Trump Scorns His Own Scientists Over Virus Data

September 17, 2020

President Trump on Wednesday rejected the professional scientific conclusions of his own government about the prospects for a widely available coronavirus vaccine and the effectiveness of masks in curbing the spread of the virus as the death toll in the United States from the disease neared 200,000.

In a remarkable display even for him, Mr. Trump publicly slapped down Dr. Robert R. Redfield, the director of the Centers for Disease Control and Prevention, as the president promised that a vaccine could be available in weeks and go “immediately” to the general public while diminishing the usefulness of masks despite evidence to the contrary.

President Trump on Wednesday rejected the professional scientific conclusions of his own government about the prospects for a widely available coronavirus vaccine and the effectiveness of masks in curbing the spread of the virus as the death toll in the United States from the disease neared 200,000.

In a remarkable display even for him, Mr. Trump publicly slapped down Dr. Robert R. Redfield, the director of the Centers for Disease Control and Prevention, as the president promised that a vaccine could be available in weeks and go “immediately” to the general public while diminishing the usefulness of masks despite evidence to the contrary.

The president’s comments put him at odds with the C.D.C., the world’s premier public health agency, over the course of a pandemic that he keeps insisting is “rounding the corner” to an end. Mr. Trump lashed out just hours after Dr. Redfield told a Senate committee that a vaccine would not be widely available until the middle of next year and that masks were so vital in fighting the disease caused by the coronavirus, Covid-19, that they may even more important than a vaccine….

Read the full The New York Times article

As Payer M&A Slows Down, What’s Next?

September 17, 2020

The climate for payer mergers and acquisitions (M&A) has cooled substantially at a national level ever since the collapse of the proposed deals between Anthem, Inc. and Cigna Corp. and between Aetna Inc. and Humana Inc. However, consolidation in the provider sector has increased since the start of the COVID-19 pandemic as such firms grapple with the rapid collapse of fee-for-service revenue.

The breakdown of Anthem’s bid to acquire Cigna resulted in a public spat and dueling lawsuits over Cigna’s attempt to exit their agreement before exhausting the firms’ option to appeal a federal ruling against the transaction. On Aug. 31, the Delaware Court of Chancery ruled that neither firm had to pay damages to the other over the failed deal.

By Peter Johnson

The climate for payer mergers and acquisitions (M&A) has cooled substantially at a national level ever since the collapse of the proposed deals between Anthem, Inc. and Cigna Corp. and between Aetna Inc. and Humana Inc. However, consolidation in the provider sector has increased since the start of the COVID-19 pandemic as such firms grapple with the rapid collapse of fee-for-service revenue.

The breakdown of Anthem’s bid to acquire Cigna resulted in a public spat and dueling lawsuits over Cigna’s attempt to exit their agreement before exhausting the firms’ option to appeal a federal ruling against the transaction. On Aug. 31, the Delaware Court of Chancery ruled that neither firm had to pay damages to the other over the failed deal.

This failed deal was a catalyst for the slowing pace of health insurance consolidation at the national scale, according to antitrust lawyer and former Federal Trade Commission official David Balto.

Ashraf Shehata, KPMG national sector leader for health care and life sciences, says that Cigna’s acquisition of Express Scripts, a transaction that the firm pursued partly because of the failed Anthem merger, set a precedent of its own.

“I would say what that has spawned instead of the health plan integration, it’s spawned…the PBM integration. Rather than health plan to health plan, it was health plan plus PBM. And we saw that across the board with all the commercial entities,” he says.

Shehata says he sees three likely types of payer transactions and reorganizations going forward. The first is the PBM-payer integration. Second, Shehata says that horizontal coordination between regional payers, if not outright mergers, is likely to accelerate. Finally, he’s tracking the emerging model of “health plan plus retail plus PBM.”

Michael Abrams, co-founder and managing partner of consultancy Numerof & Associates, says that large regional hospital systems with healthy balance sheets are likely to speed up their vertical acquisition of independent hospitals or horizontal consolidation with local peers.

Abrams also points out that this wave of consolidation will compound or accelerate the rising cost of health care. He adds this continual rise in prices will eventually drain the generous margins that payers have enjoyed over the course of the pandemic.

Lilly’s Covid-19 Antibody Helps Some Patients Rid Their Systems of Virus Sooner in Early Analysis

September 16, 2020

Adrug being developed by Eli Lilly helped sick patients rid their systems of the virus that causes Covid-19 sooner and may have prevented them from landing in the hospital, according to newly released data.

The drug is what is known as a monoclonal antibody, which experts view as being among the most likely technologies to help treat Covid-19. It’s a manufactured version of the antibodies that the body uses as part of its response to a virus.

Adrug being developed by Eli Lilly helped sick patients rid their systems of the virus that causes Covid-19 sooner and may have prevented them from landing in the hospital, according to newly released data.

The drug is what is known as a monoclonal antibody, which experts view as being among the most likely technologies to help treat Covid-19. It’s a manufactured version of the antibodies that the body uses as part of its response to a virus.

“This is a good start,” said Eric Topol, the director and founder of the Scripps Research Translational Institute. “A lot is pinned not only on Lilly but on the whole family of these [monoclonal antibodies], because even though they’re expensive and they’re not going to make a gajillion doses, they could make a big difference in the whole landscape of the pandemic….”

Read the full Stat article

Federal Officials Unveil Plan to Provide Free Coronavirus Vaccine

September 16, 2020

The Trump administration on Wednesday outlined a strategy to deliver safe and effective COVID-19 vaccine doses to the American people as quickly as possible, for free.

In a report to Congress and a separate “playbook” for states, the Department of Health and Human Services, in conjunction with the Department of Defense and the Centers for Disease Control and Prevention (CDC) laid out detailed vaccination distribution plans for states, tribal, territorial and local public health programs.

The Trump administration on Wednesday outlined a strategy to deliver safe and effective COVID-19 vaccine doses to the American people as quickly as possible, for free.

In a report to Congress and a separate “playbook” for states, the Department of Health and Human Services, in conjunction with the Department of Defense and the Centers for Disease Control and Prevention (CDC) laid out detailed vaccination distribution plans for states, tribal, territorial and local public health programs.

The playbook warned that states have never needed a pandemic response plan that is this complex….

Read the full The Hill article

Datapoint: Centene Plots Major 2021 Exchange Expansion

September 16, 2020

Centene Corp. last week said it will expand its Affordable Care Act exchange products to two new states (Michigan and New Mexico) and 400 new counties in its existing markets for the 2021 plan year. Centene is currently the largest exchange insurer in the U.S., with 2,187,894 members across 13 states. Nationally, Centene enrolls 19.1% of all exchange lives.

Centene Corp. last week said it will expand its Affordable Care Act exchange products to two new states (Michigan and New Mexico) and 400 new counties in its existing markets for the 2021 plan year. Centene is currently the largest exchange insurer in the U.S., with 2,187,894 members across 13 states. Nationally, Centene enrolls 19.1% of all exchange lives.

Source: AIS’s Directory of Health Plans

Prime Therapeutics Introduces Real Time Benefit Tool

September 16, 2020

With the deadline approaching for Medicare Part D plans to implement a Real Time Benefit Tool (RTBT) — which informs prescribers when lower-cost alternative therapies are available under a beneficiary’s drug benefit — Prime Therapeutics, LLC said on Sept. 2 that it is rolling out a tool that will meet the new requirements.

In addition to showing a drug’s price, the Real Time Benefit Check tool displays lower-cost and therapeutically equivalent alternatives to any given drug, breaks down costs based on a member’s health plan formulary, and alerts a prescriber if a drug requires prior authorization.

By Leslie Small

With the deadline approaching for Medicare Part D plans to implement a Real Time Benefit Tool (RTBT) — which informs prescribers when lower-cost alternative therapies are available under a beneficiary’s drug benefit — Prime Therapeutics, LLC said on Sept. 2 that it is rolling out a tool that will meet the new requirements.

In addition to showing a drug’s price, the Real Time Benefit Check tool displays lower-cost and therapeutically equivalent alternatives to any given drug, breaks down costs based on a member’s health plan formulary, and alerts a prescriber if a drug requires prior authorization.

To develop its new tool, Prime conducted a 14-month pilot with multiple vendors, including DrFirst, which created the myBenefitCheck tool that the PBM decided to release first.

After processing 700,000 transactions among 25,000 prescribers, Prime calculated an average annual savings of $692 for each prescription that was changed as a result of using the tool. One Blues plan involved in the pilot “realized a total estimated savings due to alternate drug choices of $348,000 from April 2019 to March 2020,” stated a news release from the PBM.

Prime’s new Real Time Benefit Check tool will fulfill its obligations under the Medicare Advantage and Part D Drug Pricing Final Rule, which was issued in May 2019 and requires each Part D health plan to adopt one or more RTBTs that can integrate with at least one prescriber’s ePrescribing system or electronic health record system starting Jan. 1, 2021. In addition to Prime’s Part D members, the Real Time Benefit Check tool will also be available to the PBM’s commercial members.

Matt Kazan, a principal at Avalere Health, says that initially the new RTBT requirement was slated to go into effect in 2020, but CMS pushed back the deadline one year in response to some industry stakeholders’ concerns over readiness.

“Generally speaking, larger organizations had a system in place…and CMS is allowing them to utilize that,” says Kazan. “I think more of the concern was from maybe smaller, midsized organizations that didn’t have their own system ready to go.”

However, “time has lapsed since that final rule, so I’ve heard less about major concerns about the upcoming deadline,” he adds.

Datapoint: Anthem, Ascension to Launch Wisconsin Exchange Plans

September 15, 2020

Anthem, Inc. last week said it will launch co-branded health plans with Ascension Wisconsin on the Affordable Care Act exchanges for the 2021 plan year. Members will have in-network access to Ascension Wisconsin’s “24 hospital campuses, 110 care locations, and more than 1,300 physicians,” according to a press release. The plans will be offered in six southeast Wisconsin counties. Anthem does not have an ACA market presence in Wisconsin, where 179,731 are currently enrolled in exchange plans.

Anthem, Inc. last week said it will launch co-branded health plans with Ascension Wisconsin on the Affordable Care Act exchanges for the 2021 plan year. Members will have in-network access to Ascension Wisconsin’s “24 hospital campuses, 110 care locations, and more than 1,300 physicians,” according to a press release. The plans will be offered in six southeast Wisconsin counties. Anthem does not have an ACA market presence in Wisconsin, where 179,731 are currently enrolled in exchange plans.

Source: AIS’s Directory of Health Plans

CMS Might Punt on Approving Georgia’s Revised Waiver Request

September 15, 2020

Georgia recently reaffirmed its proposal to make dramatic changes in its individual market, saying it plans to abandon the Affordable Care Act (ACA) marketplace in favor of a new state program despite the widespread disruptions in health care and health insurance brought by the coronavirus pandemic.

In its revised Section 1332 waiver request to CMS, Georgia said it wanted to push back the start date for part of its plan, meaning the proposal’s two parts wouldn’t take effect until 2022.

By Jane Anderson

Georgia recently reaffirmed its proposal to make dramatic changes in its individual market, saying it plans to abandon the Affordable Care Act (ACA) marketplace in favor of a new state program despite the widespread disruptions in health care and health insurance brought by the coronavirus pandemic.

In its revised Section 1332 waiver request to CMS, Georgia said it wanted to push back the start date for part of its plan, meaning the proposal’s two parts wouldn’t take effect until 2022.

The first part of the proposal, a reinsurance program, would help insurers pay high-cost claims with the goal of lowering premiums. According to Georgia’s calculations, the reinsurance program would reduce premiums for the individual market statewide by 10.2% and as a result would increase enrollment by 0.4% in 2022.

More controversially, the “Georgia Access Model” would make more drastic changes to the individual market, including directing consumers to buy coverage through private broker or insurer websites, rather than via HealthCare.gov.

Tara Straw, senior policy analyst at the left-leaning Center on Budget and Policy Priorities, warned in a Sept. 1 report that “evidence from past, far simpler transitions between federal and state marketplaces suggests that tens of thousands of Georgians might lose coverage simply because of the disruption from the state’s transition away from HealthCare.gov.”

The proposal also would “give insurers and brokers new opportunities to steer healthier consumers toward substandard plans that expose them to catastrophic costs if they get sick,” Straw wrote. “The resulting adverse selection could make comprehensive coverage more expensive for those who need it, reducing their enrollment as well.”

However, Joseph Antos, the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the right-leaning American Enterprise Institute, says that it’s not clear whether CMS will move to approve Georgia’s revised proposal, or will wait to consider it until after the election. He thinks a long wait is more likely.

“It raises a political question in my mind: ‘Do you have CMS approve this thing?’ And then get into another court battle with the headline being, ‘Trump administration approves taking away good coverage for low-income people in Georgia,’” Antos says. “This doesn’t have the feel of a sure approval.”

Datapoint: Cigna to Expand Exchange Presence for 2021

September 14, 2020

Cigna Corp. last week said it will expand its Affordable Care Act exchange offerings to 80 new counties in 2021. The company in a press release said this represents a 27% growth in customer reach. Cigna said most of its 2021 offerings will offer no-cost virtual care, including behavioral health. Cigna currently holds the 11th-largest exchange market in the U.S., with 217,300 members across 10 states.

Cigna Corp. last week said it will expand its Affordable Care Act exchange offerings to 80 new counties in 2021. The company in a press release said this represents a 27% growth in customer reach. Cigna said most of its 2021 offerings will offer no-cost virtual care, including behavioral health. Cigna currently holds the 11th-largest exchange market in the U.S., with 217,300 members across 10 states.

Source: AIS’s Directory of Health Plans

Trump’s International Drug Pricing Order Is Still Missing; Rebate Order Draws Fire

September 14, 2020

A promised executive order that would tie drug prices to their costs in other countries has yet to emerge, although President Donald Trump has promoted the order as part of his re-election campaign. Meanwhile, payers and PBMs are continuing to push back against three executive orders the Trump administration issued in July with the intention of lowering drug prices, one of which would overhaul the Medicare Part D prescription drug rebate system.

“I think the purpose of these executive orders is to give the president some talking points going into the debates,” says Avalere Health founder Dan Mendelson. He adds that, regardless of their purpose, the orders will not make a difference in the real world any time soon.

By Peter Johnson

A promised executive order that would tie drug prices to their costs in other countries has yet to emerge, although President Donald Trump has promoted the order as part of his re-election campaign. Meanwhile, payers and PBMs are continuing to push back against three executive orders the Trump administration issued in July with the intention of lowering drug prices, one of which would overhaul the Medicare Part D prescription drug rebate system.

“I think the purpose of these executive orders is to give the president some talking points going into the debates,” says Avalere Health founder Dan Mendelson. He adds that, regardless of their purpose, the orders will not make a difference in the real world any time soon.

Administration officials indicated during the rollout of the executive orders on July 24 that the international pricing order would be released within 30 days of the debut of the other three drug pricing orders. Yet the deadline passed and the administration at press time had not released the promised order.

Meanwhile, the executive orders that actually have been released are being criticized from stakeholders across health care. The order that would remove safe harbor protections from the Anti-Kickback Statute for prescription drug rebates in Medicare Part D has been panned even by conservatives.

Alex Brill, a resident fellow at the American Enterprise Institute (AEI), penned a white paper sponsored by PBM trade group Pharmaceutical Care Management Association (PCMA) that concluded the executive order would “restrict an important tool for providing savings to the federal government and Medicare Part D beneficiaries. Moreover, net drug costs and drug company revenues would rise significantly if the Medicare Part D safe harbor for rebates is eliminated.”

Mendelson says that the pharmaceutical industry is beginning to realize that it will have to change its business model one way or another.

“The pharmaceutical industry is facing a real pivot point where there are going to have to be more innovative ways to price for these products,” Mendelson observes. “…it’s really important that the industry start to figure out ways to engage positively with payers. And the government is the biggest payer.”