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News Brief | January 7, 2025 | VBID to end Dec. 31, 2025
VBID to end Dec. 31, 2025 CMS will terminate the Medicare Advantage Value-Based Insurance Design (VBID) model at the end of 2025. The reason? Its "substantial and unmitigable costs" to the Medicare Trust Funds, totaling $2.3 billion in 2021 and $2.2 billion in 2022. Since its launch in 2017, the VBID model aimed to lower Medicare spending and improve care quality through various interventions. The model offered flexibility for high-value services and cost-sharing assistance for prescription drugs to chronically ill…
News Brief | December 3, 2024 | Embedding pharmacists enhance primary care
Embedding pharmacists enhance primary care Embedding pharmacists in primary care teams boosts access, mitigates physician shortages, and improves outcomes, according to the authors of a Health Affairs Forefront piece. About 69% of visits involve medication, and PCPs spend approximately 37% of their time on activities related to chronic care management, which often includes managing complex medication regimens. Embedded pharmacists save physicians an estimated 640 hours annually while streamlining workflows. They optimize therapies, improve safety, and support high-risk patients (Health Affairs…
News Brief | November 12, 2024 | Lawsuit updates: GoodRx and PBMs sued; Walgreens settles
Lawsuit updates: GoodRx and PBMs sued; Walgreens settles Coupon aggregator GoodRx and PBMs including CVS Caremark and Express Scripts have been hit with at least three class action lawsuits accusing them of working together to suppress reimbursements to small pharmacies for generic prescription drugs. In other news, Walgreens has agreed to pay $100 million to settle a proposed class action lawsuit accusing it of fraudulently overcharging customers for a decade when they bought generic drugs through private insurance, Medicare or…
News Brief | October 8, 2024 | Study: PGx+CMM reduces utilization, saves employers money
Study: PGx+CMM reduces utilization, saves employers money A study in The Pharmacogenomics Journal found that pharmacogenomics-enriched comprehensive medication management (PGx+CMM) can reduce healthcare utilization and offer cost savings for self-insured employers. The 26-month study, using a propensity-matched pre-post design, revealed a 39% reduction in inpatient and emergency department visits and a 21% increase in outpatient visits among program participants compared to a control group. These findings suggest that PGx+CMM may improve employee healthcare outcomes and offer economic benefits, making it…
News Brief | September 10, 2024 | The cheaper choice may improve clinical and equity outcomes
The cheaper choice may improve clinical and equity outcomes The authors of a study that found aspirin as effective at preventing dangerous blood clots as expensive and painful blood thinners are now talking about equity. They point out that choosing aspirin can support health equity and prevent hundreds or thousands of unnecessary hospitalizations and deaths annually. “When given a choice between two drugs that produce practically the same result … many doctors don’t follow the latest evidence and instead turn…
News Brief | August 13, 2024 | BMJ commentary: Give patients access to their records now
BMJ commentary: Give patients access to their records now A July opinion piece in the BMJ makes the argument patients need access to their medical records now. Resistance from doctors and policy makers is strong, however. “Patients know what they want and are saying it loud and clear—we want full interactive access to our medical records,” write the authors, who include the patient editor of the BMJ. “We want clinicians, managers, and policy makers to recognize that the benefits of…
News Brief | July 9, 2024 | NYT does deep dive into PBMs. It’s not pretty
NYT does deep dive into PBMs. It’s not pretty The New York Times has set out to explain how PBMs “prioritize their interests, often at the expense of patients, employers and taxpayers.” PBMs largely escape attention “because they operate in the bowels of the health care system and cloak themselves in such opacity and complexity that many people don’t even realize they exist.” But they are driving up drug costs for millions of people, employers and the government, according to…
News Brief | June 11, 2024 | CMM primer defines and outlines benefits of CMM
CMM primer defines and outlines benefits of CMM Comprehensive medication management supports population health and value-based care performance, and a recent LinkedIn post from the Population Health Alliance spells it out. CMM can improve quality outcomes and reduce costs among the most complex patients. For example, it can produce an estimated ROI of between 3.5:1 and 12:1 for patients with chronic conditions. The post goes on to define CMM and explain how it’s different from medication therapy management. (Population Health…
News Brief | May 14, 2024 | What’s happening with telehealth?
What’s happening with telehealth? Walmart's decision to shutter its health clinics and virtual care services isn’t just a blow to retail health; it has profound implications for telehealth. And it’s happening at a critical time. Optum is shutting down its virtual care unit. Teladoc CEO Jason Gorevic is out, and the company's stock has fallen by more than 40% this year. Amwell and Doximity are also facing challenges. But telehealth executives and investors tell Modern Healthcare there’s still a tremendous opportunity in…
News Brief | April 9, 2024 | Lawsuit: Drugmakers overcharged 340B participants millions
Lawsuit: Drugmakers overcharged 340B participants millions According to a recently unsealed lawsuit from Adventist Health, some of the world’s largest pharmaceutical companies that participate in the 340B drug discount program overcharged the federal government and numerous hospitals by hundreds of millions of dollars. Among those named: AbbVie, AstraZeneca, Novartis and Sanofi. The case highlights issues with the pharmaceutical pricing system, including non-compliance with regulations and the potential exploitation of government payors, as well as concerns about the 340B program's management…
News Brief | March 12, 2024 | SOTU address promises cap on OOP drug costs
SOTU address promises cap on OOP drug cost President Joe Biden’s State of the Union Address Thursday included some sweeping proposals, including extending a $2,000 cap on out-of-pocket drug costs to all Americans. Other proposals included expanding the number of drugs that can be negotiated by Medicare, capping the cost of insulin at $35 a month for all patients, and launching a $12 billion women's healthcare initiative. (Modern Healthcare) Practice Transformation “All of Us” releases trove of genetic data The…
News Brief | February 13, 2024 | Employee sues J&J over PBM costs
Employee sues J&J over PBM costs A Johnson & Johnson employee is suing the company for allegedly violating ERISA by mismanaging prescription drug benefits. The lawsuit accuses the company of paying inflated costs for generic drugs to its PBM, Cigna’s Express Scripts, resulting in higher costs for employees. One example: a generic MS drug costing over $10,000 for a 90-day prescription through the plan. At retail pharmacies, it’s available for around $40. The J&J suit is just the more recent…
News Brief | January 9, 2024 | GTMRx releases latest CMM evidence document
GTMRx releases latest CMM evidence document The Get the Medications Right Institute has released its summary of research on comprehensive medication management (CMM). The December 2023 review, “The Outcomes of Implementing and Integrating Comprehensive Medication Management in Team-Based Care: A Review of the Evidence on Quality, Access and Costs,” highlights the best of the studies demonstrating the value of CMM in achieving all five aspects of the Quintuple Aim. It features 21 studies, three of which are from 2023: a…
News Brief | December 12, 2023 | Unions and employers agree on one thing: PBMs
Unions and employers agree on one thing: PBMs Employers and unions are getting fed up with PBMs, arguing that they favor costly over less expensive options, the Wall Street Journal reports. For example, Foot Locker dropped UnitedHealth Group’s OptumRx PBM last year, while a Teamsters fund in Philadelphia recently reupped with its replacement for CVS Health’s Caremark. The employers and unions say they likely get stuck with higher costs because PBMs can pocket some of the bigger rebates negotiated with drugmakers. But…
News Brief | November 10, 2023 | GTMRx Institute joins business and health leaders to call for PBM reform
GTMRx Institute joins business and health leaders to call for PBM reform On November 8 the GTMRx Institute joined a coalition of employers, health care providers and patient advocates in urging Congress to support strong PBM reforms this year. In a letter to Senate leadership, the coalition outlines several needed reforms, including commonsense changes to hold PBMs accountable to fair market practices when partnering with employers, the largest customers of PBMs. “PBM transparency alone is NOT enough, but it is…
News Brief | October 10, 2023 | Some states establish Rx affordability boards
Some states establish Rx affordability boards At least seven states have set up prescription-drug affordability boards to lower costs for a potentially broader set of prescription medicines, and more states could follow as some officials have expressed interest in establishing similar programs. Some of the boards have much more leeway than Medicare in selecting drugs for cost reviews. In several states, including Colorado and Maryland, the boards have the authority to set upper payment limits for drugs. Yet unlike the…
News Brief | September 12, 2023 | AI-based “credit score” for drug use draws criticism
AI based "credit score" for drugs draws criticism Narx Scores and similar tools help clinicians review controlled substance prescriptions. They influence the prescribing of painkillers much like a credit score influences the terms of a loan. The use of systems to analyze opioid-prescribing data has sparked questions over whether they have undergone enough independent testing. This prescription-drug data has led patients to be dismissed from clinician practices, which could leave patients at risk of being untreated or undertreated for pain,…
News Brief | August 08, 2023 | Investigation: PBMs divert patient assistance funds
Investigation: PBMs divert patient assistance funds A local Ohio TV station conducted an in-depth investigation into how PBMs stand between patients and funds from pharmaceutical companies to help pay for medication. They report on how pharmacy benefit managers and their partners have diverted billions in drugmakers’ assistance intended for individual patients. Instead, they use the cash to set up their own health insurance programs for major employers – typically giving themselves a 25% share of the savings, public documents show.…
News Brief | July 11, 2023 | Bipartisan efforts seek to rein in PBMs
Bipartisan efforts seek to rein in PBMs Congress continues to focus on PBMs, crafting several legislative packages that include reforms to make the role of pharmacy benefit managers in drug pricing more transparent and overhaul how PBMs are compensated, and curb potentially anticompetitive behavior. Among the specifics: requiring PBMs to report their negotiations, pricing information, and benefit designs; banning spread pricing (where PBMs reimburse pharmacies less than what they charge payers; Other proposals would ensure PBMs pass on rebates to…
News Brief | June 13, 2023 | PBM bill advances
PBM bill advances Pharmacy benefit managers would be required to report more information on their deals with pharmaceutical companies under legislation unanimously approved by a House committee last month. PBMs would need to create reports for employer clients each year that detail prescription drug spending, acquisition costs, out-of-pocket expenses, formulary placement and rebates. In addition, the Government Accountability Office would produce a report on group health plan pharmacy networks, including those that health insurers own. (Modern Healthcare) SCOTUS revives whistleblower suits Last…
