About pharma
Walgreens, Kroger sue drugmakers, allege $2.8B in overcharges for diabetes med: “According to the lawsuit, Assertio and Santarus entered into a pay-to-delay deal with Lupin in 2012 to ensure the generic drugmaker wouldn't release a cheaper version of the diabetes drug [Glumetza] until 2016.
The deal allegedly allowed the brand-name drugmakers to hike prices, leading to $2.8 billion in overcharges.”
U.S. considers easing drug protection to break deadlock over trade pact: Wall Street Journal:”The Trump administration is considering scaling back intellectual-property protections [from 12 to 10 years] for biologic drugs… to help win Democratic support for a new trade pact with Mexico and Canada…”
Astellas dives into gene therapy with $3-billion deal to buy Audentes Therapeutics: Another multibillion dollar transaction, as large pharma companies seek to add gene therapies to their portfolios. Other recent activity includes Novartis' $8.7-billion purchase of AveXis and Roche’s ongoing effort to complete its $4.3-billion acquisition of Spark Therapeutics.
About health insurance
Affordable Care Act open enrollment figures jump in Week 4: Early in the enrollment preriod signups were lagging behind last year. Now with “less than two weeks to enroll, both the number of new and renewing consumers increased this year over last.”
Trends in Peritoneal Dialysis [PD] Use in the United States after Medicare Payment Reform: Show me how someone is paid and I will tell you how they behave:
“In 2011, the Centers for Medicare and Medicaid Services (CMS) implemented the ESKD [End Stage Kidney Disease] prospective payment system (PPS), which altered payment for dialysis treatment by bundling dialysis, medications, and ancillary services into a single payment, adjusted for patient- and facility-level characteristics . The PPS also provided a training add-on for home dialysis. Because PD has historically been associated with lower costs than HD [hemodialysis], dialysis facility revenues under the PPS were expected to increase by $330 per month for PD and decrease by $117 per month for in-center HD. Thus, it was anticipated that the PPS would increase supply and use of PD across the country…In the initial years after Medicare payment reform, late PD use increased significantly, as more patients initiated dialysis with PD and more patients switched from HD to PD. Our results suggest that Medicare’s PPS for dialysis may be achieving one of its intended goals in the initial years of payment reform implementation.”
OIG expects to recover $5.9B in fraud investigations, doubling last year's haul: “The Office of Inspector General (OIG) recovered $5.9 billion from fraud investigations during fiscal year 2019, according to a semiannual report (PDF) to Congress released Monday.” When was the last time you heard of private insurers being bilked for that kind of money?
ACOs saved Medicare $755M from 2013 to 2017, new analysis finds: “The analysis found that net federal savings for the Medicare Shared Savings Program (MSSP), which oversees the 518 ACOs in the program, was $755 million from 2013 to 2017.” The savings were not evenly spread across organizations.
No Itch to Switch: Few Medicare Beneficiaries Switch Plans During the Open Enrollment Period: “Overall, a small share of MA-PD [Medicare Advantage- Prescription Drug Plans] and PDP [Free-standing Prescription Drug Plans] enrollees without low-income subsidies (8% and 10%, respectively) voluntarily switched to another plan during the 2016 annual open enrollment period for the 2017 plan year... more than one in three (35%) Medicare beneficiaries living in the community said it is very or somewhat difficult to compare Medicare options, and this share increased among beneficiaries in fair or poor self-reported health (44%) and with five or more chronic conditions (40%). In 2017, nearly half (45%) of people on Medicare living in the community said they rarely or never review or compare their Medicare options; the share was substantially higher among beneficiaries ages 85 and older (57%).” Since prices and out of pocket provisions can change substantially from year to year, there needs to be a way to reach to to seniors to help them make correct decisions. The online tools are there, they just need to be able to use them.
Reconciliation limitations led CMS to overpay hospitals $500M: “Hospitals were overpaid by roughly $502 million from 2011 to 2014, according to a report from the Office of Inspector General (OIG), which blamed the overpayment on CMS limitations on the reconciliation period.
Sixty hospitals were paid $502 million more in net outlier payments than they were owed, the report found…
According to OIG, the payment errors were not found by CMS because they didn’t meet the reconciliation requirements of a 10% threshold of cost reports. Hospitals charged higher prices than the rate of cost increases below the 10% threshold, which meant their cost-to-charge ratio (CCR) didn’t trigger reconciliation. CMS set this threshold because the agency believed it would capture the outlier payments that were substantially inaccurate.”