That type of systematic change starts by building on our collective strengths, and health plans are leading collaborations with hospitals, physician practices, pharmacies, health care agencies, and community organizations to provide the best care possible for patients. From bundled payments and value-based designs, health plans can provide the clinical data and support to help providers and clinicians identify health issues early, like high-blood pressure or other symptoms of chronic disease to avoid complicated, costly treatments later on.
And with last week’s HHS forum on how to deal with the rising cost of prescription drugs, I’m thankful that we are seeing leaders from across the health care sector focusing on the increasingly high prices being charged for health care services and advancing ways to work together to create a more affordable and sustainable system.
Ultimately, I’m grateful for the work that we are doing to empower patients. In this consumer-driven market, health plans are working to give patients the right information they need to make informed decisions about their care. Our latest cost and quality calculators make it possible for consumers to compare hospitals, providers, and specialists based on quality and cost measures so that families know where to get the best value for their health care dollars. Health plans are also expanding patients access to care and support through the use of telemedicine, mobile technology, and streamlined benefit information, so that consumers don’t need to second-guess when it comes to their health care needs.
So this Thanksgiving I encourage everyone in the health care system to keep their focus on consumers and their families – ensuring their ability to afford and access the care they need.]]>
There’s been a lot of health care activity on Capitol Hill this week, especially with The U.S. Department of Health and Human Services gathering industry stakeholders to discuss the problem and potential solutions to soaring prescription drug prices. Meanwhile, policymakers in the House and Senate introduced several prices of legislation to address additional problems of affordability and access for health care consumers.
H.R. 4090, Marsha Blackburn, to amend the Social Security Act to improve choices available to Medicare eligible seniors by permitting them to elect (instead of regular Medicare benefits) to receive a voucher for a health savings account, for premiums for a high deductible health insurance plan, or both and by suspending Medicare late enrollment penalties between ages 65 and 70
H.R. 4110, Robin Kelly, to require the Comptroller General of the United States to study the feasibility of modifying the 5-month waiting period for certain individuals entitled to disability insurance benefits under section 223 of the Social Security Act, and for other purposes
H.R. 4115, Grace Meng, to adjust the amount of monthly old-age, survivors, and disability insurance payments under title II of the Social Security Act based on locality-based comparability payment rates
H.R. 4058, Bill Shuster, to require that in cases of health insurance coverage cancelled pursuant to requirements under the Patient Protection and Affordable Care Act cancellation notices provided to enrollees include a statement such cancellation is because of such Act
H.R. 4059, Diane Black, to amend title XVIII of the Social Security Act to encourage Medicare beneficiaries to voluntarily adopt advance directives guiding the medical care they receive
H.R. 4062, Kenny Marchant, to amend title XVIII of the Social Security Act to remove the enrollment restriction on certain physicians and practitioners prescribing covered outpatient drugs under the Medicare prescription drug program
H.R. 4076, Michael Turner, to amend title XIX of the Social Security Act to allow for payments to States for substance abuse services furnished to inmates in public institutions, and for other purposes
H.R. 4077, Roger Williams, to amend title XVIII of the Social Security Act to provide for a Medicare established provider system under which providers of services and suppliers representing a low risk for submitting fraudulent Medicare claims are provided certain claim review protections
H.R. 4015, Frank Pallone, to amend title III of the Public Health Service Act to authorize and support the creation of cardiomyopathy education, awareness, and risk assessment materials and resources by the Secretary of Health and Human Services through the Centers for Disease Control and Prevention and the dissemination of such materials and resources by State educational agencies to identify more at-risk families
S. 2311, Dean Heller, to amend the Public Health Service Act to authorize the Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration, to make grants to States for screening and treatment for maternal depression
S. 2312, John Thune, to amend titles XVIII and XIX of the Social Security Act to make improvements to payments for durable medical equipment under the Medicare and Medicaid programs
S. 2262, James Inhofe, to amend title XVIII of the Social Security Act to cover screening computed tomography colonography as a colorectal cancer screening test under the Medicare program
S. 2259, Maria Cantwell, to amend title XVIII of the Social Security Act to improve the way beneficiaries are assigned under the Medicare shared savings program by also basing such assignment on primary care services furnished by nurse practitioners, physician assistants, and clinical nurse specialists
S. 2261, John Thune, to amend title XVIII of the Social Security Act to improve the way beneficiaries are assigned under the Medicare shared savings program by also basing such assignment on services furnished by Federally qualified health centers and rural health clinics]]>
When hospitals and physician practices compete on price and quality, prices go down, consumers have better access to health care services, quality improves, and investments go toward innovation. With a healthy dose of competition, providers will be motivated to do what’s best for patients and the delivery system.
It’s also important to remember that consolidation among providers is not essential to delivering the high-quality, cost-efficient, innovative health care that patients deserve.
Relationships between health plans and providers will help propel health plan efforts around care coordination, financial risk management, and value-based care. Anticompetitive mergers by hospitals and other providers on the other hand will hold back such transformative initiatives. As demonstrated in a recent issue brief, care coordination can and should be delivered without provider consolidation that enhances market power.]]>
The Orphan Drug Act was passed as a way to encourage pharmaceutical companies to invest in treatments for rare diseases – so-called “orphan diseases” that had been ignored because their small patient populations made them unprofitable.
The intent was that through incentives included in the Orphan Drug Act, pharmaceutical companies could break even or possibly post modest profits for developing and manufacturing drugs to treat orphan diseases. These incentives included market exclusivity for seven years, tax breaks, and the waiver of FDA user fees.
By some measures, the Orphan Drug Act has been a success, with hundreds of new drugs approved for rare diseases, many of which had no treatment options. Prior to the law’s enactment in 1983, the FDA had approved only 10 drugs for rare diseases. Now, more than 400 orphan products have FDA approval.
But over the years, the pharmaceutical industry has taken advantage of the Orphan Drug Act’s good intentions, turning these “niche” drugs into multibillion-dollar sellers.
Consider these facts:
In a new study in the American Journal of Clinical Oncology, Marty Markary of Johns Hopkins School of Medicine and coauthors call attention to pharmaceutical companies gaming the Orphan Drug Act to maximize profits. Although the orphan drug Rituximab was approved to treat a subtype of non-Hodgkin lymphoma, doctors prescribe it for a wide variety of common medical conditions. The drug still benefits from the financial incentives of orphan drug status while being the 12th best-selling medication of all time in the United States.
Are these the kinds of profits Congress expected to see when the Orphan Drug Act was passed? We don’t think so. It’s time that important programs like the Orphan Drug Act are refocused to their original intent – encouraging companies to invest in treatments that will help patients with rare diseases and unmet medical needs.]]>
Our Drug of the Week this time is the leukemia drug Gleevec, which is Exhibit A for what’s wrong with pharmaceutical pricing.
When Gleevec entered the market as a life-saving innovation in 2001, it cost about $30,000 a year in the United States. While the launch price was expected to cover R&D costs, what’s the excuse for Novartis more than doubling the yearly price tag for Gleevec to $106,322 this year?
And this price jump occurred despite the introduction of two new drugs to treat leukemia, including one also manufactured by Novartis – something Avik Roy of the Manhattan Institute highlighted earlier this month at a Capitol Hill briefing.
Imagine if Apple charged two and half times more for the iPod now than it did back in 2001, Roy asked. “We’d all think they were crazy … but that’s what happens in the pharmaceutical market,” he said.
When an older drug keeps getting more and more expensive, high prices clearly aren’t driving medical innovations. Gleevec’s continual and substantial price increase goes too far, forcing cancer patients to forgo a life-saving treatment they need or face potential bankruptcy.
Check out our recent issue brief to learn about AHIP’s market-based policy solutions to promote affordability and patient access to effective treatments and stay tuned for upcoming drug spotlights.]]>
Take Harvoni, Gilead’s hepatitis C medication, as an example. Harvoni comes with a $94,500 price tag. With the Affordable Care Act’s out-of-pocket limits and cost-sharing subsidies, an individual enrolled in a standard bronze plan would only be responsible for 6.8 percent of the total cost of the drug ($6,373). The health plan would pay for more than 93 percent of the remaining cost ($88,127).
Those costs are one of the many drivers of premium increases and deductibles. So as pharmaceutical companies continue to arbitrarily drive up their prices, they are increasing premiums and deductibles along with those costs.
But there are ways to solve this problem. More transparency around the pricing of prescription medications – the cost of research and development and marketing – would provide much needed clarity as to how pharmaceutical companies set their drug prices. It’s also time to re-evaluate how we pay for prescription medications. Rather than paying for drugs in the antiquated fee-for-service model of care delivery, prescription drug prices should be directly linked to clinical measures and improved health outcomes. Let’s reward innovation where it exists and provide patients with the value they deserve.]]>
The video explains that hiking up prices is all too common in the pharmaceutical industry – take diabetes drug Januvia more than doubling in price from $146 a month in 2006 to $331 a month now – and drug companies rake in billions in profits from such increases.
While the problem of unjustifiable drug price increases is something we discuss often here on AHIP Coverage, let’s let the Bloomberg video do the talking:
Private long-term care insurance offers important cost-savings for the Medicaid program. The private health insurance community has been partnering with state Medicaid programs so that people who purchase LTC policies can access Medicaid benefits without having to exhaust all of their assets to Medicaid levels, if and when their private LTC benefits run out. For example, the AHIP report found fewer than 5 percent of nursing home residents with LTC policies spend down to Medicaid, while between 21 percent and 31 percent of those without LTC coverage would spend down to qualify for Medicaid.
In this way, private LTC coverage helps Medicaid beneficiaries keep their savings and plan responsibly for future LTC needs. Public-private partnership plans protect assets that match the amount of benefits received from the policy. For example, when a consumer buys private LTC coverage with a total benefit value of $200,000, when he needs care, the consumer uses those LTC benefits first. Once LTC benefits are used up and a person needs more care later on in life, the person can apply for Medicaid with that $200,000 amount in “exempt assets,” so he doesn’t have to transfer his house to a child or sell it to qualify for low-income coverage.
What’s more, LTC policyholders receive 35 percent more total hours of long-term care than those who don’t have private coverage. In addition to extra care, LTC coverage enhances access and flexibility, as LTC policyholders are better able to get care in the setting of their choice, such as at home or an assisted living facility.
Building on the strengths of the private LTC insurance market, public-private partnerships provide and pay for critical LTC services that benefit millions of consumers and beneficiaries across the country. These partnerships are becoming more important than ever as the American population lives longer and LTC needs grow.]]>
November is National Diabetes Month. With more than 29 million people estimated to have diabetes and 86 million people estimated to have prediabetes, this is a condition we can’t ignore.
Health plans have developed innovative ways for treating and preventing diabetes that put great focus on diagnosing and treating those with prediabetes. Many plans use a health risk assessment during a preventive health services exam or health fair to identify the target population with prediabetes. Potential participants for diabetes prevention lifestyle change programs can be indentified through physician referrals and marketing as well.
As part of a cooperative agreement with the Centers for Disease Control and Prevention, AHIP and four of its member health plans – Denver Health Managed Care, EmblemHealth, Florida Blue, and Molina Healthcare – are implementing National Diabetes Prevention Program (National DPP) in six states.
The National DPP is a year-long intervention focused on healthy eating, stress reduction, and the importance of exercise. As a part of the curriculum, health plan beneficiaries who are at risk for developing type 2 diabetes learn ways to eat less fat and fewer calories, tips for eating healthy at restaurants, how to make being active a way of life, best practices for managing stress, and strategies to stay motivated.
Here’s why the health plan community is involved with National Diabetes Prevention Program and committed to preventing type 2 diabetes and its related risk factors:
“The National Diabetes Prevention Program is very important because it takes an individual who doesn’t have diabetes yet, but who is at very high risk of developing diabetes, and gives them a chance to alter the course of that condition to the point where they can try to either prevent or delay diabetes by implementing this lifestyle change program.” – Deborah Stewart, M.D., Florida Blue
“There are so many reasons to implement the National Diabetes Prevention Program. First and foremost, knowing that diabetes affects so many patients and health plan members, we needed a program that was right for them. Second, we always need an evidence-based program to gain the organizational support for implementing the intervention. That combination really allowed us to say the National Diabetes Prevention Program was the right way to go to prevent diabetes.” – Natalie Ritchie, Ph.D, Denver Health
Many health plans are using the National DPP and other diabetes prevention interventions to their members live longer, healthier lives. These are just a few examples of health insurers championing the movement toward prevention and wellness.]]>