Valuate Health Consultancy’s Post

Nuggets from day 1 of #Asembia2024! A lot of pulled threads from AMCP Annual, as well as some new learnings to help paint the fuller picture: Key trends to monitor in the CGT and rare disease space: - The booming category of self-insured employers (the TPA/stop-loss market is projected to grow to $800 billion by 2030) - SPs taking on restrictive management tactics (79% of SPs are reported to be using an NDA block) - Increased awareness that patient eligibility is expanding among CGT and rare disease products – rare disease is not so rare anymore - Expect new demand for more holistic care (think clinical management on top of bread-and-butter distribution and access services) to produce greater value that matches these complex patient journeys As far as the IRA goes.. While many aspects of program rollout (namely, drug price negotiation and Part D benefit redesign) remain uncertain, hard data is starting to emerge that provides some certainty to the unintended consequences we’ve been speculating about over the past year: - Most payers are planning to react to higher financial liability through mechanisms like narrower formularies (73%), increase in utilization for specialty products (93%) and negotiating for higher rebate (75%)* - While OOP smoothing via the Medicare Prescription Payment Plan will benefit many Part D beneficiaries, a significant proportion will still be left in the dust – such as the 75% of Medicare beneficiaries that have difficulty paying $2,000 to begin with, and the 77% that do not know about the OOP cap (especially problematic for an opt-in program) - As far as the Part D benefit redesign goes, manufacturers play a key role in raising awareness and proactivity among patients and providers to help drive greater participation *Presented as part of a series of data from Xcenda’s “Managed Care Network Survey,” to be officially unveiled in the coming months. Valuate Health Consultancy

The Congressional Budget Office weighs in on health policy priorities from pharmacy benefit management and Medicare spending to modeling the cost of care with AI. Read the biggest takeaways: https://hubs.la/Q02t40-00 #HealthPolicy #healthcare #pharma

I recently spoke with @Elise Labott at @Washington Post Live’s annual Global Women’s Summit about access and affordability barriers for patients. Elise and I discussed how health care middlemen – like PBMs – decide what drugs are covered and how much patients pay at the pharmacy counter.   Out-of-pocket costs affect every American – PhRMA's Patient Experience Survey found that 57% of all Americans worry about out-of-pocket costs for their care – but they disproportionately impact women. According to a recent study from Deloitte, women in the workforce pay as much as $15.4 billion more a year than men in out-of-pocket health care expenses.   How can we fix these problems for patients? Enacting PBM reform is a start.   PBMs are a powerful influence on our health care system. Just 3 PBMs control 80% of the market. PBMs, not doctors, decide what drugs to cover. Last year, PBMs excluded more than 1,150 medicines from their formularies, restricting patient access to these treatments. Moreover, experts have observed that PBMs have an incentive to prefer drugs with higher list prices. And because in most cases PBMs do not share the savings they negotiate with manufacturers with patients, people pay more out-of-pocket at the pharmacy counter.   Reforms that would drive transparency and more patient-centric decision-making in the U.S. health care system are within reach. We need to address the role of PBMs.   Hear more of our conversation here: https://lnkd.in/gRHs-VmW

We are dedicated to building trust across all stakeholders involved in the Medicaid Drug Rebate Program (MDRP) through the data transparency enabled through our purpose-built, AI-enabled, automated platform. Ultimately, our goal is to ensure that patients can continue to receive the affordable drugs they need and experience better outcomes – but we know that technology alone can’t do it. SriVani Ganti, MSHC, reminds us of that fact in her recent article in Health Data Management. Although Ganti is the chief equity officer of mPulse, a population health, management technology company, she writes that while data-driven practices are essential, healthcare organizations need to also pursue a “whole-person approach that grounds services in humanity and ensures all people receive the care they deserve.” We agree with those sentiments and hope that by improving the efficiency and collaboration around accurate drug discounts, we can enable the focus to remain where it belongs: on the patient. https://lnkd.in/gM5UJ_E7 #340B #MDRP #DrugDiscountMarket #HealthEquity #SDOH

Join our 45 min webinar tomorrow and discuss with us about: How can Digital Pathways Streamline the Workflow in Rheumatology? September 13th from 18:00 -18:45 Register here: https://lnkd.in/eWVmHW4Q Digital Clinical Pathways, are a disease-specific step-by-step movement of patients through the healthcare system (holistically also called the patient journey). These pathways allow monitoring of clinical indicators and digital biomarkers and with the aim of providing better disease control and even predicting future outcomes. When establishing such an end-to-end process, it is essential that clinical and personal needs are addressed in the best possible way. The optimal mix of digital / human ingredients for this process are far from being understood. This is why a collaborative approach involving all stakeholders together (patients, doctors, health care professionals, insurance, tech) is needed to develop these care pathways together. The integration of such digital clinical pathways in the clinical workflow is complex and needs change management. Moderators: Thomas Hügle Philip Hamann PD Dr. Johannes Knitza MHBA Knitza MHBA

Looking ahead to 2024, the healthcare payer sector faces ongoing challenges and opportunities. Payers are grappling with rising costs driven by expensive therapies and health system labor shortages. Leveraging generative AI and digital technology can help optimize processes and reduce administrative and medical costs. Payer executives should consider these factors as they navigate the evolving landscape of healthcare https://lnkd.in/gPkCFJZu

“The U.S. spends 2X as much per person on health as the average of peer nations. A number of studies have concluded that high prices are a major driver of this ‘excess’ spending. A better understanding of where the excess health spending is going can guide strategies to address high spending and shed light on the populations most likely to be affected. We examined published research, grey literature, and OECD data for the U.S. and comparator countries to identify potential components of higher U.S. health spending and, where possible, to estimate the order of magnitude of each component. It’s important to note that while our research was aimed at estimating ‘excess’ spending, we were not able to definitively identify or quantify all components. We estimate that higher admin costs associated with health insurance — for example, those related to eligibility, coding, submission, and rework — represent ~15% of excess U.S. health spending. Higher admin burden on providers — for example, general admin, HR, and quality reporting & accreditation — represents an additional 15% of the excess. This makes administrative complexity the single biggest component of excess U.S. spending estimated in this study. The large impact of administrative costs is consistent with previous research that found 39% of the difference between U.S. and Canadian spending on hospital and physician care was administration. OECD and international survey data show that physicians and RNs in the U.S. are paid significantly more than the average of comparator countries, with physicians earning 2X as much and RNs 1.5X as much. These wages are determined in the context of U.S. labor markets. Nevertheless, we estimate that higher wages for these two key health care occupations explain a combined 15% of excess U.S. health spending relative to other countries. Prescription drugs represent ~10% of excess health spending. This estimate is based on data showing that the U.S. spends 2X as much per person on retail prescription drugs, which may include differences in both utilization and price. U.S. prescription drug prices are 2-3X those in other OECD countries. While the U.S. compares favorably on prices for unbranded generic drugs, U.S. prices are much higher for branded drugs, which account for ~80% of prescription drug expenditures in the U.S. Therefore, we consider this component to primarily represent a price effect. We hypothesized that a potential driver of higher U.S. spending was higher capital costs associated with more frequent construction and modernization of facilities. However, OECD data comparing capital expenditures on health did not show the U.S. spending more for construction costs. Only in the capital investment subcategory of ‘medical machinery and equipment’ did the data show U.S. expenditures were higher than comparator countries, corresponding to a modest impact of <5% of excess U.S. spending”

🔍 Following a proposed class-action lawsuit alleging wrongful denial of coverage, Cigna Healthcare has clarified that its claims review process, known as the Procedure-to-Diagnosis (PxDx) system, does not use #AI or algorithms. 👩⚖️📑 The clarification, released today, comes in the wake of recent media reports that the company believes have inaccurately portrayed how the PxDx system works, leading to potential confusion and misunderstanding.📰🤔 The PxDx system, according to Cigna, matches the codes submitted by physicians with diagnosis codes that are considered medically necessary for a procedure under Cigna's publicly posted clinical coverage policies. It's designed to speed up payments for common, relatively low-cost tests and treatments.🩺💻 Critically, the review process occurs post-treatment, and doesn't deny patient care. And if a claim is denied through PxDx, most patients, especially those treated by in-network providers, do not bear any additional costs.🏥💵 The system is used for around 50 low-cost tests and procedures and the denied claims represent less than 1% of the total volume, with the majority of claims being automatically paid.✔️💼 Importantly, Cigna states that similar processes are used by the Centers for Medicare & Medicaid Services (CMS) and other health insurers, suggesting that the PxDx system is not an outlier in the industry.🔄💡 As we continue to engage with an evolving healthcare landscape, a clear understanding of these systems is crucial to promoting fairness and #transparency. 🎯🌐 #HealthInsurance #HealthTech #ClaimsManagement #PatientCare #transparencymatters #aiinhealthcare

Led by MDIC's Health Economics and Patient Value program, the Commercial Payer Council aims to streamline evidentiary requirements for coverage, expedite #patientaccess, and refine pathways for #coverage, coding, and payment—serving as a neutral platform for collaboration among diverse stakeholders. The Council's inaugural meeting covered pivotal topics like Medicare Advantage and #reimbursement for #digitalhealth technologies. As the healthcare industry continues to evolve, initiatives like the Commercial Payer Council play a vital role in shaping a more efficient, patient-centered #healthcare ecosystem, poised to meet the challenges and opportunities of the future. Learn more about this new MDIC initiative at https://lnkd.in/erMWYQ9V Key Insights from the Q1 meeting can be found at https://lnkd.in/ejRywsYP #healthcarecoverage #healthinsurance #medtech #healthtechnology #medicaldevices #patientsafety #healthequity #obesity #FDAapproval #healtheconomics #patientfirst

It was an honor to lead Medical Device Innovation Consortium (MDIC)'s inaugural quarterly Commercial Payer Council, which highlighted how #healthtech companies can better navigate the commercial payer landscape, specifically Medicare Advantage and #reimbursement for #digitalhealth technologies. If you are with a #medicaldevice or #digitalhealth company in need of guidance on this topic, please read our Key Insights document which summarizes our discussion and provides key considerations. #medicareadvantage #medtech #digitaltherapeutics