Open vs. Closed Claims: Unlocking Opportunities for Healthcare Analytics
In the complex healthcare analytics landscape, understanding the nuances of open and closed claims is critical for researchers and analysts. Open and closed claims each offer unique insights into the patient journey. Open claims, sourced from various clearinghouses and warehouses across the U.S., present a vast collection of data, while closed claims, adjudicated by insurers, […]
Digital Best Practices for Communicating Drug Coverage to HCPs
Before physicians prescribe a new therapy, they need to trust that it is the most effective and appropriate treatment for an individual patient. They need education on the drug’s efficacy and safety, dosing and administration, and the clinical criteria that define eligibility. They also need to know if the drug is affordable and accessible for […]
Tremendous Growth in 2024 Health Insurance Exchange Membership
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 […]
When Payers Become Producers: Inside the Private-Labeling Trend
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 […]
Preparing for the Inflation Reduction Act’s Impact on Medicare Plans
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. […]
Connecting the Dots: Part D Design, the IRA, and Biosimilar Uptake
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 […]
Expanding Molecular Testing: What Payers and Manufacturers Should Know
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. […]
Weight-Loss Mania: Coverage Trends for Obesity Drugs
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 […]
New Program Combats Drug Shortages by Strengthening Generics
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 […]
The Rise of Specialty Benefit Managers: What Pharma Should Know
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. What does the growing prevalence of SBMs mean for […]