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Peter Johnson

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Radar On Market Access: Surprise Medical Billing Comes to An End, Insurers Oppose Arbitration Mechanism

Posted by Peter Johnson on Dec 31, 2020

After years of failed attempts, Congress has finally come to an agreement on a measure to end the practice of surprise medical billing, AIS Health reported.

Surprise billing, also known as balance billing, is the practice of charging patients for out-of-network procedures that insurers refuse to pay for in whole or in part. Often, patients incur these balance bills without their knowledge. The new legislation would ban providers from sending such a bill to patients, and would instead require providers to negotiate reimbursement with the patient's insurer or submit the dispute to a binding arbitration process.

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Topics: Industry Trends, Payer

Radar On Market Access: PBMs Continue Integration, Face More Regulatory Challenges in 2020

Posted by Peter Johnson on Dec 29, 2020

In 2020, the PBM industry continued to deepen its integration with other industry players, a trend that experts say is likely to continue in coming years. The PBM space has consolidated to the point that five firms — UnitedHealth Group's OptumRx, CVS Health Corp.'s Caremark, Cigna Corp.'s Express Scripts, Anthem Inc.'s IngenioRx, Humana Inc.'s Humana Pharmacy Solutions, and the Blue Cross and Blue Shield affiliate-owned Prime Therapeutics LLC — manage the lion's share of the pharmacy benefits offered to U.S. health plan members.

Beyond their deepening integration with the payers that own them, these firms are working to expand their data and direct-to-consumer operations, AIS Health reported.

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Topics: Industry Trends, Market Access, Data & Analytics, Payer

Radar On Market Access: Employers Show Interest in Moving to ICHRAs

Posted by Peter Johnson on Dec 10, 2020

Health care industry insiders say that employers of all sizes are beginning to take a serious look at moving some of their health benefits to Individual Coverage Health Reimbursement Arrangements (ICHRAs) starting in 2022, AIS Health reported.

In July 2019, the Trump administration finalized new regulations for ICHRAs, giving employers greater flexibility to reimburse qualifying employees buying health insurance policies on the individual market.

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Topics: Industry Trends, Payer

Trends That Matter for Employer Health Benefits

Posted by Peter Johnson on Nov 19, 2020

Several recent surveys on employer-sponsored health insurance have found that plan sponsors are following three major trends: expanding virtual care and telehealth benefits, narrowing provider networks and emphasizing centers of excellence in their benefit designs, AIS Health reported.

According to the 2020 edition of the Kaiser Family Foundation’s (KFF) Employer Health Benefits Survey, this year's annual premium growth (4% for individuals and families) outstripped both wage growth (3.4%) and inflation (2.1%).
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Topics: Industry Trends, Market Access, Data & Analytics

Radar On Market Access: Employers Aim to Narrow Networks, Emphasize COEs, Expand Virtual Care Benefits

Posted by Peter Johnson on Oct 29, 2020

Several recent surveys on employer-sponsored health insurance have found that plan sponsors are following three major trends: expanding virtual care and telehealth benefits, narrowing provider networks and emphasizing centers of excellence in their benefit designs, AIS Health reported.

According to the 2020 edition of the Kaiser Family Foundation’s (KFF) Employer Health Benefits Survey, this year's annual premium growth (4% for individuals and families) outstripped both wage growth (3.4%) and inflation (2.1%).

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Topics: Industry Trends, Payer

Radar On Market Access: Racial Disparities Are Highlighted by Pandemic

Posted by Peter Johnson on Oct 22, 2020

The COVID-19 pandemic has been especially harmful to people of color in the U.S., as they are more likely to suffer financial hardship, extreme cases of the disease or death than the white population. Experts say the devastation to communities of color is the product of systemic racism — particularly a lack of access to insurance coverage and quality care — and the pandemic's economic consequences will make all of those problems worse, AIS Health reported.

According to a Sept. 15 report released by the Kaiser Family Foundation (KFF) and the Epic Health Research Network, people of color were more likely to test positive for COVID-19 and to require a higher level of care at the time of diagnosis compared to white patients, and they also were more likely to be hospitalized and die from the novel coronavirus than white patients were.

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Topics: Data & Analytics, Payer

Perspectives on Provider Consolidation

Posted by Peter Johnson on Oct 15, 2020

The climate for payer mergers and acquisitions (M&A) has cooled substantially at a national level ever since the collapse of the proposed deals between Anthem, Inc. and Cigna Corp. and between Aetna Inc. and Humana Inc. However, consolidation in the provider sector has increased since the start of the COVID-19 pandemic as such firms grapple with the rapid collapse of fee-for-service revenue, AIS Health reported.

The breakdown of Anthem's bid to acquire Cigna resulted in a public spat and dueling lawsuits over Cigna’s attempt to exit their agreement before exhausting the firms' option to appeal a federal ruling against the transaction. On Aug. 31, the Delaware Court of Chancery ruled that neither firm had to pay damages to the other over the failed deal.
 
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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: Trump's $200 Medicare Drug Card Proposal Prompts Criticism

Posted by Peter Johnson on Oct 15, 2020

Experts say a last-minute proposal by President Donald Trump to distribute $200 prescription drug credits to Medicare Part D enrollees on preloaded debit cards faces many unanswered questions and will be difficult to implement, especially in the short time before the Nov. 3 election, AIS Health reported.

Little is known about the drug credit plan other than what can be gleaned from public statements by the president and an unnamed HHS source cited by the Washington Post. The president announced the plan during a Sept. 24 campaign speech in North Carolina.

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Topics: Industry Trends, Provider, Payer

Trends That Matter on Trump Administration's Rebate Order

Posted by Peter Johnson on Oct 8, 2020

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

"I think the purpose of these executive orders is to give the president some talking points going into the debates," says Avalere Health founder Dan Mendelson. He adds that, regardless of their purpose, the orders will not make a difference in the real world any time soon.
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Topics: Industry Trends, Market Access, Data & Analytics

Radar On Market Access: COVID-19 Pandemic May Lower Health Care Costs, But Deferral Impact Exists

Posted by Peter Johnson on Oct 8, 2020

Health insurers will probably have lower health care expenditures in 2020 and 2021 than before the COVID-19 pandemic, according to a new analysis from Willis Towers Watson. However, the white paper emphasizes that substantial risk is still possible and says plan sponsors need to take proactive steps to blunt the future impact of deferred care, AIS Health reported.

The policy environment could change suddenly and dramatically depending on the outcome of California v. Texas, a suit that could lead the Supreme Court to overturn the Affordable Care Act, and the presidential election.

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Topics: Industry Trends, Payer