Insurance

On this episode of Managed Care Cast, we're talking with Dennis Scanlon, PhD, the editor in chief of The American Journal of Accountable Care®, about prior authorization, price transparency, the impact of health policy on the upcoming election, and more.

CMS released a final rule to help patients obtain Children’s Health Insurance Program (CHIP) coverage and issued a proposed rule to update Medicare payment policies and rates for inpatient rehabilitation facilities; debate over if gift card incentives are acceptable in health care marketing.

The Supreme Court seems likely to reject a challenge to the abortion pill mifepristone; the FDA is inspecting far fewer pharmaceutical companies conducting clinical research; AstraZeneca has sued to block an Arkansas law that it said would unlawfully expand the 340B program to include for profit-pharmacy chains.

On this episode of Managed Care Cast, we're talking with the authors of a study published in the March 2024 issue of The American Journal of Managed Care® about their findings on variations in prior authorization use across Medicare Advantage plans.

A global AIDS program that was in limbo for months got temporary relief after congressional negotiators agreed to a 1-year renewal in the next government funding package; the outcome of the November presidential election could determine the state of fetal tissue research in the US; federal officials and industry executives failed to make improvements that stop hacking attacks.

For more than a decade, certain high-value preventive care services have been covered at no cost to patients under the Affordable Care Act, but a current legal challenge has the coverage at risk.

During a session of the 2024 V-BID Summit, panelists Stacie Dusetzina, PhD, and Inma Hernandez, PharmD, PhD, discussed how access to essential medications is curtailed not just by the longstanding complexities of insurance design but also by emerging threats such as supply chain weaknesses and cyberattacks.

Most private health insurers have yet to publish criteria for when they will cover postpartum depression drug, zuranolone; state lawmakers are increasingly opposing health care mergers that they believe do not serve the public interest; Medicaid extensions made in 2021 led to a 40% decline in postpartum lack of insurance.

President Biden will preview his plan to more than double the size of Medicare’s new drug price negotiation program in the upcoming State of the Union address; Mexicans and Central Americans were most affected by the pandemic in terms of all-cause mortality; two Alabama fertility clinics said they expect to resume in vitro fertilization (IVF) services after a bill was passed to protect doctors.

Prior authorization is a common utilization-management tool among Medicare Advantage plans. However, service-, area-, and carrier-level patterns suggest variation in how plans use prior authorization.

A new federal rule will provide higher Medicare payments for homeless patients, which may encourage hospitals to identify these patients and help them with their needs.

Modeling estimates indicate that annual breast cancer screening starting at age 40 years provides the greatest benefit to women and reduces risk per examination.

Out-of-pocket costs of diabetes medications other than insulin can be quite high for individuals with employer-sponsored health insurance.

Payer costs for COVID-19 ranged from a mean of $505 for asymptomatic cases to $126,094 for severe cases with post–COVID-19 condition.

Among a cohort of insured patients with cancer, the median total monthly cost of oral lenvatinib was $17,253, and 75% of patients paid $100 or less out of pocket per month for the drug.

The Democratic Women’s Caucus is urging insurers to comply with the Affordable Care Act (ACA) contraception requirement to cover birth control without cost sharing.

The House Democratic Women’s Caucus wrote a letter urging insurers to comply with both contraceptive coverage requirements and recent Biden administration guidance; several pharmacy chains are experiencing disruptions following a hack at Change Healthcare, UnitedHealth’s technology unit; the FDA said it is not planning to take a tougher stance against clinical trial reporting requirement noncompliance.

The amount of in-network care claims jumped significantly after surprise billing protections took effect; experts say the US is in the midst of the “fourth wave” of the opioid epidemic; the prevalence of long COVID symptoms 30 and 90 days post infection was 43% to 58% lower among adults who were fully vaccinated before infection.

Carrie Kozlowski, OT, MBA, chief operating officer and cofounder of Upfront Healthcare, explains how the company emphasizes personalized engagement to overcome technological, cultural, and social barriers while Medicaid disenrollment rates are increasing.

Part of the recent Medicare reimbursement cuts could be addressed in a spending package next month; Medicaid/Medicare dual eligibles are expected to generate big profits for health insurers; FDA sent warning letters to online vendors selling unapproved and misbranded versions of semaglutide and tirzepatide.

"I'll say what I don't think the issue is—it's not technology. We can solve this problem with technology," Carrie Kozlowski, OT, MBA, explains in the interview.

On this episode of Managed Care Cast, we're talking with the authors of a study published in the February 2024 issue of The American Journal of Managed Care® about their findings on how health plans can screen for health literacy, social determinants of health, and perceived health care discrimination.

The federal State Health Insurance Assistance Program (SHIP) provides counseling and education on Medicare coverage options. This article highlights potential inequities in in-person SHIP service access.

Over the past 20 years, Medicare physician pay has plummeted by 26% when adjusted for inflation, while hospital reimbursement has surged by 70%, prompting over 100,000 doctors to abandon independent practice for hospital or corporate employment since 2019.

Overcoming insurance hurdles for critical medications; rising heat and wildfires reverse decades of clean air progress; conflicts between parents and schools arise as teens seek mental health support

This study leverages newly available hospital pricing data to explore hospital-insurer contracts from a large hospital chain.

Catch up on this week's news at the Center on Health Equity and Access.

At an Institute for Value-Based Medicine® event held in Phoenix, Arizona, experts from Banner Health and Aetna discussed how health inequities and social determinants of health can affect primary care in patients with any type of insurance.

A provision in the Inflation Reduction Act will implement a $2000 out-of-pocket cap on Medicare beneficiaries’ prescription drug spending, which could save money for more than 1 million enrollees when it takes effect next year.

House Republicans voted to ban quality-adjusted life years (QALYs) from being used as a drug pricing metric in federal health programs; insurance executives disapproved of newly proposed 2025 Medicare Advantage (MA) rates; patients with long COVID enrolled in an online exercise program said their health improved more than people who received standard care.