Welcome to my editorial page where I comment on Healthcare News & Industry changes.
September 20, 2019
Marybeth Gray has been featured on the 2019 Marquis Whos’ Who Lifetime Achievement site below.
Marquis identifies and endeavors to profile the leaders of American Society; those men and women who are influencing their nation’s development and influencing the people of today in their industry. We are proud to provide their biographical information for public record for posterity.
Sept 13, 2019
We all need a good laugh!
Good morning and happy Friday the 13th. Did you know that, according to Otis Elevator Company, as many as 85% of the high-rises in the world don’t have a 13th floor?
“People on the 14th floor, you know what floor you’re really on.”
Take it easy out there today…
Now for the serious stuff….
According to The Morning Brew: Sadly, yesterday the Environmental Protection Agency repealed a major Obama-era environmental protection for streams and wetlands.
The backstory: Before 2015, the EPA decided case-by-case whether individual streams or wetlands had significant impacts on downstream rivers and were therefore subject to federal clean water standards.
- In 2015, the Obama administration created federal pollution protections for ~60% of U.S. waters, including these smaller waterways.
Now, the EPA wants to go back to the old system. The repeal was Step 1: Next, it’ll create stricter requirements for what waterways can be federally protected.
Water they doing this for
The Trump administration says the 2015 rule stepped on states’ toes, was too broadly written, and made life unreasonably difficult for businesses.
- To give you a clue who didn’t like it…the repeal was signed at the National Association of Manufacturers’s HQ. Farmers, miners, developers, and oil and gas companies also weren’t fans.
Zoom out: This is the Trump administration’s 7th trim of water pollution regulations. To date, it’s completed or is working on rollbacks of 84 other environmental rules.
Living in Southern Florida, this saddens me due to the highly problematic water contamination issues we have been dealing with. They potentially cause red-tide on many of the beaches in Florida- killing millions of fish and wildlife each year.
September 12, 2019
Fall brings us beautiful foliage in the Northeast but also produces storms due to the warm waters in our Oceans. We all watched in the past week the destructive Hurricane Dorian wreak havoc along our East Coast and for our neighbors in the Bahamas. Our hearts and prayers go out to everyone who has been touched by this storm.
Believe it or not, these storms that have been more prevalent in the past several years, may also impact our stop loss renewals. Many insurers that provide stop loss coverage also provide Property & Casualty Insurance. They have suffered losses due to these storms. In 2018, we experienced 14 separate climate disasters in the US – each over $1 Billion in cost! Couple that with the new specialty pharmaceuticals, gene therapy and immunotherapies on the market – some over $1 million dollars – and we have a bumpy stop loss renewal season ahead of us!
Yesterday, we presented a FREE 30 minute Power Lunch with a discussion on:
How New Million Dollar Therapies are going to affect our Stop Loss Renewals
* Overview of New Therapies
* Clinical Management approaches to Control Utilization
* Stop Loss Renewal Negotiation Tactics
Click here to listen to our Power Lunch Recording!
News Items This Week:
* The Food and Drug Administration last year approved its first autonomous, artificially intelligent medical device.
In a decision that seemed to take a page from science fiction, the FDA gave the OK to the IDx-DR, a device that uses artificial intelligence to analyze images of the back of a patient’s eye to detect if they have diabetic retinopathy.
* FDA approves a $2.125Million medicine for spinal muscular atrophy manufactured by Novartis – now the most expensive pharmaceutical on the market in the US.
* California Lawmakers Push for more transparency out of Kaiser
The Food and Drug Administration approved its first autonomous, artificially intelligent medical device that uses artificial intelligence to detect if they have diabetic retinopathy.
21st Century Cures Act driving FDA changes
Diabetic retinopathy occurs when high levels of blood sugar lead to damage in the blood vessels of the retina, the light-sensitive tissue in the back of the eye. Diabetic retinopathy is the most common cause of vision loss among the more than 30 million Americans living with diabetes and the leading cause of vision impairment and blindness among working-age adults.
“Early detection of retinopathy is an important part of managing care for the millions of people with diabetes, yet many patients with diabetes are not adequately screened for diabetic retinopathy since about 50 percent of them do not see their eye doctor on a yearly basis,” said Malvina Eydelman, M.D., director of the Division of Ophthalmic, and Ear, Nose and Throat Devices at the FDA’s Center for Devices and Radiological Health. “Today’s decision permits the marketing of a novel artificial intelligence technology that can be used in a primary care doctor’s office. The FDA will continue to facilitate the availability of safe and effective digital health devices that may improve patient access to needed health care.”
The device moved through the FDA’s approval process in a record 85 days under the agency’s de novo pre-market review pathway. The device was part of the agency’s Breakthrough Device Program, which was established as part of the Cures Act—a landmark piece of legislation signed into law during the final month of the Obama administration.
Most Expensive Drug in the US approved by the FDA
In late May 2019, the FDA approved the most expensive medicine to date for a rare disorder called spinal muscular atrophy. The Novartis manufactured drug treatment targets a defective gene that weakens a child’s muscles so dramatically that they become unable to move and eventually unable to swallow or breathe. It strikes about 400 babies born in the US each year.
California lawmakers push for transparency from Kaiser Permanente
Last week, CA lawmakers passed a union-backed bill that would force each of the health systems facilities to disclose its profits. The Democratic Governor of CA has until the end of this week to sign it into law. Currently, Kaiser reports a lump sum financial report for all 35 hospitals in its system.
Note from Marybeth: Any effort to afford purchasers more transparency into cost and pricing would be better for the consumers. I am hopeful that the Governor signs this legislation into law.
March 29, 2019
I posted the Trion Pharmacy Newsletter today under the “News Alerts” Tab of my webpage. Pharmacy is the fasting growing piece of medical trend and I am hopeful we help you stay up to date on the changing environment in which we work!
As we run up to the next presidential election, it may be a very bumpy ride for healthcare in our country. The focus on pharmaceutical costs and changes or elimination of ACA will be a key focus in the coming weeks. The impact will be tremendous if the proposed changes occur (outlined below).
New York Times – March 27
What Happens if the ACA is Struck Down?
The Affordable Care Act touches the lives of most Americans. Some 21 million could lose health insurance if the Trump administration were to succeed in having the law ruled unconstitutional.
By Reed Abelson, Abby Goodnough and Robert Pear
The Affordable Care Act was already in peril after a federal judge in Texas invalidated the entire law late last year. But the stakes ramped up again this week, when President Trump’s Justice Department announced it had changed its position and agreed with the judge that the entire law, not just three pieces of it, should be scrapped.
A coalition of states is appealing the ruling. If it is upheld, tens of millions more people would be affected than those who already rely on the nine-year-old law for health insurance. Also known as Obamacare, the law touches the lives of most Americans, from nursing mothers to people eating at chain restaurants.
Here are some potential consequences, based on estimates by various groups.
People who could lose their health insurance.
Of the 23 million people who either buy health insurance through the marketplaces set up by the law (11.4 million) or receive coverage through the expansion of Medicaid (12 million), about 21 million are most at risk if Obamacare is struck down. That includes 9.2 million who receive federal subsidies.
On average, the subsidies covered $525 of a $612 monthly premium for customers in the 39 states that use the federal marketplace, HealthCare.gov, according to a new report from the Department of Health and Human Services. If the marketplaces and subsidies go away, a comprehensive health plan would become unaffordable for most of those people and many of them would become uninsured.
States could not possibly replace the full amount of federal subsidies with state funds.
Adults could lose Medicaid coverage.
Medicaid, the government insurance program for the poor that is jointly funded by the federal government and the states, has been the workhorse of Obamacare. If the health law were struck down, more than 12 million low-income adults who have gained Medicaid coverage through the law’s expansion of the program could lose it.
In all, according to the Urban Institute, enrollment in the program would drop by more than 15 million, including roughly three million children who got Medicaid or the Children’s Health Insurance Program when their parents signed up for coverage.
The law ensures that states will never have to pay more than 10 percent of costs for their expanded Medicaid population; few if any states would be able to pick up the remaining 90 percent to keep their programs going. Over all, the federal government’s tab was $62 billion last year, according to the Congressional Budget Office.
Losing free health insurance would, of course, also mean worse access to care and, quite possibly, worse health for the millions who would be affected. Among other things, studies have found that Medicaid expansion has led to better access to preventive screenings, medications and mental health services.
Medicaid spending for opioid addiction prescriptions has more than doubled.
The health law took effect just as the opioid epidemic was spreading to all corners of the country, and health officials in many states say that one of its biggest benefits has been providing access to addiction treatment. It requires insurance companies to cover substance abuse treatment, and they could stop if the law were struck down.
The biggest group able to access addiction treatment under the law is adults who have gained Medicaid coverage. The Kaiser Family Foundation estimated that 40 percent of people from 18 to 65 with opioid addiction — roughly 800,000 — are on Medicaid, many or most of whom became eligible for it through the health law. Kaiser also found that in 2016, Americans with Medicaid coverage were twice as likely as those with no insurance to receive any treatment for addiction.
States with expanded Medicaid are spending much more on medications that treat opioid addiction than they used to. From 2013 through 2017, Medicaid spending on prescriptions for two medications that treat opioid addiction more than doubled: It reached $874 million, up from nearly $358 million in 2013, according to the Urban Institute.
The growing insured population in many states has also drawn more treatment providers, including methadone clinics, inpatient programs and primary care doctors who prescribe two other anti-craving medications, buprenorphine and naltrexone. These significant expansions of addiction care could shrink if the law were struck down, leaving a handful of federal grant programs as the main sources of funds.
Americans with protected pre-existing conditions.
As many as 133 million Americans — roughly half the population under the age of 65 — have pre-existing medical conditions that could disqualify them from buying a health insurance policy or cause them to pay significantly higher premiums if the health law were overturned, according to a government analysis done in 2017. An existing medical condition includes such common ailments as high blood pressure or asthma, any of which could require someone buying insurance on their own to pay much more for a policy, if they could get one at all.
Under the A.C.A., no one can be denied coverage under any circumstance, and insurance companies cannot retroactively cancel a policy unless they find evidence of fraud. The Kaiser Family Foundation estimated that 52 million people have conditions serious enough that insurers would outright deny them coverage if the A.C.A. were not in effect, according to an analysis it did two years ago. Its estimates are based on the guidelines insurers had in place about whom to cover before the federal law was enacted.
Most Americans would still be able to get coverage under a plan provided by an employer or under a federal program, as they did before the law was passed, but protections for pre-existing conditions are particularly important to those who want to start their own businesses or retire early. Employers would sometimes refuse to cover certain conditions, and companies would have to decide if they would drop any of the conditions they are now required to cover.
The need to protect people with existing medical conditions from discrimination by insurers was a central theme in the midterm elections, and Democrats attributed much of their success in reclaiming control of the House of Representatives to voters’ desire to safeguard those protections. Many Republicans also promised to keep this provision of the law, although exactly how was unclear. Before the law, some individuals were sent to high-risk pools operated by states, but even that coverage was often inadequate.
Americans who no longer face caps on expensive treatments.
The 156 million Americans who get coverage through an employer, as well as the roughly 15 million enrolled in Obamacare and other plans in the individual insurance market, are protected from caps that insurers and employers used to limit how much they had to pay out in coverage each year or over a lifetime. Before the A.C.A., people with conditions like cancer or hemophilia that were very expensive to treat often faced enormous out-of-pocket costs once their medical bills reached these caps.
While not all health coverage was capped, most companies had some sort of limit in place in 2009. A 2017 Brookings analysis estimated that 109 million people would face lifetime limits on their coverage without the health law, with some companies saying they would cover no more than $1 million in medical bills per employee. The vast majority of people never hit those limits, but some who did were forced into bankruptcy or went without treatment.
Medicare beneficiaries would face changes to medical care and possibly higher premiums.
About 60 million people are covered under Medicare, the federal insurance program that covers people over 65 years old and people with disabilities. Even though the main aim of the A.C.A. was to overhaul the health insurance markets, the law “touches virtually every part of Medicare,” said Tricia Neuman, a senior vice president for the Kaiser Family Foundation, which did an analysis of the law’s repeal. Overturning the law would be “very disruptive,” she said.
Medicare beneficiaries would have to pay more for preventive care, like a wellness visit or diabetes check, which are now free. They would also have to pay more toward their prescription drugs. About five million people faced the so-called Medicare doughnut hole, or coverage gap, in 2016, which the A.C.A. sought to eliminate. If the law were overturned, that coverage gap would widen again.
The law also made other changes, like cutting the amount the federal government paid hospitals and other providers as well as private Medicare Advantage plans. Undoing the cuts could increase the program’s overall costs by hundreds of millions of dollars, according to Ms. Neuman. Premiums for as many as 55 million people under the program could go up as a result.
The A.C.A. was also responsible for promoting experiments into new ways of paying hospitals and doctors, creating vehicles like accountable care organizations to help hospitals, doctors and others to better coordinate patients’ care.
If the groups save Medicare money on the care they provide, they get to keep some of those savings. About 12 million people are now enrolled in these Medicare groups, and it is unclear what would happen to these experiments if the law were deemed unconstitutional. Some of Mr. Trump’s initiatives, like the efforts to lower drug prices, would also be hindered without the federal authority established under the A.C.A.
Young adults with coverage through their parents’ plans
The A.C.A. required employers to cover their employees’ children under the age of 26, and it is one of the law’s most popular provisions. Roughly two million young adults are covered under a parent’s insurance plan, according to a 2016 government estimate. If the law were struck down, employers would have to decide if they would continue to offer the coverage. Dorian Smith, a partner at Mercer, a benefits consulting firm, predicted that many companies would most likely continue.
Medical care for the uninsured could cost billions more dollars.
Doctors and hospitals could lose a crucial source of revenue, as some people lose insurance. The Urban Institute estimated that nationwide, without the A.C.A., the cost of care for people who cannot pay for it could increase as much as $50.2 billion.
Hospitals and other medical providers would incur losses, as many now have higher revenues and reduced costs for uncompensated care in states that expanded Medicaid. A study in 2017 by the Commonwealth Fund found that for every dollar of uncompensated care costs those states had in 2013, the health law had erased 40 cents by 2015, or a total of $6.2 billion.
The health insurance industry would be upended by the elimination of A.C.A. requirements. Insurers in many markets could again deny coverage or charge higher premiums to people with pre-existing medical conditions, and they could charge higher rates to women. States could still regulate insurance, but consumers would see more variation from state to state. Insurers would also probably see lower revenues and fewer members in the plans they operate in the individual market and for state Medicaid programs.
Menu labels are among dozens of the law’s provisions that are less well known.
The A.C.A. requires nutrition labeling and calorie counts on menu items at chain restaurants.
It requires many employers to provide “reasonable break time” and a private space for nursing mothers to pump breast milk.
It created a pathway for federal approval of biosimilars, which are near-copies of biologic drugs, made from living cells.
March 19, 2019
Big Pharma went to Washington for the Senate hearing 2 weeks ago. The seven pharmaceutical manufacturers pointed fingers back at the PBMs and the rebates -as the culprit for high drug prices. (Not surprised – we saw that coming). Late last week, UnitedHealth Group Inc. (the largest carrier in the US and owner of OptumRX (their own PBM) said it would significantly expand a change to how it handles rebates from drugmakers by requiring new employer clients to pass them on to people who take the medications. (Not giving them back to employers.) The move will apply to employers that sign new contracts after Jan. 1, 2020, but UnitedHealth will grandfather in existing clients that chose a different setup.
While this may appear they are “giving up the rebates from the drugmakers”, it may undermine the plan design cost shares we have painstakingly worked hard to set up to incent members to use lower costing drugs. More to come!
February 26, 2019
Big Day for Big Pharma!
Senate Hearing Today for Big Pharma
This morning, many of the major drug manufacturer executives will testify in a highly anticipated (and in a rare united front of lawmakers on both sides of the aisle) Senate hearing, where they’ll attempt to defend the exploding cost of prescription drugs in the U.S.
Who’s on the guest list?
Top brass from Pfizer, Merck, AstraZeneca, Johnson & Johnson, Bristol-Myers Squibb, AbbVie, and Sanofi will face Senate Finance Committee Chairman Chuck Grassley (R-IA) and his fellow legislators.
The Issue at hand
Most think the drug makers will argue the industries malfunctioning reimbursement system is at fault. That system allegedly forces companies to hike prices then offer deep discounts (in the form of rebates) in order to win a spot on the insurance companies formulary or preferred list.
The stats are staggering
Recent estimates suggest total U.S. prescription drug spending will grow 60% from 2019 to 2027 to reach $576.7 billion.
An example of the cost explosion: A vial of insulin that cost under $200 a decade ago now goes for about $1,500. Osteopetrosis drug Actimmune costs $350/month in Britain…and $26,000/month in the U.S.
Politics in play
Drug pricing is already a major issue for 2020 election cycle and reforming this industry will be a focal issue that is argued over the next several months.
Sharing an article below on the topic:
Wall Street Journal – Feb 26
Pharmaceutical Industry CEOs Face Senate Hearing on Drug Prices
Lawmakers are expected to pose questions about rebates and patents
By Jared S. Hopkins and Peter Loftus
Executives for some of the biggest pharmaceutical companies will visit Capitol Hill on Tuesday to face tough questions in a Senate hearing on the rising cost of medicines.
The executives lead companies with some of the highest-grossing drugs in the world, and have routinely raised prices on many of their products. Scheduled to testify are chief executives from AbbVie Inc.; Bristol-Myers Squibb Co.; Merck; Pfizer Inc.; AstraZeneca; and Sanofi SA. Johnson & Johnson, the world’s largest health-care company, is sending an executive who oversees its drug division.
Members of the Senate Finance Committee, chaired by Sen. Chuck Grassley (R., Iowa), are expected to question the executives on their pricing practices and how the companies can reduce costs for patients, according to people familiar with the matter. They are also likely to face questions about their strategies to fight off cheaper generic alternatives, according to the people.
The hearing could inform bipartisan legislation this year to target high drug prices. Sen. Grassley and Sen. Amy Klobuchar (D., Minn.) have introduced bills to legalize personal importation of lower-priced medicines from Canada, and to curtail patent-infringement-litigation settlements in which makers of brand-name drugs pay generic manufacturers to delay competition.
Americans continue to grapple with the rising cost of health care, including out-of-pocket costs for prescription drugs. In Washington, drug pricing may be one of the few issues that President Donald Trump and the Democrats could find common ground. While the pharmaceutical industry has for years been a major lobbying player, its critics are also spending millions of dollars to influence lawmakers.
On Tuesday, when senators ask about high list prices for drugs, expect the companies to respond by saying the prices aren’t meaningful because they don’t include discounts and rebates that companies give to pharmacy-benefit managers in order to gain plan coverage, said Ira Loss, senior health-care analyst at research firm Washington Analysis.
“The drug industry is going to come in and blame the pharmacy-benefit managers for the problems and say, ‘It’s not our fault,’ ” Mr. Loss said.
Industrywide, net prices have been falling as list prices rise, according to data from SSR Health. Few patients pay “list” prices, which don’t take into account rebates, discounts and insurance payments, but some pay the full price at times, such as when they haven’t met their deductible.
AbbVie’s rheumatoid arthritis treatment Humira is the top-selling drug in the world, and the company said that both volume and pricing fueled the drug’s growth during the fourth quarter. AbbVie raised the drug’s list price by 9.7% in January 2018 and then 6.2% more last month.
AbbVie has pledged to limit its overall drug-price increases to less than 10% annually, and only once a year, which the company says would be offset by rebates and discounts paid to insurers and other industry middlemen.
AbbVie Chief Executive Richard Gonzalez also may face questions about the company’s patent strategy. Humira’s main U.S. patent expired in 2016, but the company has fought off generic competition with a series of other patents and is expected to hold exclusive U.S. marketing rights until 2023.
New York-based Pfizer, which had regularly increased prices over the years, temporarily put off raising prices last year amid pressure from President Trump, but resumed increases on about 10% of its portfolio this year. Chief Executive Albert Bourla, who began leading the company in January, said on its fourth-quarter earnings call that Pfizer’s growth won’t be driven by price.
Bristol-Myers Squibb has been heavily criticized for how it prices its drugs. It will acquire costly multiple myeloma drug Revlimid, should it close its January agreement to acquire rival Celgene Corp. for $74 billion. Revlimid is Celgene’s top-selling drug, and has regularly gone up in price. In 2007, a 10-milligram dose cost $247.28. This year, on the day of the planned deal between the two companies, the price went up 3.5% to $719.82.
The hearing comes as the Trump administration pursues its own proposals aimed at drug prices. One, opposed by the industry, would tie the price of some Medicare drugs to prices in foreign countries where drugs are cheaper. However, the drug industry has supported the administration’s proposal limiting the rebates that drug companies pay to middlemen in federal pharmacy programs. The move doesn’t directly limit drug manufacturers’ pricing power, although the administration hopes list prices will fall and savings will be steered to consumers.
The drug industry has been proactive the past few years amid criticism of prices. Some including Allergan PLC have pledged to take just one price increase each year, and by less than 10%, while others have made similar proclamations. Companies increasingly are touting how their net prices are staying the same or falling. Last year, Merck cut the cost for some of its medicines and promised to limit its net price increases. Nevertheless, the drug industry continues to raise list prices on many of its medicines.
Senators may also ask about the growing cost of insulin. Sanofi’s chief executive, Olivier Brandicourt, could be questioned on the rising cost of insulin, a treatment for diabetic patients. The drugmaker sells the world’s top-selling insulin, Lantus.
While the hearings might not lead to substantive legislation, they will allow the senators to showcase themselves, Mr. Loss said. “Get your popcorn,” he said.
Sen. Grassley hasn’t always sided with the pharmaceutical industry. He has long supported re-importing drugs from other countries, such as Canada, which the industry opposes. He also helped write legislation that requires disclosure of gifts from drugmakers to doctors and hospitals.
Last year, Sen. Grassley introduced bipartisan legislation mandating that television commercials for drugs include list prices. The measure didn’t pass the House, but the industry’s lobbying group said companies would voluntarily include price-related information in television ads by directing consumers to websites where they can find information on list prices and costs. This month J&J included its list price in a television ad for blood thinner Xarelto.
As an update to the story below – CVS & Wal-Mart did reach an agreement late last month to keep Wal-Mart in the CVS Network.
January 15, 2019
CVS Informed us today that Walmart has opted to leave the CVS Caremark pharmacy benefit management commercial pharmacy networks. CVS Caremark has requested that Walmart continue to fill prescriptions as an in-network participating pharmacy through April 30, 2019. This transition does not affect Walmart’s participation in the CVS Caremark Medicare Part D pharmacy network. In addition, Walmart’s Sam’s Club division remains in the CVS Caremark pharmacy networks.
Statement from CVS: At a time when everyone is working hard to find ways to reduce health care costs, Walmart requested rates that would ultimately result in higher costs for our clients and members. While we have enjoyed a long relationship with Walmart as a low-cost provider in our broad national networks, based on our commitment to helping our clients and consumers manage rising pharmacy costs, we simply could not agree to their recent demands for an increase in reimbursement.
Our focus now is an orderly transition for any affected plan members and ensuring we place patient care as our highest priority. With continuity-of-care in mind, we have requested that Walmart continue to fill prescriptions as an in-network participating pharmacy through April 30, 2019, and are awaiting a response on the transition period.
As we begin to prepare members for a transition, we are hopeful that Walmart will agree to work amicably with us in the best interest of patients. Our priority is to ensure that patients continue to have access to their medications during this transition period. We also remain open to continuing timely, good-faith negotiations with Walmart in the hopes of reaching an agreement to provide quality pharmacy care at a reasonable cost.
Walmart will remain in CVS Caremark Medicare Part D networks
Remember – CVS Health purchased Aetna (the third largest Insurer in the US) for $69 billion.
Senior Vicec President Health & Welfare Consulting
Trion Group, a Marsh & McLennan Agency LLC
Marybeth will attend the following conferences in 2019!!
North American HR Executive Summit – NEW February 11-12
San Diego Mid-Sized Retirement & Healthcare Plan Management (MB will be the opening Keynote Speaker) March 24-27
CFO Connect Spring April 14-16
Boston Mid-Sized Retirement & Healthcare Plan Management May 5-8
Chicago Mid-Sized Retirement & Healthcare Plan Management (MB will be the opening Keynote Speaker) June 4-7
Nashville Mid-Sized Retirement & Healthcare Plan Management September 15-18
January 9, 2019
Happy New Year! I Hope everyone had a wonderful Holiday!
Texas Federal Court Rules ACA Unconstitutional…But Please Sit Tight
January 9, 2019
Given the heavy media attention, you are probably aware that a Texas federal district court issued a decision on December 14, 2018, declaring the entire Affordable Care Act (ACA) unconstitutional. The final outcome will take a while, and the ACA remains in effect as this case moves through the appeals process. Employers (and their group health plans) should continue to comply with the ACA in the meantime.
Do not halt or delay your 2018 Form 1094/1095 reporting.
Texas v. Azar
In its 2012 National Federation of Independent Businesses (NFIB) v. Sebelius decision that preserved most of the ACA as originally written, the U.S. Supreme Court held that Congress had the authority to implement the individual mandate and its penalty under the taxing power given to it by the U.S. Constitution. The individual mandate penalty was reduced to zero effective January 1, 2019, by the Tax Cut and Jobs Act of 2017 triggering the Texas v. Azar lawsuit over the continuing constitutionality of the ACA. This case was ultimately joined by thirty-six states and the District of Columbia giving it a distinctive red versus blue feel.
In his decision, Judge O’Connor determined that the elimination of the individual mandate penalty meant the individual mandate itself could no longer be viewed as a valid exercise of Congress’ taxing power. Judge O’Connor also determined that the individual mandate was so essential to and inseparable from the ACA that this renders the entire ACA unconstitutional.
Predicting the Future
Judge O’Connor’s ruling did not include an injunction, meaning the ACA is still in effect pending the appeals process. This fact was verbally repeated by the Trump administration. It is probably foolish to attempt to predict the future of Texas v. Azar, but if we had to:
- The 5th Circuit – This is a coin flip, but the U.S. Court of Appeals for the 5th Circuit overrules the district court opinion. While the court agrees that the individual mandate is unconstitutional, the 5th Circuit is unable to conclude that the individual mandate cannot be severed from the rest of the ACA. Whatever the outcome, the side that comes up short appeals to the U.S. Supreme Court.
- Congress – If the 5th Circuit finds the ACA unconstitutional, lawmakers work in earnest to draft legislation preserving ACA protections that are popular with voters and to avoid massive disruption in the insurance industry. One of these bills will have enough bipartisan support to be enacted by Congress and signed into law by the President should the Supreme Court declare the ACA unconstitutional.
- The Supreme Court – The U.S. Supreme Court agrees to hear the case and preserves the ACA again by holding that the individual mandate is severable from the remainder of the ACA and/or for other reasons. Remember, the appointments of Justices Gorsuch and Kavanaugh notwithstanding, the five justices who ruled in favor of the ACA in NFIB v. Sebelius in that 5-4 opinion are still present.
We’ll keep you updated as this progresses. If you have any questions regarding this brief, feel free to contact me at MBGray@Trion.com
484-755-9444. Feel free to visit my website for regular updates.
October 17, 2018
Anthem to pay $16M in record data breach settlement
Anthem, the nations second largest insurer, has agreed to pay the federal government $16 million in a settlement over its 2015 data breach that hit nearly 79 million people, HHS said Monday.
The agreement is by far the largest settlement reached by HHS’ Office for Civil Rights for a Health Insurance Portability and Accountability Act (HIPAA) breach. Stolen information included the names, birth dates, Social Security numbers, home addresses and other personal information in this 2015 cyberattack.
As part of the settlement, Anthem agreed to a corrective action plan where it will conduct a risk analysis and fix any deficiencies. HHS will oversee Anthem’s work.
Today, we are seeing healthcare companies becoming attractive targets for hacks, and they’re expected to have adequate cybersecurity defenses.
Also in the news today:
Four people indicted for $931 million telemedicine fraud scheme
Federal officials indicted four people in Tennessee for an alleged scheme that involved using telemedicine to bilk insurers out of about $174 million. The defendants allegedly submitted at least $931 million of fraudulent claims after tricking tens of thousands of patients and more than 100 doctors.
The telemedicine company, HealthRight, where the 4 people indicted worked, were found to be producing fraudulent insurance coverage information and prescriptions from patients, according to court documents. After getting doctors to approve the prescriptions, which were invalid, the defendants would bill payers, including Blue Cross and Blue Shield of Tennessee, for greatly marked-up prescriptions, reaping the rewards of overpayment. They did this repeatedly over the course of three years, with the scheme ending in April 2018, the Justice Department alleged. HealthRight and its CEO, Scott Roix, pleaded guilty to felony conspiracy.
October 12. 2018
Good Morning, several interesting items in the news this week! The Insurance carrier marketplace is in flux with mergers and acquisition never seen before. Many believe they are attempting to meet the new demands for a change in the way we receive healthcare in the U.S. and garner market share. These traditional carriers may be concerned with how they will compete with the likes of Amazon, who is attempting to disrupt and reshape how healthcare is delivered. These established insurers have recognized they need to change their business model to adapt to customer demands for quicker, more nimble healthcare delivery options that are less expensive while being more convenient. Below are several updates to the consolidation taking place.
- CVS Health Acquisition of Aetna Approved to move forward. This Landmark merger in healthcare inches towards the finish line with the DOJ approval this week. The $69 Billion acquisition will drastically reshape the landscape in the insurance marketplace for employers and their members. The transaction is on track to close in early part of Q4 2018. This is the largest health insurance deal in history.
WOONSOCKET, R.I., Oct. 10, 2018 /PRNewswire/ — CVS Health (NYSE: CVS) today announced that it has entered into an agreement with the U.S. Department of Justice (DOJ) that allows it to proceed with its proposed acquisition of Aetna (NYSE: AET). DOJ clearance is a key milestone toward finalizing the transaction, which is also subject to state regulatory approvals, many of which have been granted. CVS Health’s acquisition of Aetna remains on track to close in the early part of Q4 2018.
“DOJ clearance is an important step toward bringing together the strengths and capabilities of our two companies to improve the consumer health care experience,” said CVS Health President and Chief Executive Officer Larry J. Merlo. “We are pleased to have reached an agreement with the DOJ that maintains the strategic benefits and value creation potential of our combination with Aetna. We are now working to complete the remaining state reviews.”
Following the close of the transaction, Aetna will operate as a standalone business within the CVS Health enterprise and will be led by members of its current management team
2. On September 17, 2018 Cigna and Express Scripts also received the nod from the DOJ to merge. Express Scripts, the largest Pharmacy Benefits Manager in the country, will be acquired by Cigna in a $52 Billion deal. Aligning the pharmacy and medical programs in an attempt to integrate data and lower costs. The results remain to be seen.
- United Healthcare, the largest insurer in the U.S. has long established an integrated approach to medical and pharmacy and owns the third largest PBM – OptumRX. They have recently begun to purchase physician practices, such as DaVita Medical Group.
Trump Signs New Laws Aimed at Drug Costs and Battles Democrats on Medicare!
President Trump signed bipartisan legislation on Wednesday that would free pharmacists to tell consumers when they could actually save money by paying the full cash price for prescription drugs rather than using health insurance with large co-payments, deductibles and other out-of-pocket costs.
The legislation on gag clauses has been praised by lawmakers in both parties, but the signing was nearly eclipsed on Wednesday by a separate health care furor: Mr. Trump asserted in an essay in USA Today that Democrats supporting “Medicare for All” would wreck the program for older Americans, infuriating Democrats who said he was lying to millions of Americans.
Also in the news, expensive new treatments for oncology with precision medicine using genetic analysis. The world of genetics is quickly evolving, taking the industry by storm, and will undoubtedly have a tremendous impact on the care received by employees and impacting employers’ health care costs. From pharmacogenomics to genomic sequencing to tumor profiling – genetic capabilities are seemingly boundless and thus overwhelming for employers looking for ways to interpret and leverage this new opportunity. We are entering a new era of targeted therapy which is both less toxic and providing better outcomes… but this progress has not been cheap! The cost of treatment and cure keeps increasing, and many plan sponsors are worried about having an affordable benefit program that allows them to protect members’ health as well as the company’s bottom line.
Where should employers be focusing their energies when it comes to genetics in health care? Treatment for cancer has become one of the top drivers of healthcare costs for most employers. Advancements in cancer treatment is something that employers should understand so they can develop programs to improve quality of care and outcomes for their members. Genetic analysis can help medical providers understand and better diagnose a person’s risk for disease, correct dosage of medication and the proper medication with a better understanding of adverse effects. For the member, genetic insights help people learn how their genes impact their health— from their risk for common hereditary cancers and heart conditions to the effectiveness of their medications. The opportunities come with a cost but have enormous potential to more accurately treat illness for better outcomes, higher quality of treatment and potentially lower healthcare expenditures in the long run.
We have seen a shift in strategy with the 2019 and 2020 plan designs. Employers are increasingly focused on strategies to manage health benefit cost growth without shifting cost to employees. That’s no small challenge, but surveys like the EBRI study suggests, in a period of low unemployment and tough competition for talent, your health benefit program may be the X-factor that helps you get and keep the workers you need. We should all be asking: Can we make this system more efficient and more effective for those paying for the majority of the spending today? An employer health-driven economy means employers collectively bear the burden of healthcare in our country. We’re paying the lion’s share for the care of most Americans in the U.S. Employers need to expect more from the current healthcare system from end to end.
Opioids: Very hot topic and a key strategy consideration going into the 2019-2020 renewal planning. A successful strategy includes your Healthcare Plan, PBM and Disability Carrier in partnership to solve for this significant problem. An estimated 2.9 million Americans use prescription opioids non-medically, which is about 1.4% of adults over 25. Opioid misuse and abuse affects working people of all ages and their dependents. Abusers have higher health care costs and a greater number of disability claims and miss more work days. Why its an issue employers are focused on? Misuse and abuse of opioids could impact employee productivity, workplace costs, absenteeism and disability costs, workers compensation claims, overall medical expenses, and the labor participation rate. Additionally, a recent research survey found that opioid abuse costs employers approximately $10 billion from absenteeism and presenteeism alone!
Here are some things employers should be thinking about when building a strategic response in their benefits programs:
Ø Annual utilization review with the Medical Carriers and PBM’s: Common opioids to look for in your claims:
Fentanyl (also available as a patch)
Ø PBM Clinical Programs in place to set standards to ensure
- Quantity limits to a 3-5 day prescription
- The Lowest effective dose in initial prescription
- Non- opioid pain medication where possible
Join us December 5, 2018 for our next Power Lunch!
Our topic: Gearing Up for 2019: Benefits Strategies to Recruit and Retain Talent in an almost Zero Unemployment World
We will discuss:
- What does our workforce now look like?
- What do “Best Places to Work” employer benefits contain?
- Check-List of benefits to consider adding in 2019 & 2020
To Register : www.MBGrayHealthcare.com “Events Tab”
June 21, 2018
The DOL Releases Final Rule Expanding
Association Health Plans
For a full detailed overview – click on the “News Alerts” Tab
March 21, 2018
Good Morning –Here is an update on the Industry Disruption: Mergers & Acquisitions happening in our Industry!
It has been very busy in our industry and quite frankly hard to keep up with who is buying who!
To start, here is how the Commercial Insurers in the US Rank:
- United Healthcare (Market Value $112.7 B)
- Anthem (Market Value $41B)
- Aetna (Market Value $38 B)
- Cigna (Market Value $33.8 B)
- Humana (Market Value $27.2 B)
They fall off significantly, revenue wise, from there….
Early in 2017, Cigna was being purchased by Anthem…. and Aetna was buying Humana. Both have been thwarted by federal regulators. Now, in the past 6 months, major acquisition news:
- Anthem (the second largest insurance company in the US) announced it was dissolving its relationship with ESI in 2020 as its Pharmacy Benefits Manger (PBM) partner and starting its own PBM called IngenioRX. Anthem is moving towards a business model with an integration of Medical and Pharmacy like that of UHC with They hired their first female CEO, Gail Boudreaux, who is a former United Healthcare President.
- CVS Health announces its purchase of Aetna (the third largest Insurer in the US). It had reached an agreement to acquire Aetna for $69 billon. The companies expect to close the deal in the second half of 2018 pending a review by US antitrust agencies. On March 13, shareholders of both companies voted to support the acquisition.
- As a result of Aetna preparing for the CVS Health acquisition, it sold its disability block of business to The Hartford.
- United Healthcare purchased DaVia Physician Network. This was an interesting purchase as it will add hundreds of medical clinics to United’s growing business of not just paying for benefits but providing medical care directly. Already the biggest U.S. health insurer, the company has been expanding its front-line care business to take more control over how its insurance dollars are spent.
- Amazon, Berkshire Hathaway & JP Morgan Chase form a Healthcare company for their own employees. What this model is remains to be seen in the coming months.
- Amazon Launches Its Own Line of OTC Drugs. This Online Retailer Could Squeeze Pharmacy Giants.
- Teladoc to Acquire Best Doctors to Provide a Comprehensive Virtual Healthcare.
- Unum enters the stop loss marketplace.
- Walgreens is in talks to buy the rest of giant distributor AmerisourceBergen Corp. that it doesn’t already own, according to reports. (It already owned about 26% of the pharmaceutical manufacturer).
Wait – I am not quite finished yet!!!
- Last week, Cigna is back and said it would buy pharmacy benefits manager Express Scripts (The largest PBM in the US) for about $54 billion. Now there are no “dance partners” left in the freestanding PBM Marketplace.
You definitely need a scorecard to keep track! The last one, Cigna purchasing Express Scripts will take the largest remaining independent pharmacy benefits manager off the street. One can begin to see a clear trend in the insurance industry – insurance companies are trying to integrate the delivery of care and pharmacy into their own operations. With CVS now enabled to expand their onsite clinics and be a “front line caregiver” and United Healthcare doing the same with the purchase of DaVita with their doctors, practices, and surgery centers… it is clear they are trying to control all of the pieces.
In my opinion, less competition in the marketplace is never good for purchasers or consumers. There are upsides to having the pharmacy and medical more integrated for quality of care and management of illnesses. We have seen in the last 10 or so years, carving out pharmacy and placing it with a standalone PBM has delivered higher focus and management and lower cost to employers. We will have to wait and see if some of the efficiency will yield greater savings for us or if less competition will drive costs.
The new head of HHS, Alex Azar has stated this week he is demanding more transparency from insurers to help consumers. The marketplace has not responded to this directive yet. Controlling soaring drug prices is also at the top of his agenda. As a former executive from big pharma – Eli Lilly, we have yet to hear his plan to achieve this lofty goal.
The public exchanges in the US enrolled 11.8 million Americans, a 3% decrease from 2017. Most expected a lower enrollment given the cuts to the advertising budget and the shorter enrollment period.
New Trend In 2018, there is a growing number of large employers with an appetite for direct employer partnerships with providers. This would eliminate the “middle man” traditional insurance co. This will expand the current common practice of “centers of excellence” deployed by large employers. Whole Foods rolled out a new partnership with a 19 hospital system to give employees direct access to the providers without going through a traditional insurer. Currently about 3% of large employers contract directly with ACO’s or providers but there are more employers looking at what Boeing, Walmart and Lowes are designing in this new model. More to come on this topic.
Big News at the end of January with 4 Not-for-profit health systems announcing they were taking on Big Pharma by creating their own generic-drug manufacturing company in an attempt to alleviate shortages in basic antibiotics and IV Products in short supply in the hospitals. The US generic drug manufactures saw a dip in their stock prices with this news. Most experts think it will take over a year to get approval for hospitals to move into this space with the proper approvals from the FDA. We will be watching this to monitor their progress.
A few compliance updates:
March 8, 2018 – The IRS announced reductions to the 2018 HSA and Adoption Credit Tax Limits. See my website under “News Alerts” for the full brief.
March 5, 2018 – Agencies proposed regulations on Short-Term Limited Duration Insurance. This will not generally affect employer coverage but something to be aware of. I have posted a full brief of both on my webpage under “News Alerts”.
Also on my website, under the “events” tab, you will find a full list of the free webinars taking place for the rest of 2018. The next one will be held March 22 at 1pm EST. The topic is FMLA and employee benefits programs with a discussion on how to administer benefits while employees are on leave.
I hope to see some of you in San Francisco next week March 25-28!
January 24, 2018
ACA Cadillac Tax Delayed Another Two Years !
Great News!! On January 22, 2018, Congress passed a short-term funding resolution to end the federal government shutdown that began last Friday at midnight. While ending the shutdown is the main part of the legislation, Congress also pass relief for employers from certain Affordable Care Act (ACA) taxes, (at least temporarily) with an additional two-year delay for implementation of the high-value health plan excise tax (Cadillac Tax)! Now set for 2022.
As you know, the Cadillac tax imposes a 40% excise tax on the aggregate cost of applicable employer-sponsored coverage in excess of certain statutory limits, which is assessed on the plan’s insurance carrier or self-funded plan sponsor. Originally set to begin this year, the 2018 limits were to be $10,200 per year for self only coverage and $27,500 per year for coverage other than self-only, with adjustments allowed for pre-65 retirees, high-risk professions, and significant age and gender factors. The tax is now set for 2022 in the newly passed legislation, which is great news for employers!
Opponents of the tax fear it will lead to shifting of health care costs to employees through increased deductibles, coinsurance, and copayments in an effort by employers to keep plan costs down and avoid the tax. Opponents also argue that, because annual adjustments to the thresholds after 2018 are tied to general inflation rather than annual change in health care costs, a significant number of employer plans could be affected by the tax by the time it is implemented.
Many hoped the initial two-year delay passed in 2015 was an indication that a full repeal might follow, but to-date, permanent relief from the Cadillac tax has not come. Although the figure is a topic of debate, the Congressional Budget Office previously projected the tax would generate $87 billion over a 10-year period. So, while there is considerable support for repeal of the Cadillac tax among lawmakers, employers ad other stakeholders, potential loss of the Cadillac Tax’s projected revenue on a permanent basis is an obstacle for some legislators.
At the very least, today’s action is recognition of the Cadillac tax’s unpopularity and it suggests Congress is likely to continue to at least contemplate workable plans for eliminating it. The move also provides some more breathing room for the many employers that have been evaluating strategies to curb the impact of the Cadillac tax. The additional time may allow employers to identify effective cost-management strategies that would enable them to avoid aggressive plan design modifications if and when the tax becomes a reality. Despite significant chatter regarding the possibility of a full repeal of the Cadillac tax, until any new developments occur, employers should plan for its implementation in 2022.
As always, I am here to answer any questions you might have as you prepare to comply with upcoming ACA requirements. If you are not currently a Trion client and would like assistance navigating the changes required by health care reform, please contact me by emailing MBGray@Trion.com
January 19, 2018
This morning, it was announced that Liberty Life Assurance Company of Boston has signed an agreement to be purchased by Lincoln Financial Group. Lincoln will retain Liberty Mutual’s Group Benefits business and immediately reinsure the Individual Life and Annuity business to Protective Life Insurance Company. It is expected that this transaction will be completed in the second quarter of 2018, pending regulatory approvals and other customary closing conditions.
We wait as Congress remains deeply divided on how to avoid a government shutdown prior to this weekend. Two big items being used as leverage in the negotiations are re-funding the CHIP program for 9 million American Children who access healthcare services through this essential program and DACA with 700,000 people brought into the US illegally as children waiting to see if their protected status is removed or residency made permanent. Hundreds of thousand federal workers and military personnel watch and wait to see if Congress can reach consensus in Washington DC.
The City of Philadelphia announced this week it was joining a growing number of other US Cities and States suing opioid makers over the epidemic they are facing in their city. It is clear there is an unprecedented public health crisis that needs to be solved.
US Stock market soars this week with the DOW topping 26,000 for the first time. It will be interesting to see if worries over a Government Shutdown will stifle this climb. Millions of women this weekend will march on Washington DC in protest.
I hope everyone had a safe and happy holiday season and HAPPY NEW YEAR!
Wishing everyone a prosperous, happy and exciting 2018! We have much to focus on this year in healthcare. Catching up on the news over the past few weeks was exciting! Here are some of the items that caught my attention.
Americans were stressed in 2017
According to the American Psychological Association, Healthcare ranked very high on the list of concerns within the survey. 43% of Americans were concerned about the future of Healthcare, followed by 35% concerned about the economy and 30% had concerns with trust in our government, hate crimes and the potential for terrorist attacks.
Are the State Exchanges in Trouble in Future Years?
With the recent passage in Congress of the Tax Reform Legislation, the elimination of the individual mandate for Americans to have health insurance means healthier people will have less need to purchase insurance and will be less likely to buy it. The remaining pool of people, who will likely purchase insurance on the exchanges, will be the higher cost individuals who will need healthcare coverage. Insurers that still participate in the exchanges are going to increase premiums to cover the higher risk.
Is Obamacare dead?
NOPE! A Strong Showing as Nearly 9 Million Sign Up for 2018 in a remarkably strong showing of consumer demand for health insurance in the individual market. The government numbers proved predictions of its collapse wrong yet again.
Why ¾ is the key statistic
The Federal Government still pays on average ¾ of the premium for people purchasing coverage through the state exchanges. Further, ¾ of the participants purchasing health insurance on the exchanges qualify for the following subsidies:
*Individuals earning less than $48,240 qualify and
*Families earning less than $98,400 annually.
What does this mean?
As premiums on the state exchanges increase, so will the cost to the government in the form of subsidies. Additionally, 31 states expanded Medicaid since the inception of ACA. Now over 75 million Americans are on Medicaid covering substantially more than Medicare for older Americans.
The current administration has vowed to propose new rules to allow people to buy less expensive and less comprehensive coverage for healthcare through expansion of association plans and other private venues.
What does this all mean for Employers?
There is just not enough space on this page for me to outline all the ways this will affect us in our world of employer benefits! Suffice to say, with these changes, it should effect and change the reporting requirements, minimum coverage limits among many other items we have worked hard to manage and be compliant with over the past several years. One thing that has not changed? Our need to continue to focus on managing costs and trend to continue to offer benefits to our employees and their families. What the tax overhaul did not change? The final bill did not delay or repeal the ACA’s excise (“Cadillac”) tax on employer-sponsored coverage still set for 1/1/2020.
Join me for the next “20 minute Power Lunch” session to be held on January 10th at 12 noon EST. Registration will be open tomorrow through my “events tab” on this webpage:
We will cover in our discussion:
* Tax Reform removes ACA Individual Mandate
* CVS to purchase Aetna
* Anthem to start up their own PBM IngenioRX
* United Healthcare new marketplace business strategy
December 6, 2017
In the news this week, CVS Health announced it had reached an agreement to acquire Aetna for $69 billon. The companies expect to close the deal in the second half of 2018 pending a review by US antitrust agencies. This will be an interesting business model, combining pharmacy management and health plan services with CVS Health’s extensive retail network of 9,700 + stores nationwide and over 1000 retail clinics. This mix could bring greater retail and customer service focus to health care, more integration of pharmacy and medical benefits, and increased emphasis on primary and preventive care at lower costs for plans and patients. Of course my thoughts go to price competitiveness. Will this model inhibit clients from carving out RX to a more competitive PBM if they are mid-size employer groups? We can only wait and see…. Your CEO’s may ask how this will effect your plan if you are current client of either company. I would point out you may not see any changes until 2019. With this merger of services, we could see better options with the integration of the CVS Minute Clinic availability to members with improved access to care at a lower price. We may also see a potential integration on the pharmaceuticals that are running through your medical program due to being delivered in the doctors office (Oncology is a big driver of this). About 50% of specialty pharmaceuticals are currently running through your medical plans and missing the key clinical programs we have put in place on the pharmacy side to help manage the cost and utilization. This integrated model may improve our ability to tackle that problem and improve management. There are certainly opportunities here that have yet to be explored with this new model.
Join my next Power Lunch on January 10, 2018 for a robust discussion on the marketplace changes occurring! Registration on my “Events” tab will be posted shorty!
November 24, 2017
Hope everyone enjoyed their Thanksgiving Holiday. It was nice to have my family together and relax for a few days. Lots to be thankful for. My son Nick is a Junior at Penn State majoring in Health Policy and Administration (where I am a graduate). I asked why he choose that major and he said simply, “I want to have a job I love to do as much as you love your job mom.” Very nice to hear. I do love my job, my clients and the great people I have the privilege to work with every day. Thank you!
As usual, there is lots of news to talk about in the past two weeks. Here are some of the key news stories:
Anthem becomes the second-largest company with a women as CEO
Anthem, the nation’s second largest insurance company in the US named Gail Boudreaux as CEO last Monday. The only other US Company with more revenue and a women CEO is General Motors with Mary Barra at the helm since 2014. IBM is led by Virginia Rometty and PepsiCo is led by Indra Nooyi. These are the only US companies among the Fortune 50 with women in charge.
Anthem has been in the news in the past two weeks due to interest in their business strategy. Noteworthy – Gail Boudreaux is a former United Health President. Industry speculation is Anthem is moving towards a business model more like United Healthcare with an integration of Medical and Pharmacy model (like that of UHC with RX arm OptumRX). Anthem recently announced plan to launch its own PBM, IngenioRX. They have announced the move away from using their current PBM partner Express Scripts (ESI) beginning in 2020. In a similar move, CVS CareMark announced an offer to purchase Aetna Inc. in an effort to achieve the same business model goal.
Nov 1st CMS announced it was moving forward with a $1.6 Billion cut to the federal drug discount program known as 340B.
These cuts will most effect not-for-profit hospitals and urban hospitals with a high mix of uninsured patients and Medicaid recipients. Moreover, it is unclear how the CMS is making these decisions and what is next leaving hospitals more confused about the future of programs like these.
Congress missed the September 30th deadline to extend funding for the Children’s Health Insurance Program (CHIP) leaving almost 9 million children and 370,000 pregnant women hanging in the balance of having no access to health care. Since this in an editorial section of my website, I will share this is deeply troubling to me as a Healthcare Consultant, An American and Mother. Most pediatric care is preventive care and without immunizations this leaves an at-risk population of children in the US in an even greater vulnerable position. The last minute funding of this program for short periods of time – leaves providers and the CHIP program managers in a difficult position with the uncertainty of funding. In a country as rich as ours, this is unconscionable.
CVS CareMark’s announcement of an offer to buy Aetna has left the industry experts debating whether or not the FTC will allow this large acquisition to occur. We remember early in 2017, the U.S. Justice Department stopped Anthem’s purchase of Cigna, a deal that would have created the largest U.S. health insurer by membership, and Aetna’s planned $33 billion acquisition of Humana. This leaves most with the speculation that even though Aetna sold their life and disability business (seemingly) in preparation of this acquisition, it still remains unclear if this will be blocked.
November 8, 2017
IRS Indicates 2015 Employer Mandate Penalty Letters Are Imminent
Read the details under the “News Alerts” tab of my webpage. I have also provided a link to the Nov. 8th Power Lunch Webinar “Value-Based Plan Designs” under the “Events” Tab.
November 1, 2017
So much in the news in the past week it is difficult to keep up! Here are some headlines to be aware of:
- Aetna made 2 BIG news splashes in the last couple of days with the announcement that they had entered into an agreement to sell its U.S. Group Life and Disability Insurance Business to The Hartford. The transaction is expected to close in early November 2017, and is subject to state regulatory approvals. With the addition of the Aetna Group Insurance business, The Hartford will be the second largest group life and disability insurer in the U.S. And then this!….
U.S. pharmacy benefits manager – CVS Health Corp has made an offer to acquire No. 3 U.S. health insurer Aetna Inc for over $66 billion! The deal would merge one of the nation’s largest pharmacy benefits managers with one of the oldest health insurers, whose far-reaching business ranges from employer healthcare to government plans nationwide.
3. Last week No. 2 insurer Anthem Inc. announced plans to manage its own pharmacy benefits with the help of CVS, a move that would give it a set-up similar to UnitedHealth Group Inc. and its Optum unit. Insurers want more control over the pharmaceutical component of care as they implement pricing models with doctors and hospitals that are based on health outcomes, not just procedures.
4. The rate of uninsured is up 1.4% in the last year. An additional 3.5 million more adults are uninsured than had been in late 2016. Unless action is taken to stabilize the individual marketplace, this rate is likely to increase. Employees & retirees who rely on the exchanges could benefit in future years to the extent that funding the cost-sharing reduction payments would stabilize exchange premiums.
So what does all this mean? There is a large amount of consolidation taking place. The upside to this is if greater efficiencies are achieved, it could mean cost savings. The downside to the consolidation may be price control, fewer carrier options and we all know competition leads to better pricing.
October 12, 2017
Trump issues an executive order to relax health insurance rules
President Donald Trump signed an executive order this morning to direct the Departments of Treasury, Labor, and HHS to consider expanding coverage through low-cost, short-term health plans that are exempt from Affordable Care Act insurance market rules. This would potentially allow Americans to purchase cheaper, skimpier health plans by easing some standing policy restrictions under ACA. These plans may not have to comply with the minimum essential benefits set forth in the current ACA legislation.
Expansion of Association Health Plans– Allowing employers, particularly small businesses and professional groups, to join together to offer health coverage to their employees. Employers must be in the same line of business.
Short-Term, Limited Duration Health Insurance – Permitting low-cost, short-term health coverage in the individual market that is exempt from some of the ACA mandates. The aim is to offer options to people between jobs, those with limited choice of coverage options individual market, and those who missed open enrollment but want coverage. The order apparently would allow individuals to buy these short-term plans lasting up to 364 days. The Obama administration rules limited the duration of short-term plans to 90 days.
Expands HRA Flexibility – Expanding the ability for employers to use Health Reimbursement Arrangements (HRAs) to help employees pay for their health care expenses. Currently IRS rules prohibit employers from having freestanding HRAs for employees’ health care expenses unless they also offer health coverage. It is unclear whether the expansion would remove this prohibition.
One concern, potentially a byproduct of these “Skinny Plans” with less coverage is the attractiveness to the younger, healthier population…. leaving the older and higher utilizers in the current plans, further creating adverse selection for the exchanges. This could result in insurers raising rates for more comprehensive plans or exiting the market entirely.
Pharmacy is at the top of the list of concerns for employers in managing cost. Specialty drugs are driving costs and with 50% of the drugs in development falling into the specialty drug category, there is no question it needs to be the focus. Additionally, with many specialty medications running through the medical program instead of the pharmacy plan, due to being administered by the physician offices, we need to be watching those as well. What are employers doing? Link to the white paper we wrote for EBenNews here:
October 10, 2017
Last week we had several major news items of interest:
- The Trump Administration announced plans last Friday to reduce the mandate that requires insurance benefits to cover birth control at no cost under the standing ACA preventive care. If an employer registers a religious or moral objection they may now opt out of no-cost birth control for workers within their benefits plans.
- Secretary of HHS, Tom Price resigned due to the scandal of his use of private planes for travel on the taxpayer dime. Price was ineffective as the promoter of the Repeal and Replace effort of the ACA (aka Obamacare) legislation.
- CVS on Friday announced it would limit opioid prescriptions to 7 days for certain conditions. Limiting the daily dosage of pain pills and strength of the pain medicine. The change will be effective February 1, 2018. Sales of prescription opioids quadrupled from 1999 to 2014.
Friday, (10/6) President Trump stated the effort to “repeal and replace” Obamacare was not dead and would be back on the list for the new year. He stated in a press release he would be open to “cutting a one to two year deal with democrats” if necessary, skirting his own Republican Party efforts.
September 25, 2017 Good morning everyone- We have a lot going on in Healthcare this week… Repeal and Replace Obamacare is back in the news! The Senate may vote this week on the Graham-Cassidy Plan put forth by Republicans trying to take another run at dismantling the current system. Medicaid is on the chopping block (1 in 5 Americans take advantage of Medicaid programs). Bernie Sanders is picking up steam as well with the “Medicare for all” idea in an effort to sustain the state and federal exchanges with a healthcare option in every county that is in peril. He has garnered the support of 16 of his fellow Democrats support. I don’t know about you – but I have the popcorn ready for the debate on CNN tonight between the two: Lindsey Graham & Bill Cassidy (Republicans) will debate Sen. Bernie Sanders & Amy Klobuchar (Demarcates) in a town hall at 9pm on CNN.
Strategic focus – We talked a lot about the new breakthroughs that will affect our healthcare costs shortly… I liken this to the entry of specialty pharmaceuticals just a few years ago. Heart disease and cancer continue to be the leading causes of death and top drivers of medical cost for employers in the US. With scientific advancements and the plummeting cost of genetic sequencing, genetic information has the potential to drive unprecedented levels of prevention and early detection. But employers are unsure of what the increased use of personalized medicine and genetic testing means for them and how it can benefit employees. Many employers are investigating how genetics is changing the role of prevention in health care today and how leading companies are turning to genetics as an integral pillar of their overall preventive health strategy.
High Claimants need to be an area of focus in your upcoming plan year strategy! Here are some statistics to think about (specialty RX is playing a role in this as well)
- $25,000+ claims are up 13% over 2016
- $250,000+ claims are up 47% over 2016
- $1,000,000+ claims are up 124% over 2016
I will be reviewing this topic and the 2018 Survey Data for plan changes by large employers on Wednesday, Oct 11th in our free Power Lunch Webinar series (registration info. on the Events tab)
2 news alerts this week:
Check out full details on these new legislative alerts (NEWS ALERT tab)
- Court Requires EEOC to Substantiate 30% Limit on
Wellness Program Incentives
- Reminder: Medicare Part D Creditable Coverage Notice Deadline is October 14, 2017
2018 Survey Data is in! What are large employers rolling out to employees for 2018? Full details and a summary of the National Business Group on Health Survey for both Medical and Pharmacy can be found under the “Survey Data” tab on my webpage. Additionally, we will be holding a 30 minute webinar on October 11 at 12 noon EST. You can register for this event under the “Events” tab of my webpage beginning Friday.
8/21/17 Happy Summer!! Hope everyone is enjoying the warm weather and some time with the family! Two news stories that got little attention in the last two weeks that surprised me: 1. Aetna posted a second quarter profit of 52%! 2. The Collapse of one insurance company in PA left the other US Health Insurance companies on the hook for millions in losses. The PA long-term care insurance co. went belly up, leaving all insurance cos (by law) required to pay the liabilities approaching $4 Billion. This is one of the largest insurance failures in US history! CA may be the hardest hit with its fee liability estimated at $400.6 million. Florida is next with an estimate of $360.4. This may lead to health insurers passing along premium surcharges to customers (employers and their employees) in higher premiums. Anthem Inc. the nations second largest insurer estimates it will pay $253.8 million to cover its portion of the bill.
8/19/17 ACA Public Exchanges take a beating:
The Trump Administration has not stated if they will kick in the money to subsidize insurance companies thus lower rates so enrollees in the state exchanges can afford the premiums ($7-10 Billion in subsidies). This uncertainty of funding has lead to many US insurance company’s that still participate in the exchanges to pull out. On August 16, 2017 the insurance companies had to commit to offering in the exchanges or alert the pull out. 4 large insurer have told officials they are pulling out of the state exchanges, leaving at least 868,460 participants losing coverage in 2018. Nationally, premiums are set to go up on average, approximately 22% in 2018 on the exchanges. Sadly, some parts of the country will see increases of 40% or more. As of last Friday, according to the HHS, 2.3 million Americans or 25% enrolled in Obamacare will have no choice for insurance cos on the exchange in their counties. WHY should we be concerned about the state exchanges? If the number of uninsured people in the US increases, the care they receive with providers and hospitals will be cost shifted to those who can pay – the people WITH insurance… so the cost for employer sponsored coverage increases. Additionally, if the uninsured go without simple initial treatment for ailments, the cost for care when catastrophic occurrences hit, is much greater than if the person were able to seek care earlier at a lower price.
9/5/17 Anthem, the largest Blue Cross/ Blue Shield plan in the US announced new outpatient imaging policy for fully insured clients beginning March 2018. Anthem states they will no longer pay for MRIs and CT delivered on an outpatient basis at hospitals. They are typically more expensive services in a hospital setting vs. a free-standing imaging center. This will significantly impact hospitals negatively as a large degree of profit is generated by these services. This may lead other insurance companies to follow this lead with similar new cost cutting measures. For Self Insured Plan sponsors, they are still counting on the CDHPs to push employees to lower costing options. Transparency tools are assisting in this effort which many employers are rolling into their 2018 plan changes.
3/29/17 Now more than ever – we must continue to build our strategies to control cost on both Medical and Pharmacy!
Last Friday, House Speaker Paul Ryan cancelled a vote that would have undone Obamacare. It would have delayed the ACA’s excise tax until 2026, eliminate the penalty for the employer mandate retroactive to 2016 and make other important ACA changes. Republicans could not come to consensus and it was unlikely to reach the 216 votes necessary to pass, even with the Republicans having the majority. Many Republicans stated they could not support the bill and were seeking additional concessions to drive down premiums and address the predicted loss of coverage for millions of Americans under the newly proposed plan. It was not a “well-thought out” piece of legislation and would have left younger Americans with no financial means to purchase insurance on the exchanges with lower or no subsidies. It would have further eroded the already failing plan options on the state exchanges. Congress will need to enact reform quickly to ensure there are viable coverage options on the existing exchanges over the next 6-12 months.
House speaker Paul Ryan stated in a press conference on Tuesday, that the legislation would be continued and concessions made to bring the bill back to the House floor in the near future for a vote. For now, they have put aside the ACA reforms to focus on other issues like tax reform. The excise tax will be the focus of much discussion as it is now back on and set to take effect in 2020. This will reignite employer focus and shift strategies back to the problem of trying to reduce plan costs below the allowable thresholds of the excise tax or employers will face a 40% tax on the amount above the allowable limits for each of their employees. If left unchanged, this tax will affect the 150 million Americans who rely on employer-sponsored health coverage.
You are all invited to my “20 Minute Power Lunch” webinar series beginning April 5th at 12:00 pm est. They will be held every first Wednesday of the month to bring you up to date on the healthcare landscape and how it will effect employers; your plans and your strategies! Invite and registration info coming soon!!
3/1/17 Many of us watched the Presidents address to Congress last night with anticipation… but the details on how this administration plans to reform the current ACA is still unclear. He did re-state many of the themes we have outlined below in our news alert briefing yesterday…. Clearly many Americans are concerned they will lose the coverage they currently have under the exchanges. We will watch closely as they release more details.
2/28/17 Below is our latest alert regarding President Trumps “Repeal and Replace” strategy. The President has promised to outline more details in his televised address tonight. (We can only hope it is as good as the Oscars was on Sunday night… Let’s hope he has the correct envelope!) I will be commenting tomorrow on the strategy his administration is planning to roll out… Lets hope we get some details on what the plan will include and the changes to current they are planning so we can plan the best strategy for our employer partners!
Trion Group, a Marsh & McLennan Agency LLC
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www.mbgrayhealthcare.com Updated to include some other news updates from the past two weeks:
Posted Slides and the recording of the webinar I held in Mid November: “The Power of Data—Strengthen & Focus Your Strategies”
Link to the recording directly on YouTube: https://www.youtube.com/watch?v=Yi1aSkikj_E