Our leading subject matter experts share their insightful analysis and points of view to help you stay abreast of industry trends
For the past year, Medicaid has been the predominant topic of conversation for those who monitor insurance market share shifts. Medicaid enrollment peaked at 94.5 million in April 2023, when states resumed eligibility redeterminations after a multi-year pause. In the year that followed, Medicaid enrollment declined 10.4%, and has continued to plummet in recent quarters, with this channel losing nearly 4.9 million beneficiaries from Q3 to Q4 2023.
As a direct result of this decline, membership in health insurance exchange plans is…
This article was originally published in Drug Channels.
Vertical integration between payers, PBMs, specialty pharmacies, and providers has grown in the last decade, with more negotiating power concentrated among a handful of major players. Now insurers are adding production arms into the mix, following CVS Health’s bid to cash in on the race for Humira biosimilar market share.
Adding a manufacturing arm brings undeniable advantages for PBMs, from better cost control to smoother supply chain dynamics. Payer-production entities can align an…
For manufacturers of medical benefit drugs, ensuring accurate provider reimbursement is essential. If providers are unaware of how to appropriately bill for a particular drug, their errors will result in claims denials, which in turn may lead them to stop prescribing that drug in favor of another. Inadvertent underbilling for services rendered is also a top provider concern, especially given the popularity of buy-and-bill procurement.
In an attempt to manage medical drug spend, a majority of payers are now enforcing an…
This article was originally published in BioPharma Dive.
For years, many manufacturers have assumed that pre-market physician education was not strictly necessary unless their brand was the first to market or had a novel mechanism of action. With the advent of precision medicine, however, ongoing disease state education has become increasingly critical. Today’s molecular-targeted therapies have very different treatment paradigms, not to mention cost structures.
While it stands to reason that purportedly curative therapies, like those for hemophilia, would require more…
Since its passage in 2022, many have speculated on the impact of the Inflation Reduction Act (IRA) on providers, manufacturers and payers—especially those with Medicare Advantage plans. Just over half of all Medicare beneficiaries are currently enrolled in a Medicare Advantage plan, and enrollment is projected to reach 60% of the eligible population by 2029.
The 2025 and 2026 plan years will see the full implementation of some of the largest Medicare changes, including the Medicare Drug Price Negotiation Program, which…
Although the biosimilar market is expected to continue growing over the next few years, adoption thus far has been somewhat slow and uneven. Recent research published in Health Affairs takes a look at how upcoming provisions of the Inflation Reduction Act (IRA) are likely to impact biosimilar coverage, concluding that both Medicare beneficiaries and the government could realize substantial savings if Part D formularies resembled those of employer-sponsored plans.
In Benefit Design and Biosimilar Coverage in Medicare Part D: Evidence and…
Medicine has been trending towards personalization for decades. The growth of individualized medicine and new diagnostic technologies has resulted in drugs that are tailored towards patients’ profile and condition—and are much more effective as a result. These therapies rely on the existence of molecular tests, including genetic testing, predictive and prognostic biomarkers, and companion diagnostics.
But how well are payers keeping up with this sea change? How are they managing new brands that utilize molecular testing to identify patient cohorts? How…
We are in the midst of a weight-loss drug explosion. Mania for Novo Nordisk’s Wegovy/Ozempic has taken hold of both celebrities and everyday patients, leading to massive shortages and a surge of interest in all glucagon-like peptide 1 (GLP-1) agonists. Industry experts say that obesity has become a top five global market driver, and MMIT’s sister company, Evaluate, estimates the obesity opportunity as exceeding $35 billion by 2028.
The propensity for weight-loss drugs to induce a swell of public enthusiasm is…
According to the American Society of Health-System Pharmacists (ASHP), U.S. drug shortages are the highest they’ve been in more than two decades. As of the end of 2024’s first quarter, 323 drugs were in short supply, including many chemotherapy, ADHD, and pain and sedation medications. These drugs run the gamut from basic drugs to life-saving therapies, and are predominantly generics, with 46% of the quarter’s new shortages being injectables.
While drug shortages are a well-documented issue across the globe, pressure has…
This article was originally published in Fierce Pharma.
In the shift toward value-based care, more payers are outsourcing the management of specific therapeutic areas to third-party specialty benefit managers (SBMs). These companies help payers manage high-cost, high-complexity disease states by leveraging provider networks and making coverage recommendations intended to improve outcomes and lower cost.
Unlike PBMs, which support employers and MCOs in managing prescription drugs and formularies, SBMs are centered on improving the care experience for patients and providers through specialization.…
