are in plans that have offered some form of premium credit or reduction during the pandemic.

For the individual and fully insured group markets combined, just 7% of enrollees were in a plan that offered a premium grace period — in which insurers don’t immediately cancel policies for people who fail to pay their premiums on time, while just 2% were in a plan that offered fast-tracked medical loss ratio rebates.

Radar On Market Access: Insurers Expand Flu Vaccination Outreach to Blunt COVID-19 Effects

September 3, 2020

Even as the COVID-19 crisis continues, public health officials are warning that an influenza pandemic might emerge this fall or winter. A double pandemic would kill even more people than COVID-19 on its own and strain the already overworked health care system. To prevent that deadly combination, plans have stepped up their usual flu-season member outreach programs, particularly for seniors, AIS Health reported.

In the Aug. 21 edition of its Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention tied improved flu vaccination rates to reducing the strain that COVID-19 has put on the health care system.

Even as the COVID-19 crisis continues, public health officials are warning that an influenza pandemic might emerge this fall or winter. A double pandemic would kill even more people than COVID-19 on its own and strain the already overworked health care system. To prevent that deadly combination, plans have stepped up their usual flu-season member outreach programs, particularly for seniors, AIS Health reported.

In the Aug. 21 edition of its Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention tied improved flu vaccination rates to reducing the strain that COVID-19 has put on the health care system.

Flu vaccines are fairly easy to access. However, Richard Hughes IV, managing director of Avalere Health’s vaccine team, says that payers need to consider how to make special accommodations for patients who are immunocompromised or have other viral infection comorbidities. He points out that those patients have the most need for the flu vaccine — but that they paradoxically have the highest risk from COVID-19 exposure.

“A lot of employers have workplace flu clinics,” Hughes adds. But now, he observes, “we have a lot of people working remotely in our economy. So I think you’re going to see some additional challenges to getting people vaccinated.”

UnitedHealth Group is taking a proactive approach to flu vaccination, according to Jennifer Brueckner, Pharm.D., head of the company’s Enterprise Flu Committee. She says the company will email all members who have an address on file and UnitedHealth will target certain at-risk members for extra communication.

Meanwhile, Cigna Corp. is also expanding its annual vaccine outreach. Cigna members do not pay any cost sharing for flu vaccinations if they get their shots at an in-network provider or pharmacy, according to a company statement.

Humana Corporate Medical Director Todd Prewitt, M.D., tells AIS Health via email that the insurer has expanded flu vaccination outreach beyond its usual scope.

“Humana has initiated our ‘Safer Sooner’ campaign theme to encourage all members to obtain the vaccination as soon as it is available through their local providers,” Prewitt explains. “As part of the campaign, we’ve distributed personal safety kits to over seven million members and associates including two cloth masks for personal protection,” he says.

Radar On Market Access: USPS Delivery Slowdown Is Unlikely to Cause Major Rx Fill Disruption

September 1, 2020

The recent, sudden disruption of U.S. Postal Service (USPS) deliveries has caused concern about people receiving their medications later than they normally would. While news reports and statements by lawmakers indicate that many Americans have lost prescriptions in the mail or received them late, drug benefit and supply chain experts tell AIS Health the disruption to the most vulnerable patients served by specialty and mail order pharmacies should be minimal.

An Aug. 24 Axios-Ipsos poll shows that one in five Americans received medication through the mail during the preceding week. One in four of that group, or 5% of Americans overall, didn’t receive their medication or got it late.

The recent, sudden disruption of U.S. Postal Service (USPS) deliveries has caused concern about people receiving their medications later than they normally would. While news reports and statements by lawmakers indicate that many Americans have lost prescriptions in the mail or received them late, drug benefit and supply chain experts tell AIS Health the disruption to the most vulnerable patients served by specialty and mail order pharmacies should be minimal.

An Aug. 24 Axios-Ipsos poll shows that one in five Americans received medication through the mail during the preceding week. One in four of that group, or 5% of Americans overall, didn’t receive their medication or got it late.

In addition, PBMs have not reported significant disruption to their supply chains.

“Most of the drugs shipped from a mail order pharmacy — a non-specialty pharmacy — you worry about them being perishable, but they tend to be pretty stable. They’re oral pills, things like that,” says Mike Schneider, a principal at Avalere Health.

Schneider also suggests that mail order pharmacies’ longer fills, which typically keep shipping costs down by filling for 90 days or more, should insulate patients from major disruptions. He adds that most mail order medication businesses also build logistical complications into their shipping schedules.

Omar Hafez, a principal at Avalere and a former supply chain executive at specialty pharmacy McKesson Specialty Health, says that time- and temperature-sensitive therapies have very specific delivery windows that are mandated by law. He says the strict requirements mean that the bulk of the supply chain for temperature-sensitive specialty drugs is managed by specialized logistics firms, not the USPS.

Schneider says the pharmacy supply chain as a whole has proved remarkably resilient over the course of 2020 — despite the tumult caused by the pandemic and the USPS brouhaha.

“I think a lot of supply chain issues never really materialized, at least not to my knowledge,” Schneider says. “There are a certain drugs that have shortages, but nothing that seemed like it was a national emergency. I think part of the reduced supply might have been everybody was going and filling their prescriptions as the virus was hitting, and everybody was getting some longer-term fills.”

Radar On Market Access: Payers Face Challenges to Enroll Newly Uninsured

August 27, 2020

Health insurers are conducting outreach to people who may have been left without coverage as a result of the COVID-19 crisis, but experts say they may be partially stymied in their efforts to get people enrolled in new plans by the difficulties of operating within a pandemic environment, AIS Health reported.

AmeriHealth Caritas, which is run by Independence Blue Cross in partnership with Blue Cross Blue Shield of Michigan, says it has launched a series of videos designed to help potential Medicaid enrollees learn how they can apply.

Health insurers are conducting outreach to people who may have been left without coverage as a result of the COVID-19 crisis, but experts say they may be partially stymied in their efforts to get people enrolled in new plans by the difficulties of operating within a pandemic environment, AIS Health reported.

AmeriHealth Caritas, which is run by Independence Blue Cross in partnership with Blue Cross Blue Shield of Michigan, says it has launched a series of videos designed to help potential Medicaid enrollees learn how they can apply.

Meanwhile, Fort Worth, Texas-based Care N’ Care Health Plan, which offers Medicare Advantage (MA) plans, is urging newly unemployed seniors — who already were Medicare-eligible but delayed signing up because they still had health insurance through a job — to get coverage now. So it’s deploying a public relations campaign stressing that those people don’t need to wait until open enrollment begins later this year to choose an MA plan.

In addition, most state Medicaid agencies have tried to make it easier for people to apply for coverage during the pandemic by offering a dedicated phone line for enrollment assistance, providing real-­time eligibility decisions, and waiving interviews and other documentation requirements, according to a Health Affairs blog post.

Medicaid managed care organizations are conducting their own outreach, and “they’re really great at consumer engagement with the Medicaid population,” Jerry Vitti, founder and CEO of Healthcare Financial, Inc., tells AIS Health. “But the folks who are newly uninsured are not a typical Medicaid population,” and states and plans may need different types of communications to reach people and enroll them, he says.

So far, Medicaid plans are not seeing as big an influx of enrollees as they might have expected in the pandemic.

“People are forgoing health care, mostly preventive non-emergency visits, in favor of more pressing needs like eating and paying rent — addressing these underlying social determinants of health is primary, so health coverage kind of falls between the cracks,” Vitti says. “Another reason may be that people are expecting to return to work when this is all over and are just waiting to get their old employer coverage back.”

Since “at the very least I think we’re looking at a protracted COVID-related recession,” he says, “we should eventually see the enrollment increase they were expecting.”