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Leslie Small

Recent Posts

Radar On Market Access: Don’t Expect Major Action on Drug Prices in 2019, Experts Say

Posted by Leslie Small on Jan 15, 2019

As 2019 gets under way, public outrage over high prescription drug prices does not appear to have abated, especially in light of recent news reports indicating manufacturers are raising prices on hundreds of drugs this month, AIS Health reported.

Yet there are plenty of reasons why this concern over drug prices might not result in any significant legislative or regulatory action, experts tell AIS Health. And whatever does occur might benefit health plans and PBMs more than challenge them.

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Topics: Industry Trends, Payer, Specialty, Provider

Perspectives on Potential Humana/Walgreens Tie-Up

Posted by Leslie Small on Jan 10, 2019

In November 2018, reports emerged that retail pharmacy giant and health insurer— Walgreen Co. and Humana Inc. — are in preliminary talks to take equity stakes in each other.

Walgreens and Humana are already collaborating on a pilot project in which the insurer opened senior- focused primary care clinics in two Walgreens stores in the Kansas City, Mo., region. Now the companies are in “wide-ranging” talks about either expanding that venture or taking stakes in each other, according to The Wall Street Journal.

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Topics: Industry Trends, Payer, Provider

Radar On Market Access: PBMs May Be Able to Handle Pressure From State Medicaid Programs

Posted by Leslie Small on Jan 8, 2019

As states take a hard look at how they can reduce prescription drug spending in their Medicaid programs, they've put an already heavily scrutinized type of organization in their crosshairs: PBMs, AIS Health reported.

Ohio, for example, is forcing PBMs to abandon their current "spread pricing" models — in which PBMs pocket the difference between the amount they reimburse a pharmacy for a drug and the (usually higher) amount they charge a plan sponsor. Instead, they’ll move to a "pass-through" model, where PBMs will be paid an administrative fee by the Medicaid program and have to pay pharmacists the same amount that they bill the state for drugs, The Columbus Dispatch reported.

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Topics: Industry Trends, Payer, Provider

Radar On Market Access: Judge OKs CVS Plan to Keep Aetna Separate Pending Review

Posted by Leslie Small on Jan 3, 2019

Facing an unexpected judicial roadblock in the plan to combine their two business, CVS Health Corp. and Aetna Inc. successfully negotiated a deal to keep their PBM and health insurance operations separate for at least the next few months, AIS Health reported.

At the heart of the holdup is U.S. District Court Judge Richard Leon, who has the right to review the agreement that CVS and Aetna struck with the DOJ to resolve antitrust concerns with their deal.

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Topics: Industry Trends, Payer, Provider

Perspectives on Drug-Price Action

Posted by Leslie Small on Dec 27, 2018

In the wake of the 2018 midterm elections — which handed Democrats control of the House of Representatives — President Trump said he hoped to work with lawmakers on the other side of the aisle to lower the cost of prescription drugs.

Some industry analysts, though, are skeptical that sentiment will be enough to enact meaningful change, at least on the legislative front, AIS Health reported.
 
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Topics: Industry Trends, Provider

Radar On Market Access: New PBM Models Respond to Public Pressure, Market Demand

Posted by Leslie Small on Dec 20, 2018

Express Scripts Holding Co. and CVS Health Corp. have in recent months unveiled new programs that appear designed to transition away from the PBM status quo, AIS Health reported.

One factor driving both new programs could be a proposed rule that's still under review by the Office of Management and Budget, which might remove prescription drug rebates' safe-harbor protections from the federal antikickback statute. But one industry expert says it looks less likely that may actually transpire.

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Topics: Industry Trends, Payer, Specialty, Provider, Data & Analytics

Radar On Market Access: Despite Threatening to Halt Integration, Judge Is Likely to Sign Off on CVS/Aetna Deal

Posted by Leslie Small on Dec 11, 2018

According to CVS Health Corp., its acquisition of Aetna Inc. closed on Nov. 28 after receiving the last required approval from a state regulator. But a federal judge appears to have other ideas.

In a hearing on Dec. 3, Judge Richard Leon of the U.S. District Court for the District of Columbia said he might halt CVS and Aetna’s integration efforts while he reviews the $69 billion deal, according to The Wall Street Journal.

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Topics: Industry Trends, Payer, Provider

Trends That Matter for HIV Treatments

Posted by Leslie Small on Dec 6, 2018

At the annual Medicaid Health Plans of America conference, Express Scripts Holding Co. Senior Vice President and Chief Medical Officer Steve Miller, M.D., had a simple message for health plan leaders: "You have to think long term if you're going to have better outcomes," AIS Health reported.

One area in which Medicaid is not heeding that call, Miller said, is how it approaches treating and preventing HIV.

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Topics: Specialty, Market Access, Payer

Radar On Market Access: Future of Potential Humana/ Walgreens Tie-Up Is Murky

Posted by Leslie Small on Dec 6, 2018

Just days before CVS Health Corp. said it closed its $69 billion acquisition of Aetna Inc., reports emerged that another retail pharmacy giant and health insurer— Walgreen Co. and Humana Inc. — are in preliminary talks to take equity stakes in each other.

Walgreens and Humana are already collaborating on a pilot project in which the insurer opened senior- focused primary care clinics in two Walgreens stores in the Kansas City, Mo., region. Now the companies are in “wide-ranging” talks about either expanding that venture or taking stakes in each other, according to The Wall Street Journal.

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Topics: Industry Trends, Payer, Provider

Radar On Market Access: CMS's Second Swing at Part D Protected Classes Might Work

Posted by Leslie Small on Dec 4, 2018

On Nov. 26, CMS issued a proposed rule that would let Medicare Advantage and Part D plans limit coverage of certain drugs in the six "protected classes," which include antidepressants, antipsychotics, anticonvulsants, immunosuppressants for treatment of transplant rejection, antiretrovirals and antineoplastics, AIS Health reported.

Under CMS's Contract Year 2020 Medicare Advantage and Part D Drug Pricing Proposed Rule, plans would be able to:
 
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Topics: Industry Trends, Provider, Payer