About health insurance/insurers/cost
States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model Read this announcement from CMS. Too many moving parts to summarize. Some news media say it is an all-payer system, but hospitals would be on global budgets. No mention is made of patients being assigned to providers/systems; which creates a financial incentive to hand off more intense cases to others. One of the program’s goals is to enhance primary care; but the details of how that will happen when choices in medical school will not be affected.
Health Benefit Cost Expected to Rise 5.4% in 2024, Mercer Survey Finds “According to the survey, even after taking into account changes US-based employers made to healthcare plans that are designed to slow cost growth, employers expect total health benefit cost per employee to rise 5.4% on average in 2024.
The estimate suggests that last year’s high inflation and labor shortages in the healthcare industry have pushed healthcare costs higher, contributing to higher health benefit costs. The projected increase comes after more than a decade of annual cost increases typically averaging 3 to 4%. Over 1,700 employers responded to the survey when the preliminary results were analyzed in August.”
Humana sues feds over Medicare Advantage risk adjustment changes “Humana has filed suit against the feds, saying the Biden administration's bid to claw back overpayments in Medicare Advantage (MA) is built on "shifting justifications and erroneous legal reasoning."
Earlier this year, the Centers for Medicare & Medicaid Services (CMS) finalized a hotly anticipated rule that would overhaul risk adjustment data validation (RADV) audits, which determine whether MA plans were overpaid. In a win for insurers, the agency elected not to backdate these audits beyond 2018.”
States ranked by percentage of employers offering health insurance “Hawaii has the highest rate of private employers that offer health insurance to their employees, while Montana has the lowest, according to 2022 data published by KFF and sourced from the Agency for Healthcare Research and Quality.”
The national average is 48.3 percent.
Medicare Switching: Patterns Of Enrollment Growth In Medicare Advantage, 2006–22 “We found that switching from fee-for-service Medicare to MA more than tripled between 2006 and 2022, whereas switching from MA to fee-for-service Medicare decreased, with the change rates accelerating since 2019. The share of switchers among all new MA enrollees rose from 61 percent in 2011 to 80 percent in 2022. Black, dual-eligible, and disabled beneficiaries had higher odds of switching in both directions, whereas younger and healthier beneficiaries had higher odds of switching from fee-for-service Medicare to MA but lower odds of switching from MA to fee-for-service Medicare. Two-thirds of annual switching between MA and fee-for-service Medicare in 2022 occurred in January, likely reflecting the open enrollment period.”
Health Care Service Price Comparison Suggests That Employers Lack Leverage To Negotiate Lower Prices “We compared prices for common services in self-insured plans with those in fully insured plans. Using the Health Care Cost Institute’s data set of claims for one-third of the US population with employer-sponsored insurance, we found that unadjusted prices were higher in self-insured plans for most of the services we studied, with the largest differences found for endoscopies (approximately 8 percent higher in self-insured plans), colonoscopies (approximately 7 percent), laboratory tests (approximately 5 percent), and moderate-severity emergency department visits (4 percent). When patient characteristics, plan type, and geography were adjusted for, differences were generally smaller but were consistent with these findings. Higher prices in self-insured plans suggest that there may be opportunities for employers to lower prices and for policy makers to act where employers have limited leverage to negotiate with providers.”
MA Beneficiaries With Cancer Spend Less on Healthcare Than Traditional Medicare Beneficiaries “Medicare Advantage beneficiaries with a cancer diagnosis spend $3,996 on out-of-pocket costs and premiums annually, versus $6,091 for traditional Medicare beneficiaries with cancer, a new report found.”
Wide Variation In Differences In Resource Use Seen Across Conditions Between Medicare Advantage, Traditional Medicare “Total resource use in MA was generally lower than in traditional Medicare but by varying amounts across conditions, and it was not significantly different from traditional Medicare for some conditions. This variation was explained by resource use for hospital inpatient services in MA relative to traditional Medicare. Resource use for treatments was considerably lower in MA than in traditional Medicare across all conditions, whereas resource use for imaging and testing was consistently higher in MA for all conditions.”
About hospitals and healthcare systems
Utilization, Steering, and Spending in Vertical Relationships Between Physicians and Health Systems “Findings In this case-control study involving 4 030 224 observations, PCP–health system vertical relationships were associated with increased total specialist visits and total spending per patient-year as well as specialist visits, emergency visits, and hospitalizations within the health system. There was no change in readmission rates or use of hospitals with low readmission rates.
Meaning Findings of this study suggest that the vertical relationships between PCPs and large health systems were associated with steering patients into health systems and increased spending on patient care.”
Comment: Yet another finding about increase costs of health system consolidation.
About pharma
The 10 highest value R&D projects in biopharma “The top 10 most valuable projects have a net present value of $79.1 billion, with a combined potential product revenue of $19.4 billion worldwide by 2028. The estimated cost of developing a drug—even if it never makes it to market—is on the rise, according to a report by Deloitte covering 2022. Drugmakers spent an estimated $2.2 billion last year, a $298 million rise over 2021. Meanwhile, forecast peak sales per pipeline asset declined from $500 million in 2021 to $389 million in 2022.”
The article also provides a list of the top ten.
California pharmacists make 5 million mistakes every year: Report “Pharmacists are overworked and understaffed, according to the California Board of Pharmacy, and it may be what is leading them to make up to 5 million errors each year, the Los Angeles Times reported Sept. 5.
Ninety-one percent of pharmacists surveyed in California working in chain settings like Walgreens, Rite Aid or CVS stores told the state's Board of Pharmacy in a 2021 survey that staffing at their place of employment is not adequate for providing patients proper care.”
Cross-Sectional Analysis of Out-of-Pocket Payments forCommonly Prescribed Generic Medications Versus DiscountCard Pricing “Out-of-pocket payments made by patients exceededAmazon and GoodRx prices for about 20% and 43% of the prescrip-tions included in this analysis, respectively. Out-of-pocket payments exceeded Amazon and GoodRx prices for 40% and 79% of the pre-scriptions assumed to be in the deductible phase, respectively. Theestimated cumulative OOP cost savings, assuming patients obtainedtheir medications using Amazon and GoodRx discount cards,amount to approximately $969 million and $1.83 billion (Table 2),respectively. Most of the cumulative OOP savings were generatedfrom 90-day prescriptions (Table 2)…
Of note, most prescriptions where OOP payments exceededdiscount card pricing were during the deductible phase.”
Comment: This situation can be a “Catch-22.” The discount site purchases can be cheaper in the deductible phase of pharma benefits, but insurers may not recognize these payments as counting toward the deductible. This situation leads to the conclusion that for frequently used, expensive drugs, it may be cheapest in the long run to use the drug benefit.
Walgreens to pay $44M to Theranos blood test customers “Walgreens Boots Alliance has agreed to a $44 million settlement to resolve class-action claims related to its partnership with Theranos, according to Bloomberg.
The proposed settlement is still in need of court approval.”
FDA Reviewers Say OTC Decongestant Doesn't Work “When weighed by that standard, ‘we have now come to the initial conclusion that orally administered PE [phenylephrine] is not effective as a nasal decongestant at the monographed dosage (10 mg of PE hydrochloride every 4 hours) as well as at doses up to 40 mg (dosed every 4 hours),’ the FDA documents noted.
The agency is weighing whether to scuttle the indications for phenylephrine hydrochloride and phenylephrine bitartrate due to lack of efficacy.
‘However, we are concerned about avoiding potential unintended consequences,’ the reviewers added. ‘We anticipate that any action taken by the Agency in this regard will have significant downstream effects, including effects on both industry and consumers, because the only other oral decongestant listed in the CCABA [Cold, Cough, Allergy, Bronchodilator, and Antiasthmatic Drug Products for OTC Human Use] Monograph is pseudoephedrine, which is now regulated as a 'behind-the-counter' product under the Combat Methamphetamine Epidemic Act of 2005.’”
Kroger shares rise on 2Q earnings beat as investors brush of $1.4B opioid charge “The company said the settlement, with payments scheduled over the next 11 years, won’t affect its ability to complete its proposed merger with US grocery rival Albertsons Companies Inc and it still expects to meet debt targets that were set out as part of the merger agreement.
Kroger said it agreed to pay up to $1.2 billion to states and subdivisions and $36 million to Native American tribes in funding for abatement efforts, and approximately $177 million to cover attorneys' fees and costs.”
About the public’s health
Defining Usual Oral Temperature Ranges in Outpatients Using an Unsupervised Learning Algorithm
“ In this cross-sectional study, machine learning was applied to 618 306 adult outpatient encounters to define the usual or mean “normal” temperature as 36.64 °C. Using individual and temporal characteristics, the range of mean temperatures for the coolest to the warmest individuals was 36.24 °C to 36.89 °C.
These findings suggest that age, sex, height, weight, and time of day are factors that contribute to variations in individualized normal temperature ranges.”
Note: 37°C is 98.6°F.
Global trends in incidence, death, burden and risk factors of early-onset cancer from 1990 to 2019 “Results Global incidence of early-onset cancer increased by 79.1% and the number of early-onset cancer deaths increased by 27.7% between 1990 and 2019. Early-onset breast, tracheal, bronchus and lung, stomach and colorectal cancers showed the highest mortality and DALYs in 2019. Globally, the incidence rates of early-onset nasopharyngeal and prostate cancer showed the fastest increasing trend, whereas early-onset liver cancer showed the sharpest decrease. Early-onset colorectal cancers had high DALYs within the top five ranking for both men and women. High-middle and middle Sociodemographic Index (SDI) regions had the highest burden of early-onset cancer. The morbidity of early-onset cancer increased with the SDI, and the mortality rate decreased considerably when SDI increased from 0.7 to 1. The projections indicated that the global number of incidence and deaths of early-onset cancer would increase by 31% and 21% in 2030, respectively. Dietary risk factors (diet high in red meat, low in fruits, high in sodium and low in milk, etc), alcohol consumption and tobacco use are the main risk factors underlying early-onset cancers.
Conclusion Early-onset cancer morbidity continues to increase worldwide with notable variances in mortality and DALYs between areas, countries, sex and cancer types. Encouraging a healthy lifestyle could reduce early-onset cancer disease burden.”
Racial Disparities in Obesity‐Related Cardiovascular Mortality in the United States: Temporal Trends From 1999 to 2020 “Absolute, crude, and age‐adjusted mortality rates (AAMRs) were calculated by racial group, considering temporal trends and variation by sex, age, and residence (urban versus rural). Analysis of 281 135 obesity‐related cardiovascular deaths demonstrated a 3‐fold increase in AAMRs from 1999 to 2020 (2.2‐6.6 per 100 000 population). Black individuals had the highest AAMRs. American Indian or Alaska Native individuals had the greatest temporal increase in AAMRs (+415%). Ischemic heart disease was the most common primary cause of death. The second most common cause of death was hypertensive disease, which was most common in the Black racial group (31%). Among Black individuals, women had higher AAMRs than men; across all other racial groups, men had a greater proportion of obesity‐related cardiovascular mortality cases and higher AAMRs. Black individuals had greater AAMRs in urban compared with rural settings; the reverse was observed for all other races.”
Ten-Year Follow-up of 9-Valent Human Papillomavirus Vaccine: Immunogenicity, Effectiveness, and Safety “The 9vHPV vaccine demonstrated sustained immunogenicity and effectiveness through ∼10 years post 3 doses of 9vHPV vaccination of boys and girls aged 9 to 15 years.”
U.S.-funded hunt for rare viruses halted amid risk concerns “The Biden administration has halted funding for a research program that sought to discover and catalogue thousands of exotic pathogens from around the world, officials confirmed Thursday, effectively ending a controversial virus-hunting endeavor that opponents say raised the risk of an accidental outbreak.
The U.S. Agency for International Development quietly notified the program’s main contractor in July that the $125 million project was being terminated less than two years after its inception, amid opposition from lawmakers as well as a number of prominent scientists and public health experts.
A USAID spokesman said the funding was halted following a reevaluation of the ‘relative risks and impact’ of various government-backed efforts to prevent future pandemics.”
About healthcare personnel
Biden administration proposes minimum staffing standards for nursing homes “The Centers for Medicare & Medicaid Services (CMS) has made good on President Joe Biden’s word during the 2022 State of the Union with new proposed staffing requirements for nursing homes.The proposed rule, issued Friday, includes for the first time national minimum nurse staffing standards that have been broadly opposed by the long-term care industry.
It would require nursing homes participating in Medicare and Medicaid to provide a minimum of 0.55 hours of care from a registered nurse per resident per day, as well as 2.45 hours of care from a nurse aid per resident per day—a bottom floor that CMS estimates three quarters of nursing homes would need to increase hiring to achieve. Facilities would also be required to have at least one registered nurse onsite at all times.”
The shrinking number of primary-care physicians is reaching a tipping point “The percentage of U.S. doctors in adult primary care has been declining for years and is now about 25 percent — a tipping point beyond which many Americans won’t be able to find a family doctor at all.
Already, more than 100 million Americans don’t have usual access to primary care, a number that has nearly doubled since 2014. The fact that so many of us no longer regularly see a familiar doctor we trust is likely one reason our coronavirus vaccination rates were low compared with those in other countries.
Another telling statistic: In 1980, 62 percent of doctor’s visits for adults over 65 were for primary care and 38 percent were for specialists, according to Michael L. Barnett, a health systems researcher and primary-care doctor in the Harvard Medical School system. By 2013, that ratio had exactly flipped and has likely ‘only gotten worse,’ he said…”
About healthcare finance
Healthcare Dealmakers—Oregon's $6.6B hospital merger; Syntellis' $1.3B sale and more FYI