Capital Rx’s Post

UnitedHealth, CVS, and Cigna's PBMs are using their market share and influence in Washington to push independent pharmacies out of business. This is all in the name of controlling healthcare costs. But at what expense? Independent pharmacies provide personalized care to patients, especially those in rural areas. The healthcare industry's consolidation is something we must consider, as it will have an impact on both patients and communities. Let's not forget the importance of personalized care, especially for those who can't travel to larger cities. It's important to take a step back and think about the long-term effects of these decisions on our healthcare system. #IndependentPharmacies #HealthcareConsolidation #PersonalizedCare #PatientAdvocacy

In my 2024 healthcare forecast, I predicted that insurers would start incorporating GLP-1 medications into their formularies, a decision driven not by mysticism but by sound economic reasoning. This shift aligns with the recent guidelines from Medicare, now adopted by insurers like CVS Aetna and Elevance, with others expected to follow. These policies cover the drugs for Medicare beneficiaries diagnosed with both obesity and heart disease. The average cost of these medications is around $1,000 per month, totaling approximately $12,000 annually. Patients using GLP-1s typically experience weight loss, leading to a decreased risk of heart disease-related complications such as hospitalizations, surgeries, and post-acute rehabilitation. Insurers, after analyzing the costs, recognize that it is more economical to spend $120,000 over a decade on these medications (assuming the price remains constant, though it is likely to decrease) than to bear the expenses of extensive medical interventions in the near term. Additionally, delaying such costs is beneficial to insurers for several reasons: (i) it aligns the costs more closely with premium inflows, (ii) deferring expensive treatments increases the chance that another insurer will bear these costs if the patient switches providers, and (iii) improved patient health, mobility, and engagement in life, driven by the use of these drugs, is likely to enhance member satisfaction. This is particularly significant in today’s revenue models, where patient satisfaction increasingly impacts revenue, as seen in the enhanced emphasis on the patient experience in the Stars rating system. Expect to see more payers join in as the actuaries tune their models and calculate the net economic value of these amazing medications. #HealthcareInnovation #InsuranceTrends #MedicareUpdates #HealthcareEconomics #PatientCare #MedicalCostManagement #GLP1Therapy #HealthcareForecasting #PatientExperience #FutureOfHealthcare

email to your MPs and MPPs now , #communitypharmacy : Subject: Protect Patient Access: Support Local Pharmacies Dear [MP's Name], I'm reaching out to highlight a pressing issue impacting our healthcare system: the erosion of patient access due to the neglect of local community pharmacies and the escalating crisis resembling US pharmacy deserts. Local pharmacies are essential hubs of care, offering personalized services and fostering trust within our communities. Yet, they're often sidelined in legislative decisions, leaving patients at risk of losing vital healthcare access. Pharmacy Benefit Managers (PBMs) exacerbate this problem by prioritizing profits over patient needs. The US is grappling with pharmacy deserts as countless local pharmacies shutter due to PBM pressures. As our MP, I urge you to prioritize patient access by championing policies that support local pharmacies. Transparency in PBM operations and fair reimbursement practices are crucial steps to prevent our communities from facing similar crises. Thank you for your attention to this urgent matter. Your advocacy for patient-centered healthcare is invaluable. Sincerely, [Your Name] #pharmacists #healthcare #patientcare https://lnkd.in/gcHgwchV

Email your MLA, health minister, premier and MP More great leadership from a frontline pharmacist-owner. Thanks for this excellent letter template that we can all adapt to contact our MLAs, health ministers, premiers and MPs Rami S.! And remember to explain the PPN threat to your patients and encourage them to contact their politicians too. Let’s all do our part. #PhiercePhrontlinePharmacyProfessionals!

The shift to value-based care is accelerating rapidly. According to the Centers for Medicare & Medicaid Services, participation in these models has seen a remarkable 25% increase from 2023 to 2024. Going into 2025, we can expect this growth to continue! At Innovista Health, we're at the forefront of this transformation, and remain dedicated to partnering with health care organizations to deliver high-quality, cost-effective care that's easy to implement, manage, and measure. Want to learn more about the current state of value-based care? Check out this insightful article from Medical Economics: https://bit.ly/4gFrmXD #ValueBasedCare #HealthcareInnovation #Partnerships

House panel passes key PBM reform for sliver of commercial market The House of Representatives is cracking down on PBMs in the first of a series of expected reform bills, which recently passed in committee, but the scope of the new rules is limited. The bipartisan Delinking Revenue from Unfair Gouging (DRUG) Act targets the Federal Employees Health Benefits program, whose 8 million subscribers account for just a fraction of the nearly 160 million Americans who participate in employer-sponsored health plans. Under the legislation, PBMs would be permitted to charge only a flat service fee, ending their practice of tethering fees to the list price of drugs. Critics have said the approach gives PBMs an incentive to place high-cost medications in preferred formulary positions compared with more affordable options. The proposal would also block the middlemen from charging insurers more than they pay pharmacies — a tactic known as spread pricing — and bar them from steering patients to pharmacies that share an affiliation with the PBM. A measure in the Senate, which also has cleared committee, would ban PBMs from linking fees to prices as well; but it does not touch the commercial market — only the Medicare and Medicaid programs. https://buff.ly/3HRB2OH

House panel passes key PBM reform for sliver of commercial market The House of Representatives is cracking down on PBMs in the first of a series of expected reform bills, which recently passed in committee, but the scope of the new rules is limited. The bipartisan Delinking Revenue from Unfair Gouging (DRUG) Act targets the Federal Employees Health Benefits program, whose 8 million subscribers account for just a fraction of the nearly 160 million Americans who participate in employer-sponsored health plans. Under the legislation, PBMs would be permitted to charge only a flat service fee, ending their practice of tethering fees to the list price of drugs. Critics have said the approach gives PBMs an incentive to place high-cost medications in preferred formulary positions compared with more affordable options. The proposal would also block the middlemen from charging insurers more than they pay pharmacies — a tactic known as spread pricing — and bar them from steering patients to pharmacies that share an affiliation with the PBM. A measure in the Senate, which also has cleared committee, would ban PBMs from linking fees to prices as well; but it does not touch the commercial market — only the Medicare and Medicaid programs. https://buff.ly/3HRB2OH

House panel passes key PBM reform for sliver of commercial market The House of Representatives is cracking down on PBMs in the first of a series of expected reform bills, which recently passed in committee, but the scope of the new rules is limited. The bipartisan Delinking Revenue from Unfair Gouging (DRUG) Act targets the Federal Employees Health Benefits program, whose 8 million subscribers account for just a fraction of the nearly 160 million Americans who participate in employer-sponsored health plans. Under the legislation, PBMs would be permitted to charge only a flat service fee, ending their practice of tethering fees to the list price of drugs. Critics have said the approach gives PBMs an incentive to place high-cost medications in preferred formulary positions compared with more affordable options. The proposal would also block the middlemen from charging insurers more than they pay pharmacies — a tactic known as spread pricing — and bar them from steering patients to pharmacies that share an affiliation with the PBM. A measure in the Senate, which also has cleared committee, would ban PBMs from linking fees to prices as well; but it does not touch the commercial market — only the Medicare and Medicaid programs. https://buff.ly/3HRB2OH

Great article that came from the Healthcare Innovations Summit on how to enable and scale value-based care. SonarMD is honored to be recognized in the article as one of the leading examples for specialty #vbc models with commercial payers.   The barriers to value-based care mentioned in this article are real. With five years of commercial payer VBC arrangements, we can attest and have the experience to navigate these challenges. We're glad to see these conversations happening and hope we can continue to push innovation and collaboration in specialty value-based care. https://lnkd.in/eiWuKegG A few key takeaways: - Currently, most value-based programs focus on primary care with limited attribution to or integration with specialists. In limited situations, specialty care has been carved out into episodes of care and bundled payments (e.g., total joint replace­ment), but broader application to more chronic conditions has been limited. - Innovation needs investment. Capital also follows alignment of incentives. It is critical to create functional partnerships so that stakeholders across the health care continu­um will be aligned on goals/outcomes and work together. #SonarMD #healthcare #GIcare #vbc

"Every one of us has a reason why we should want to make the current system better. Tearing down the barriers and re­placing them with innovative and effective alternatives is needed and can be achieved if we continue to talk to and not past each other, as was accomplished at the Aspen Summit and, hopefully, going forward." Excellent article from the Healthcare Innovations Summit on some of the barriers and opportunities to scaling value-based care. We have the battle wounds to show how to design a proper #specialty #vbc model. It's not easy but the outcomes are worth it! #gastroenterology #valuebasedcare #gi #crohnsdisease #ulcerativecolitis #patientoutcomes #healthcareinnovation