Insurance

Catalyst for Payment Reform (CPR) explores stakeholder perspectives in Florida, Michigan, and Nevada, revealing both the challenges and opportunities states face in reforming health care pricing structures.

The House of Representatives unanimously passed the bipartisan Seniors’ Access to Critical Medications Act (HR 5526), which would reverse CMS restrictions on mail delivery of cancer medications to Medicare beneficiaries.

Linda Bosserman, MD, PhD, FASCO, FACP, of City of Hope, emphasizes the need for a sustainable health care system that balances cost with care so patients can achieve the best survival and quality of life after a cancer diagnosis.

Medicaid coverage was able to help some people lower their blood pressure according to a new study.

The proposed Medicare High-Value Drug List Model, also known as the Medicare $2 Drug List, could have modestly reduced out-of-pocket costs for 38% of beneficiaries if implemented in 2021.

"As CMMI continues to test new equity adjustments, it is important that changes be grounded in scientific principles with extensive testing and validation to ensure the tightest linkage to social needs and health outcomes for underserved communities across the entire US," authors wrote.

The authors examine how insurer and patient out-of-pocket payments for advanced prostate cancer differ by drug and health plan type and describe the relationship between these payments and utilization.

On this episode of Managed Care Cast, we're talking with the author of a study published in the September 2024 issue of The American Journal of Managed Care® that explored the factors consumers consider essential for an adequate provider network.

Patients seeking free preventive care continue to face cost-sharing and administrative hurdles, a study reveals.

Chris Barton, LCSW, of Horizon Blue Cross Blue Shield of New Jersey, explores how the Youth Behavioral Health Strategy program focuses on addressing the specific needs of youth with mental health and substance use issues through a comprehensive approach.

Accountable care organizations (ACOs) with a major teaching hospital were associated with lower mortality, lower inpatient spending, lower emergency department utilization, and higher overall outpatient spending.

The rate of uninsurance in 2023 was 8.0%, a statistically insignificant change from the 7.9% uninsured rate in 2022.

The findings may help inform policy changes at the federal level aiming to address unfair and deceptive pharmacy benefit manager (PBM) practices.

Ian Neeland, MD, of University Hospitals and Case Western Reserve University, recommended a team-based, comprehensive approach to managing diabetes and its related complications.

Payers must continue to assess their prior authorization practices to uphold the goals of clinical quality, safety, and utilization management.

Manisha Jhamb, MD, MPH, of the University of Pittsburgh Medical Center (UPMC), is excited about CMS's negotiated drug prices under the Inflation Reduction Act (IRA) for patients with kidney disease; conversely, she highlights the challenge of low kidney disease awareness.

Analysis of 2012-2021 commercial claims demonstrates that spending growth was concentrated among the highest spenders and there was increasing subsidy across enrollees through cost-sharing design.

At the 25th International AIDS Conference, Emmanuel Nazaire Essam, MD, MPH, presented the analysis, "Medicaid Insurance Expansion and Its Association With HIV Outcomes in Nebraska, USA: An Observational Prospective Cohort Study."

Eli Lilly has introduced discounted single-dose vials of tirzepatide (Zepbound) for self-pay patients with obesity to increase accessibility.

Aetna has become the first major US insurer to expand access to fertility services by covering intrauterine insemination as a medical benefit for all eligible plans, marking a significant move toward greater equity in family-building options for people of all backgrounds.

Celltrion's adalimumab-aaty biosimilar is now accessible for all Costco members, while Amgen sues Samsung Bioepis over the latter’s denosumab biosimilar candidate, and GlycoNex progresses its denosumab biosimilar SPD8 to phase 3 trials.

Changes in formulary coverage for 2024 are impacting Medicare patients' access to and ability to afford various prescription medications.

Some groups praised CMS after it announced the 10 negotiated Medicare drug prices while others criticized its potential impacts on drug competition and development.

Health plans can improve their Medicare Advantage Star Ratings by focusing on member relationships, ensuring proper documentation, grouping measures, staying updated with regulatory changes, and optimizing their strategy based on numerical targets.

On this episode of Managed Care Cast, we discuss strategies to improve 2025 Medicare Advantage Star ratings, especially for smaller plans, with Marge Ciancetta, the product manager of Cotiviti's Star Intelligence solution.