Nicholas Opalich

https://lnkd.in/d_BchY5u If your insurance no longer covers injectable GLP-1 RA medications like Semaglutide or Tirzepatide, you may be wondering about your next steps. This is a common concern that pharmacists across the country are addressing, especially as insurance plans start to announce coverage changes for 2025. One option to consider is compounded sublingual Semaglutide in SubMagna™ HMW.  Visiting www.subsema.com can provide information on providers that offer this service, or you could consult with a local independent pharmacist to see if they can prepare it for you, provided you have a prescription. When considering a provider for compounded medication, it's crucial to verify their credentials and standing with the State Board of Pharmacy. #compoundingpharmacy #independentpharmacy #submagna #subsema #semaglutide

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Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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What does health insurance do? The conversation in the attached screenshot sums it up. We have a distorted market in healthcare. For drugs, there is a middleman called PBM between the insurance and the drug companies. The PBM negotiates a higher rate than the cash price - usually 2x or 3x and then receives an under the table rebate from the drug company. It passes of portion of this rebate to the insurer. The end effect is that the bottom price for the consumer is increased. The consumer believes that their insurance saved them a lot of money. #healthcare

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Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

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Reason #1 why geographic restrictions are bad policy for #340B contract pharmacies. Reduced Access - It is common for patients established at a CHC to have physical and geographic access challenges. CHCs often rely on mail-order or home delivery pharmacies to fill these gaps and ensure patients have access to care. Local Pharmacies and even CHC owned pharmacies are often prohibited by payors from mailing prescriptions. This leaves no option but to contract with a select few nationally recognized home delivery pharmacies to ensure CHC patients have access to their medications. Health Resources and Services Administration (HRSAgov), HHS Centers for Medicare & Medicaid Services National Association of Community Health Centers (NACHC) PhRMA #340B #CoveredEntities Advocates for Community Health

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Health insurance Prior authorization rationing of physician recommended preventive, medical, surgical and palliative care occurs over 1 million times a day in America. Medicare Advantage insurance plans ration care causing delays, changes and abandonment of physicians recommended care 100’s of thousands of times a day devastating patient health and physician workflow. #quadrupleaim #vbc #valuebasedcare

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Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

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If you click on the link you will see a report called Expense Distribution. I know this report more than you can imagine. It's based on paid claims. It shows that for this plan half the members were essentially self-insured as individuals. If I was the CEO of this company, you can bet I would make sure the rates my employees were paying for their own care were reasonable. If not, I'd be personally liable. #deerhold #ContractRateExplorer #MRFInsights

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New CMS Rules Hope to Curb Consumer Fraud! KFF Health News reports, “Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators.” CMS “credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.” But “now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?” The article says “the clampdown could add complexity to enrollment and slow the process.”

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With over 2 million members displaced by major healthcare players exiting underperforming Medicare Advantage markets, regional insurers face both a challenge and an opportunity. This influx of high-cost members demands innovative solutions to manage chronic conditions like diabetes and heart failure effectively. At Circadian Health, we’re helping regional insurers navigate this disruption with virtual-first specialty care, reducing costs and improving outcomes for the most complex members. This market shake-up isn’t just a challenge—it’s a chance to redefine care delivery. Discover how regional insurers can transform disruption into opportunity—read more on our blog. #MedicareAdvantage #HealthcareInnovation #VirtualCare #CircadianHealth #ValueBasedCare #HealthEquity

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I have written before with conviction and faith about NADAC pricing for drugs reimbursed to pharmacies. Why retail and independent pharmacies cling to faulty PBM contracts with the usual suspect of reimbursement benchmark of AWP. AWP is archaic and it certainly does not favor a pharmacy. As a Founder & CEO of a Hospice PBM and my past business experience of owning a pharmacy for over 20 years - pharmacies especially the independents have a soft place in my heart. That is why I believe treating the independent pharmacy as your partner we can all share in the success of the paying client or the customer as a happy customer. Margins are tight and the squeeze is tightening further. CMS gave all hospice providers a 2.5% increase. In the hospice PBM world think of it this way the average national cost per patient per day is around $12.50. Now reflect on all other nursing costs, visit costs, caregiver costs, aids etc and then you realize AWP is hurting the paying client not helping. Cap Rx keep on, keeping on!

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Dr. Jain...THANK YOU for this insight and support for the kind of work I do every day! Building complex geriatrics longitudinal care programs is where I cut my value based teeth! These programs - when structured with attention to detail - can create a profoundly positive impact. A fully integrated program that is carefully facilitated, orchestrated, and navigated WITH a patient quite literally changes lives. As a system we have to shift our thinking and embrace the FACT that cookie cutter medicine is NOT effective as well as the notion that precision medicine is not scalable, replicable or sustainable....because it CAN be. Been there, done that (and continue to do it) and have the results to prove it! At Synergy 3C, THESE are the models we build and have a track record of success! We would love to have a conversation with you about HOW these models can and do work! #complexpopulationhealth #complexgeriatrics #medicareadvantage

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Value based care is a scam. The clinical consequence’s of Humana’s (and every other Health insurer in the USA’s) value based care including prior authorization rationing of physician recommended care, limited physician and hospital panels to diminish Humana’s labor costs and and diminished labor (physician) and overhead reimbursement (hospital, outpatient, ASC) are clearly evidenced here.

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Privatized Medicare Advantage plans have raised costs for Medicare by $612 billion since 2007, including $82 billion last year alone, according to congressional advisory group MedPAC. Managed Medicare membership continues to grow exponentially, while the costs to taxpayers also grows exponentially…and, these plans are the most profitable in the entire managed care sector…which should be a red flag to all consumers and healthcare professionals. #healthcare #leadership #managedcare Honor Aging

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PBM Practices Exposed: 10 Hidden Profit Tactics How do traditional PBMs boost their profits? Our free guide details: - 10 lesser-known PBM money-making strategies - The impact on your organization's costs - How DisclosedRx eliminates these surprises As The Fiduciary and The Fully Disclosed PBM®, we prioritize your interests. Download our guide to see how we're reshaping the industry. Get your free guide: https://lnkd.in/g5PFiFRY #PBMPractices #EmployerHealthcare #DisclosedRx

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PBM Practices: 10 Profit Tactics How do traditional PBMs boost their profits? Our free guide details: - 10 lesser known PBM money making strategies - The impact on your organization's costs - How DisclosedRx eliminates these surprises As The Fiduciary and The Fully Disclosed PBM®, we prioritize your interests. Download our guide to see how we're reshaping the industry. Get your free guide: https://lnkd.in/g5PFiFRY #PBMPractices #EmployerHealthcare #DisclosedRx

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Proof of Purpose; PDPs kept afloat Good for Manufacturers, too? The intricacies of IRA Part D benefit redesign dramatically reshape the OOP for millions of beneficiaries, reducing financial toxicity and raising utilization (I will post to past non adherence figures in comments) Unlike MA PDPs, freestanding PDPs can’t shuttle money over from the medical benefit to moderate premium increases, so some speculated that PDPs would fail. I commented several times that given this administrations view of the private market exemplified by MA that was highly unlikely. And after all PDPs are holding up half the benefit. CMS moves forward. “CMS is also announcing a voluntary demonstration program for standalone prescription drug plans (PDPs). The Part D Premium Stabilization Demonstration is designed to test whether additional policy changes stabilize year-over-year changes in premiums for participating standalone PDPs, leading to more predictable options for beneficiaries during the initial implementation of the IRA’s) benefit improvements, creating more gradual enrollment changes… Under the voluntary demonstration, there will be a reduction in the base beneficiary premium of $15 for all participating PDPs, combined with a year-over-year plan premium increase limit of $35 and narrowed risk corridors..” Thanks Tom Thoughts on implications, such as spillover from reducing headwinds, moderating adoption of narrower formularies and networks? If so possible plus for Phrma —not to mention if it slows down MA train with attendant Part B drug prior auths. #PartD #PDPs

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