Medical cost trends: tougher contract negotiations

A coalition of 20,000 advocates and 12 major healthcare groups is urging CMS to expand Medicare and Medicaid to cover FDA-approved anti-obesity medications. Dr. Eleanor Yusupov, an obesity medicine physician and assistant professor at NYITCOM, was featured as an expert in the Newsweek article, stating: "The high cost of anti-obesity treatments and lack of insurance coverage remain major barriers... Policy change will improve access to medications recommended to prevent diabetes, improve heart health, and enhance quality of life." Read more: https://lnkd.in/dvhUqM-X

What Employers Need to Know for Prescription Drug Data Collection (RxDC) The Prescription Drug Data Collection program, established by the Consolidated Appropriations Act of 2021, requires insurance companies and employer-based health plans to provide details about prescription drug benefits and healthcare spending and costs to the Center for Medicare & Medicaid Services. Reporting obligations apply to both self-insured and fully-insured group health plans and reporting is due by June 1 of each year for the prior year’s coverage. Read more here - https://hubs.ly/Q02sBrYy0

Why are certain steps in healthcare transitions so difficult that they make it nearly impossible for patients to access life-saving medications? A recent case at my pharmacy underscored this frustrating, systemic issue. A patient was discharged from the ER with a prescription for fondaparinux to treat acute DVT. However, the medication wasn’t covered by their insurance and required a prior authorization. Fortunately, I was able to contact the prescribing ER physician, who was still on shift. After discussing the situation, they approved a switch to enoxaparin, a preferred alternative covered by the patient’s insurance. Together, we calculated the appropriate dose for the next four days, ensuring the patient had access to treatment until they could see their PCP for further management. In this instance, everything worked out—thanks to timely action, collaboration, and patient advocacy. But what happens when prescriptions are sent after hours or to a different shift? On-call providers are often reluctant to modify plans made by another physician, and many hospitals discharge patients without addressing or even knowing about pending prior authorizations. This leaves patients stranded—without the medication they urgently need. In cases like DVT or PE, even a short delay in treatment can have life-threatening consequences. #Community #pharmacists, who have dedicated their lives to patient care, have shouldered the weight of policies that disregard the human element of healthcare for far too long. Until meaningful change is made, the already overburdened and overwhelmed community pharmacists will continue to stand at the #frontlines—fighting tirelessly for their patients, bridging the gaps in transitions of care, and ensuring no patient is left without life-saving medications. This daily struggle to provide life-saving care in a flawed system cannot continue. Patients deserve a system that works for them, not against them. We need better solutions—streamlined prior authorizations, improved coordination between hospitals, insurance companies, and pharmacies, and policies that prioritize patient care over administrative barriers. The current system is unsustainable. It’s time for change—before more lives are put at risk.

What Employers Need to Know for Prescription Drug Data Collection (RxDC) The Prescription Drug Data Collection program, established by the Consolidated Appropriations Act of 2021, requires insurance companies and employer-based health plans to provide details about prescription drug benefits and healthcare spending and costs to the Center for Medicare & Medicaid Services. Reporting obligations apply to both self-insured and fully-insured group health plans and reporting is due by June 1 of each year for the prior year’s coverage. Read more here - https://hubs.ly/Q02sBrR20

New from ATI Advisory: Analysis of nonmedical supplemental benefits in Plan Year 2025 #Medicare Advantage (#MA) plans finds important shifts in MA plans' offerings this upcoming year: 💡 More MA plans are offering nonmedical supplemental benefits targeting food, transportation, and housing than in PY2024. Moreover, more plans are employing the value-based insurance design (VBID) demonstration model to offer those benefits (as opposed to through SSBCI authority). 💡 Fewer MA plans are offering long-term services and support (LTSS)-like benefits, such as in-home services and support, support for caregivers, adult day health, and social needs benefits, than in PY2024.   We will continue to update this analysis with a deeper dive into the trends. In the meantime, tune in today at 1p ET as Allison Rizer, MHS, MBA, Tyler Cromer, and Claire Boozer Cruse, MPH discuss a first look at the CY 2025 Medicare Advantage Market Trends & Supplemental Benefits data. Register now: https://lnkd.in/einW-EBy   ATI’s research portfolio on supplemental benefits: https://lnkd.in/guvbbGzv   *Note: Analysis of CMS PBP files (2024-2025), excludes Employer Group Health Plans (EGHPs), Prescription Drug Plans (PDPs), Medicare-Medicaid Plans (MMPs), Part B-only plans, and PACE. A plan is the combination of contract ID, plan ID, and segment ID. Total MA plans are 5,786 in 2024 and 5,687 in 2025.   This work was completed with support from The SCAN Foundation. #medicareadvantage

Nonmedical #supplementalbenefits are evolving everyday, highlighted by ATI Advisory's latest analysis for 2025. #Dental, #Vision, #Hearing and #OTC continue to be table stakes with an increase focus on #food, #transportation, and #housing to address Social Determinants of Health #SDOH, all while leveraging the Value-Based Insurance Design model, better known as #VBID. There is a reduction in plans offering benefits for services like caregivers assistance, in-home support and adult day health. Time will tell whether that shift was a result in less PMPY (from the #StarRatings fluctuation) to support these benefits or unsupported data around improving #healthoutcomes. I'm already thinking about 2026!..... with additional changes on the horizon including updated reporting requirements around #supplementalbenefits and mid-year benefit notifications. ATI Advisory Centers for Medicare & Medicaid Services

Affordable health care (and rational governing) is on the ballot. Kamala Harris will accelerate efforts to lower prescription drug prices, expand subsidies that help people pay for health insurance, and protect access to medication abortion. The alternative? Donald Trump and Republicans in Congress want to revoke the ability of Medicare to negotiate lower drug prices, end health insurance subsidies, and get the government between a doctor and their patient considering medical abortions. https://lnkd.in/gJXdNwhR 

Affordable health care is on the ballot. Kamala Harris will accelerate efforts to lower prescription drug prices, expand subsidies that help people pay for health insurance, and protect access to medication abortion. The alternative? Donald Trump and Republicans in Congress want to revoke the ability of Medicare to negotiate lower drug prices, end health insurance subsidies, and restrict access to medication abortion.

Since January 1, 2023, individuals who meet certain criteria and whose Medicare coverage based on End Stage Renal Disease (ESRD) ends 36 months after a successful kidney transplant might qualify for a new Medicare benefit known as the Medicare Part B Immunosuppressive Drug Benefit. This benefit specifically covers the cost of immunosuppressive drugs required after a kidney transplant. 💊🎉 Eligibility for the Medicare Part B Immunosuppressive Drug Benefit includes: - Being entitled to Medicare based on ESRD, with coverage ending 36 months after a successful kidney transplant. 📅🏥 - Confirming you are not enrolled in other healthcare coverage that would make you ineligible for this benefit. 🚫📋 Examples of other healthcare coverage that could make an individual ineligible for the Medicare Part B Immunosuppressive Drug Benefit include: - Employer or individual health plans - Health Insurance Marketplace plans as defined in section 2791 of the Public Health Service Act - TRICARE for Life - Enrollment in the patient enrollment system of the Department of Veterans Affairs (VA) or eligibility to receive immunosuppressive drugs from the VA - Medicaid or State Children’s Health Insurance Program (CHIP) coverage that includes immunosuppressive drugs. This new Medicare benefit aims to provide crucial support to individuals who have undergone kidney transplants by ensuring they have continued access to the medications necessary to maintain the health and function of their transplanted organs. 🫁💪 Learn More: https://lnkd.in/gFwdJwQe . . . #medicare #independentseniorinsurance #medicareagent #medicareprofessional #medicareinsurance #medicareadvantage #medicaresupplement #medicarepartd #medicaresimplified #medicareplans #indiana #indianapolis #healthcare

Prior authorization in healthcare is a complex topic demonstrating the challenge in balancing healthcare costs, quality of care, and provider efficiencies. Recent developments aim to streamline this process: 📑 𝐂𝐌𝐒: In January, CMS finalized a rule requiring insurers to send prior authorization decisions within 72 hours for urgent requests and 7 days for non-urgent requests. 🖋 𝐒𝐭𝐚𝐭𝐞 𝐋𝐞𝐠𝐢𝐬𝐥𝐚𝐭𝐢𝐨𝐧: States like Colorado, Illinois, and Minnesota have enacted laws to reduce prior authorization requirements and improve transparency. 👍 𝐈𝐧𝐬𝐮𝐫𝐞𝐫 𝐈𝐧𝐢𝐭𝐢𝐚𝐭𝐢𝐯𝐞𝐬: UnitedHealthcare and Cigna have expanded prior authorization exemptions for certain treatments and services. What else can be done? ⏭ According to clinicians in a recent Cancer Therapy Advisor article, additional updates to the process, such as 𝐞𝐚𝐬𝐢𝐞𝐫 𝐟𝐨𝐫𝐦𝐬 𝐚𝐧𝐝 𝐢𝐦𝐩𝐫𝐨𝐯𝐞𝐝 𝐞𝐥𝐞𝐜𝐭𝐫𝐨𝐧𝐢𝐜 𝐬𝐮𝐛𝐦𝐢𝐬𝐬𝐢𝐨𝐧 𝐬𝐲𝐬𝐭𝐞𝐦𝐬, would go a long way in reducing their burden. In a 2023 AMA survey, physicians reported the most common method to complete the prior authorization process is 𝐭𝐡𝐞 𝐩𝐡𝐨𝐧𝐞 and only 23% reported that their EHR system offers electronic prior authorization for prescription medications.