Wednesday, October 30, 2013

Insurers, PBMs Take Varied Approaches to Addressing Specialty Drug Copay Coupons

Reprinted from DRUG BENEFIT NEWS, biweekly news and proven cost management strategies for health plans, PBMs, pharma companies and employers. By Angela Maas, Managing Editor October 25, 2013Volume 14Issue 20 Many health plans and PBMs agree that copay coupons offered by makers of traditional brand-name drugs thwart formulary compliance, and have attempted to combat their use through tactics such as enlarging copay differentials and applying utilization management. But when it comes to coupons and discount programs associated with high-cost specialty drugs, payers are taking a more selective approach, as these programs may improve medication compliance by offsetting a patient’s financial responsibility. UnitedHealth Group’s UnitedHealthcare unit, for one, has launched a widely publicized initiative limiting the coupons, while PBMs like Prime Therapeutics LLC and MedImpact Healthcare Systems, Inc. subsidiary ScriptSave suggest there are ways to embrace them. Whereas the issue around traditional coupons is “rather simple,” addressing specialty drug coupons is “very nuanced,” observes Pat Gleason, director of health outcomes at Prime Therapeutics LLC. “With the small molecule drugs…we feel that coupons simply circumvent the formulary, leading to the use of more branded products when there are equally effective, safe generics that are very inexpensive, and just add cost to the system,” he tells DBN. But the specialty realm presents medication compliance and therapy abandonment concerns that are closely tied to cost share, which is often higher for specialty drugs, even preferred agents, he says. “I understand the philosophy of ‘there’s more skin in the game’ [with higher cost share]. But then you’ve got the corollary issue of, as you get above $150 a month, people may choose to abandon therapy and that’s not what we want,” says Gleason. “We want to help people get the medicine they need to feel better and live well.” As a result, Prime currently allows the use of coupons and patient assistance programs (PAPs) for both preferred and nonpreferred specialty agents, and recently quantified members’ cost savings associated with those discount programs with new research presented at the Academy of Managed Care Pharmacy’s (AMCP) Nexus 2013 conference held Oct. 15-18 in San Antonio. To determine the impact of discount programs, Prime looked at prescriptions filled between January and June 2013 for 17 different specialty drug categories by its own Prime Therapeutics Specialty Pharmacy. That entity created a file for each prescription that contained detailed information on the pharmaceutical manufacturer coupon or PAP amount reimbursed to offset share. The file was then linked back to the PBM claim records to identify pharmacy only claims that were final paid claims. Of the nearly $418 million spent on drugs during the study period, Prime determined that members were responsible for 5.2% — or close to $22 million — of total costs. Coupons and/or PAPs were associated with 47,924 (38.2%) of 125,303 prescriptions and totaled more than $10.6 million (48.6%) of the member share offset. In other words, coupons and PAPs were applied to four out of 10 prescriptions going through the Prime Therapeutics Specialty Pharmacy. Moreover, the cost share for 40% of claims prior to the use of coupons/PAPs was $50 or less, whereas with the coupons, individuals’ cost share dropped below $50 fully 95.6% of the time. “That’s a pretty dramatic shift,” says Gleason. The autoimmune category had the most specialty pharmacy prescriptions and accounted for $153.6 million total paid; the members’ share was $10.5 million (6.8%), of which nearly $8 million (73.4%) was offset by coupons/PAPs. Gleason adds that while the study included PAPs, about 90% of the discounts applied were from coupons. The difference between the two, he explains, is that coupons are directly administered by the pharmaceutical manufacturer, while PAPs are usually administered by a nonprofit third party, sometimes sponsored by a manufacturer but not always, and typically require that the patient have an income below a certain level. Prime Optimizes Use of Specialty Coupons In conducting the study, the PBM was “just trying to get an understanding of what’s happening with specialty coupons in order to build better benefit designs,” explains Gleason. As of now, the PBM is “optimizing” all coupons, applying them to both preferred and nonpreferred formulary agents. “We’re reaching out to the members to encourage them to use the preferred specialty products, but we’re not blocking coupons for the nonpreferred specialty products,” Gleason tells DBN. Also presenting at the AMCP conference was UnitedHealth Group’s UnitedHealthcare unit, which this year began disallowing coupons for six drugs going through its network specialty pharmacies (DBN 12/7/12, p. 1). Effective Jan. 1, the insurer’s network specialty pharmacies stopped accepting coupon cards when a member calls to fill a prescription for one of six drugs: Extavia (interferon beta-1b) and Gilenya (fingolimod) for multiple sclerosis, CellCept (mycophenolate mofetil) for patients receiving transplants, Humira (adalimumab) for rheumatoid arthritis, and Victrelis (boceprevir) and Peg-Intron (peginterferon alfa-2b) for hepatitis C. The action does not impact needs-based assistance programs. Speaking at AMCP and at the Magellan Pharmacy Solutions 10th Annual Oncology Summit held Sept. 19 in Baltimore, Vice President of Pharmacy Management Strategies Lida Etemad, Pharm.D., said the key to a successful implementation was a “high-touch member support campaign” that included letters sent to members 45 days before the new program took effect. If members called the specialty pharmacy to refill one of the included drugs, they were rerouted to a call center, where staffers explained the program. United also gave members the opportunity to have specialty pharmacies reach out to physician offices. An early program analysis revealed the following: • The largest member base was for people taking Humira and CellCept. • “Just under 3,000 members had contact with the specialty pharmacies,” said Etemad. • During contact with the specialty pharmacies, 21% of those members “indicated they would like the specialty pharmacies to do outreach to the physician’s office, while 79% declined outreach.” • Of those turning down the outreach offer, 3% said it was because they had “prior use of a lower-cost alternative,” but the majority said it was because “cost was not a concern.” • One-third of members who authorized outreach and 23% who spoke with their physician on their own switched to a lower-cost alternative. • Overall, said Etemad, “43% of members had an interest in a lower-cost alternative.” Perhaps not surprisingly, “as members’ total pharmacy costs went up, so did the switch rate,” explained Etemad. If members were taking “five or more medications, they were more likely to switch.” Likewise, “the cost share that the member would now face” also had a big impact. For those with a copay of $50 to $60, the switch rate was “just over 10%,” but for those with 25% coinsurance, the switch rate was more than 40%. United will add 25 specialty drugs to the program on Jan. 1, according to Etemad. Therapeutic categories include growth hormone, which will see Genotropin (somatropin [rDNA origin]) added to the list, as well as hepatitis B, hepatitis C, infertility and others. “Regarding other products, we do allow for the adjudication of coupons for products that are lower cost alternatives to the products included in the program,” Etemad clarifies in an email to DBN. While the Prime study concluded that specialty pharmacies should consider optimizing the use of coupons and PAPs in an effort to improve drug adherence, that doesn’t mean Prime won’t consider blocking the use of certain specialty drug coupons in the future. “I think [the United effort] is very interesting. We learned from that program and may very well be doing something similar in the near future,” says Gleason. “But at this point in time, we’re optimizing all coupons.” Plans, Pharma Could Align to Offer Cards Meanwhile, another PBM executive suggests that health plans take a targeted approach when it comes to allowing or disallowing the use of coupons. “I think the knee-jerk response and managed care plans’ frustration is, ‘Oh, you’re screwing up my formulary.’ But I think those cards can be used in a more directed and strategic fashion than today’s shotgun scatter approach,” says Marcus Sredzinski, Pharm.D., executive vice president of pharmacy with the “consumer-focused” PBM ScriptSave, now a wholly owned subsidiary of MedImpact Healthcare Systems, Inc. Sredzinski says he believes there are yet unexplored ways for pharmaceutical manufacturers and plans to work together to “reward” members with discount cards. For example, for specialty conditions like hepatitis C or multiple sclerosis, a plan could “work with the pharmaceutical company [offering] the copay card — maybe even [on] a preferred product in the class — get a patient on board with the product, waive the first copay with the copay card and then track the patient through time,” Sredzinski tells DBN. “So to incent compliance we’ll say, ‘We’ll reduce the cost of the drug at the point of sale through a copay card, so if you pick up the drug on time or you hit a certain biomarker, you get rewarded through a copay waiver or a buy-down in your copay.’” Sredzinski adds that something similar could be done with diabetes patients who show improved A1C levels over time. “I don’t think the marketplace has looked at copay cards in that fashion and it’s something I would like to do,” he says. “Could it upset the formulary balance? Sure, but why not align yourself with [the cards] and work in a different fashion? I think the pharmaceutical companies obviously have the money; in their copay cards they’ve underwritten net value in their marketing budget.”

Today's Datapoint

52% … of Medicare Advantage enrollees are in plans earning four stars or more in 2014, up from 38% in 2013, according to CMS.

Quote of the Day

“By the end of November, will work smoothly for the vast majority of users….The site is fixable. It will take a lot of work. A lot of problems need to be addressed. But let me be clear: is fixable.” — Jeffrey D. Zients, President Obama’s troubleshooter on the project to fix, told The New York Times for an article on Oct. 26.

Thursday, October 24, 2013

Senior's Misconceptions About Medicare and Exchanges

According to a national survey from Express Scripts, of those age 65 and older, one-in-five seniors mistakenly thinks they can enroll in a medical and prescription drug plan through a health insurance exchange, even though the eligibility age ends at 65. Another 17 percent believe health exchanges could replace their Medicare plan altogether. Eighty-six percent of survey respondents reported confusion about how healthcare reform will affect their Medicare prescription drug coverage. Among the notable misconceptions: -Nearly one-third of seniors (29 percent) believe the ACA raises the Medicare eligibility age, with 68 being the average age cited; -52 percent falsely believe they're paying more for their prescription drugs in the Coverage Gap under healthcare reform; and -65 percent do not know that Medicare enrollment begins in October. Source: Express Scripts

Employer Healthcare Coverage and Healthcare Costs

Based on early responses from a survey conducted annually by Mercer, employers expect health benefit cost per employee will rise by 4.8% on average in 2014. Cost growth slowed to 4.1% in 2012, a 15-year low. The projected increase for 2014, while still relatively low, represents a slight uptick in the rate of growth. Some employers will minimize the number of newly eligible employees by cutting back on hours for at least a portion of their workforce - 11% of all large employers say they will do so. Few large employers - just 5% - say it's likely they will terminate their health plans within the next five years, even though public insurance exchanges will provide another source of health coverage. About a fifth of employers with fewer than 200 employees say it's likely they will terminate their plans; employers of this size are much less likely to offer coverage to begin with. Source: Mercer

3.3 Million Expected to Spend $7,202 in Out-of-Pocket Medical Costs in 2016 Under the ACA

According to a RAND Corporation study, Out-of-pocket medical expenses will decline for most consumers who become newly insured or change their source of health insurance under the federal Affordable Care Act. The largest reduction in out-of-pocket spending will be for the 11.5 million consumers who become newly insured under an expanded Medicaid program, with the analysis predicting their annual out-of-pocket medical costs will fall from $1,463 to $34. The largest increase in overall health costs is expected to be among people who become newly insured on the individual market and have incomes more than four times the federal poverty level. An estimated 3.3 million consumers are expected to spend $7,202 in 2016 under the Affordable Care Act, compared to $5,368 if the law was not in place. Some low-income people in states that do not expand Medicaid could see higher health spending compared what would happen if Medicaid was expanded. For example, a Texas resident with an income below the federal poverty level who does not qualify for Medicaid will face costs of $1,831 per year, compared to $28 if they were covered by Medicaid. Nationally, the 11.5 million people who become newly insured by Medicaid will see their risk of spending at least 10 percent of their income on medical costs drop from 45 percent to 5 percent. Source: RAND Corporation

Savings Needed for Medigap Premiums, Medicare Part B Premiums, Medicare Part D Premiums and Out-of-Pocket Drug Expenses for Retirement at Age 65 in 2011-2013

By Percent Chance of Having Enough Savings with Median Prescription Drug Expenses Throughout Retirement Men 2011 2012 2013 50% $71,000 $70,00 $65,000 75% 107,000 105,000 96,000 90% 136,000 135,000 122,000 Women 50% 95,000 93,000 86,000 75% 124,000 122,000 111,000 90% 156,000 154,000 139,000 Married Couple 50% 166,000 163,000 151,000 75% 231,000 227,000 207,000 90% 287,000 283,000 255,000 Source: Employee Benefit Research Institute

Emergency Department Visits by Persons Aged 65 and Over

In 2009-2010, a total of 19.6 million emergency department (ED) visits in the United States were made by persons aged 65 and over. The visit rate for this age group was 511 per 1,000 persons and increased with age. The percentage of ED visits made by nursing home residents, patients arriving by ambulance, and patients admitted to the hospital increased with age. Twenty-nine percent of ED visits by persons aged 65 and over were related to injury, and the percentage was higher among those aged 85 and over than among those aged 65-74 or 75-84. The percentage of ED visits caused by falls increased with age. Source: CDC/National Center for Health Statistics

Prevalence of Obesity, by Age Group, Among Adults Aged 20 and Over

United States, 2011-2012 Ages Obesity Rate 20-39 30.30% 40-59 39.50% 60+ 35.40% All Adults, 20 and Over 34.90% Source: CDC/NCHS

Risk of Developing Breast Cancer in the Next 10 Years

Starting Age Percent Incedence Age 30 .44% 1 in 227 Age 40 1.47% 1 in 68 Age 50 2.38% 1 in 42 Age 60 3.56% 1 in 28 Age 70 3.82% 1 in 26 Publication Source: Managed Care, September 2013 Data Source:

Employer-Reported Understanding of Specialty Pharmacy Benefits

Very Little 4% Average 37% Above Average 49% High 10% Source: Managed Care, September 2013

House Committees Return to the Capitol with More of the Same

The House Energy and Commerce Committee and House Committee on Ways and Means recently released the first in a series of discussion papers identifying what they believe to be key flaw in the existing traditional Medicare framework and detailing their own concepts for reforming the Medicare program. The discussion paper reviewed Medicare cost-sharing, the effects of supplemental insurance, or Medigap plans, and ways in which “modernizing” cost sharing in traditional Medicare would reduce overall Medicare costs. The discussion paper proposes establishing a single combined annual deductible for Medicare Part A and Part B, changing current coinsurance rates and adding an out-of-pocket spending maximum. According to the House Committees, beneficiaries who purchase supplemental insurance plans, or Medigaps, in order to protect themselves against Medicare’s cost sharing requirements have an “incentive” to see the doctor more often because their out-of-pocket costs are covered by the Medigap plan, giving them so-called “first-dollar” health coverage. According to the House Committees, these beneficiaries over-utilize services, thus increasing costs in the Medicare program overall. However, eliminating first-dollar Medigap coverage shifts costs to Medicare beneficiaries who purchase Medigap insurance as a means of protecting themselves against high out-of-pocket expenses. Further, the other components of the plan that would “simplify” Medicare could also shift costs to people with Medicare as laid out in the discussion paper. Proposals like those mentioned above, as well as others like raising the eligibility age, increasing premiums for wealthy individuals, and increasing cost sharing on Medicare supplemental plans, save money in Medicare by shifting costs to older adults and people with disabilities. These proposals fail to address the real threat to our nation’s economic health—rising costs throughout the health care system. In contrast, Medicare Rights Center supports solutions that eliminate wasteful spending and promote the delivery of high value care, thus increasing quality while saving money in Medicare.

Medicare Continues Its Slow Growth in Spending

In a recent article, Peter Orszag, the former director of the Office of Management and Budget under President Obama, discusses the continued slow growth in Medicare spending. Medicare spending per beneficiary has gone from 7.1 percent a year from 2000 to 2005 to 3.8 percent from 2007 to 2010. Over the past year total Medicare spending increased by only 3 percent. Many wonder whether the decline in spending is due to the economic downturn or other causes—the implication being that the decrease in spending will reverse once the economy improves or may continue the decline if attributed to other factors. Mr. Orszag writes that the current economic recession has had “almost no effect” on Medicare spending. He says this is because Medicare beneficiaries have relatively small out-of-pocket costs, and their income is steady since it mostly comes from Social Security, which does not decrease due to a weak economy. However, according to a technical paper by researchers at the Congressional Budget Office (CBO), the slow growth in Medicare spending may be attributed to changes in the delivery of health care. The rate of hospital admissions per beneficiary has decreased, and more palliative care is occurring in hospices instead of hospitals, which are more expensive. The CBO suggests that these trends are due to a “heightened public focus on cost containment.” Many providers expect, in the future, for payments to be based more on the quality of their services rather than the quantity. According to Mr. Orszag, these expectations are having a significant impact. How far can providers go to reduce costs without negatively impacting quality of care? According to a paper from Harvard University and Dartmouth College examining why Medicare spending is so different from region to region, the researchers found that the different ways doctors practice medicine, as opposed to patient demand, appears to explain the regional variation in Medicare spending. Through survey data, the paper found a significant correlation between the way doctors would treat hypothetical patients and the actual spending patterns across regions. According to the paper, if doctors who offer care beyond the medical guidelines were to instead follow the suggested guidelines, Medicare spending would decrease by 17 percent. Presumably, regions with higher Medicare spending would see a spending decrease.

Panel Discusses Transitions to Medicare for People with Insurance Provided through the ACA

Earlier this week, Medicare Rights joined colleagues from the Center for Medicare Advocacy, Inc. and the National Senior Citizens Law Center for a panel at the annual Home and Community Based Services Conference on the transition to Medicare for people who will gain new health care coverage through the Affordable Care Act (ACA)—including from the Health Insurance Marketplace to Medicare and from expanded Medicaid to Medicare. Panelists reviewed beneficiary and policy considerations pertaining to the following transitions: • Individual Qualified Health Plan (QHP) à Medicare • Small Business Options Program (SHOP) plan à Medicare • Expanded Medicaid à Medicare • Expanded Medicaid à Medicare/Medicaid • Expanded Medicaid à Medicare + Medicare Savings Program (MSP) + Extra Help People newly eligible for Medicare transitioning from the Health Insurance Marketplace, both QHP and SHOP plans, must consider several factors to avoid gaps in health coverage and avoid late enrollment premium penalties. Among these factors is ensuring timely enrollment in Medicare and timely disenrollment from the Health Insurance Marketplace alongside assessing eligibility for low-income assistance programs, including Medicare Savings Programs (MSPs) and Extra Help. The federal government must ensure that beneficiaries are adequately educated about when and how to enroll in Medicare as well as about critical coordination of benefits rules. For those transitioning from expanded Medicaid to Medicare, transitions are made more complicated by misaligned eligibility criteria for expanded Medicaid and traditional Medicaid. Based on income and asset tests, some may remain eligible for full Medicaid, others may be eligible for other types of cost sharing assistance, including MSPs and Extra Help, and some may only be eligible for Medicare. It is critical that federal and state governments actively enforce policies to automatically screen newly eligible Medicare beneficiaries for the health care assistance programs for which they might be eligible, and newly eligible Medicare beneficiaries must be vigilant about applying for these programs. Poorly managed transitions from new ACA coverage options to Medicare may result in gaps in health coverage and significantly increased health care costs for newly eligible beneficiaries. Anticipating potential challenges for beneficiaries will help to lessen the likelihood of these burdens.

The Facts about the Affordable Care Act and Medicare

This week, US News & World Report published an article on the myths and facts of how the Affordable Care Act (ACA) affects Medicare beneficiaries. According to the article, older adults are often confused about how Medicare works and ACA changes are compounding some of that confusion. The article summarizes five myths about the ACA and Medicare and provides the facts on how the ACA impacts Medicare beneficiaries, both now and going forward. “Medicare is ending.” False. The ACA is not replacing Medicare, and Medicare has grown stronger as a result of the ACA. In fact, the ACA adds eight years to the solvency of Medicare’s Part A Trust Fund, increasing the years of the program’s guaranteed benefits to 2026, 10 years longer than before the ACA. “Seniors on Medicare must buy more health insurance to comply with the ACA.” False. Seniors and people with disabilities will not be required to purchase more health insurance coverage to comply with the ACA. Further, Medicare beneficiaries will not need to purchase health insurance in the new marketplaces. “Medicare beneficiaries will pay more for their medications under [the ACA].” False. While the Part D premium will increase slightly for Medicare beneficiaries with higher incomes (individuals with annual incomes over $85,000 or couples with annual incomes over $170,000), the majority of Medicare beneficiaries have already started paying less for their prescriptions. Over time, the ACA closes the prescription drug coverage gap, or doughnut hole, and according to a recent CMS press release, more than 6 million seniors had saved over $7 billion on prescription drugs at the end of June 2013. “Medicare beneficiaries won’t be able to see their current doctors.” False. Nothing in the ACA expressly changes the doctors that Medicare beneficiaries can see. “Medicare premiums are rising.” False. The ACA has not attributed to the rise in Medicare premiums. In fact, Medicare costs are rising more slowly as a result of provisions in the ACA. Also, according to the most recent Medicare Trustees’ Report, the Medicare Part B premium will remain relatively unchanged between 2013 and 2014, and Medicare Advantage plan premiums as well as Part D premiums are also stable year-to-year generally.

What Seniors Need to Know about Scams Related to New Health Insurance Marketplaces

Medicare Rights Center President Joe Baker was quoted in a recent Reuters article on seniors and marketing fraud. With the launch of the Health Insurance Marketplaces on October 1, Medicare beneficiaries are at increased risk of identity theft related to scams targeting seniors with Medicare. According to the Reuters article, consumer protection advocates worry that scammers will falsely tell seniors that they need to renew their Medicare coverage or sign up in the new Marketplaces in order to get them to divulge critical personal information on application forms. Advocates have also received reports of fake websites purporting to offer Affordable Care Act (ACA) insurance policies, also known as Qualified Health Plans. "Many seniors already think the worst about the law, so they're ready for some of these false pitches," said Mr. Baker in the article. "[The scammers] will tell you Obamacare means you need to change your Medicare, or that you need to re-apply for Medicare—or that if you don't buy a new kind of insurance you're going to get fined or go to jail." Mr. Baker adds, "If anyone tells you that you have to do that, they're lying.” Seniors are also having to distinguish between two different enrollment periods and marketing messages—one for the Health Insurance Marketplaces, which began enrollment on October 1, and another for Medicare’s Fall Open Enrollment, which runs from October 15 to December 7. According to the Reuters article, the challenge for seniors will be sorting out scams from the massive, legitimate outreach now under way to promote the new law. Mr. Baker and other advocates have a simple message for seniors—you don't have to make any changes in your Medicare coverage because of the ACA. Anyone who is already on Medicare has no need to use the Health Insurance Marketplaces; in fact, it is illegal for insurers to sell a Marketplace policy to anyone on Medicare.

As the Marketplaces Open, Things Stay the Same for People with Medicare

This week, millions of people without health insurance were finally able to shop for affordable health coverage thanks to the Affordable Care Act (ACA). On October 1, the U.S. Department of Health and Human Services (HHS) launched the Health Insurance Marketplaces, a new way for people without insurance to purchase coverage for themselves and their families without being denied or charged more because they have a pre-existing condition. People may enroll in insurance plans from the Marketplaces until March 31, 2014. Coverage starts as early as January 1, 2014 for individuals who enroll by December 15, 2013. States have the option to either set up their own Marketplace or allow the federal government to set up a Marketplace in their state. For example, New York has chosen to set up its own Marketplace, called NY State of Health, which is managed by the New York State Department of Health (NYSDOH). On the NY State of Health website, individuals, families and small businesses can shop for affordable insurance coverage, as well as check their eligibility and sign up for programs like Medicaid. The Health Insurance Marketplaces created by the ACA are only for people who do not already have insurance. The Marketplaces are not for people with Medicare. People with Medicare should not enroll in the insurance plans offered in the Marketplaces. In addition, Medicare Advantage plans, Medigap supplemental policies and stand-alone Part D plans will not be sold through the Marketplaces. People with Medicare will be able to make changes to their coverage during the Medicare Fall Open Enrollment Period, which runs from October 15 to December 7 of each year. Making changes to Medicare coverage is no different than last year—simply go to or call 1-800-Medicare.

Report Shows That Few People Switch Part D Plans, Despite Potentially Lower Costs

Relatively few people on Medicare use the Fall Open Enrollment Period to switch Part D prescription drug plans (PDP), according to a recent issue brief published by the Kaiser Family Foundation (KFF). Using information between 2006 and 2010, KFF found that 87 percent of people enrolled in Part D did not switch plans, even though people who did switch were often able to reduce their out-of-pocket drug costs. According to the KFF issue brief, of the Medicare beneficiaries who switched prescription drug plans at some point between 2006 and 2010, nearly half (46 percent) saw their premiums fall by at least five percent the following year. In contrast, only eight percent of beneficiaries who did not switch plans saw their premiums fall by at least five percent. Additionally, most beneficiaries who did not switch plans between 2006 and 2010 faced large premium increases (of at least $10 per month) from one year to the next. The KFF analysis shows that many Medicare beneficiaries could lower their Part D premiums by comparing their plan options during the Fall Open Enrollment Period. Although the reasons why more beneficiaries don’t switch PDPs is unclear, qualitative evidence from various polls and focus groups supports the notion that that the current Part D landscape is too complicated and offers too many choices. According to KFF, policymakers may want to consider ways to simplify beneficiaries’ decision-making, including providing better tools to support beneficiaries during the decision-making process.

People with Medicare Should Review Their Health and Drug Coverage Options Carefully

Medicare’s Fall Open Enrollment Period is October 15 through December 7, and the Medicare Rights Center urges everyone with Medicare who is enrolled in a private health or drug plan to use the Fall Open Enrollment Period to review their choices. Because plans make changes to their benefit packages every year, even people who are currently happy with their plan should review their coverage. Those enrolled in Original Medicare can also decide at this time to switch to a private plan, or choose a new stand-alone drug plan. During the Fall Open Enrollment Period, Medicare beneficiaries have the right to make as many changes as they need, and the last change they make on or before December 7 will go into effect on January 1, 2014. “Medicare beneficiaries need to be aware of any changes to their current plan and carefully review all of their options in time to make a decision by December 7,” said Joe Baker, President of the Medicare Rights Center. “While reviewing your options, it is important that you contact the plan to confirm any information you find. Once you have made your decision, you can enroll in the plan by calling 1-800-MEDICARE.” The Medicare Rights Center urges people to consider the following questions before enrolling in a Medicare Advantage or stand-alone prescription drug plan: • Will I be able to use my doctors? Are they in the plan’s network and are they taking new patients who have this plan? • Which specialists, hospitals, home health agencies and skilled nursing facilities are in the plan’s network? • Who can I choose as my Primary Care Physician (PCP)? • How much is my monthly premium? • Do I need a referral to see a specialist? • Are my prescription drugs on the plan’s formulary (list of covered drugs)? • Does the plan require that I get “prior authorization” before my prescription will be covered, or impose other restrictions (like limiting the quantity or requiring that I try a cheaper medication before it will cover a more expensive one)? • How much will I have to pay out of pocket before coverage starts (what is the deductible)? • How much will I pay for brand-name drugs? How much for generic drugs? • What service area does the plan cover? • What kind of coverage do I have if I travel outside of the service area? Use the Medicare Plan Finder tool at or call 800-MEDICARE to review your options and get details. Medicare Rights recommends that beneficiaries call the plan to confirm the information they find, and keep a record of the conversation with the plan representative. Medicare Rights also recommends enrolling in a plan by calling 800-MEDICARE rather than the plan itself. State Health Insurance Assistance Programs (SHIPs) also provide free counseling services. To find your local SHIP, go to or call 800-677-1116.

Medicare and the Health Insurance Marketplace

Medicare Rights Center President Joe Baker recently contributed to a blog post for the New York Times, Q & A: Medicare and the Insurance Exchanges. The post featured questions about the online health insurance exchanges (also known as marketplaces) created by the Affordable Care Act (ACA), and how it works with Medicare. According to the blog post, here are some shopping tips for people with Medicare and caregivers: • The health insurance exchanges are for people without health insurance, and are not for Medicare beneficiaries. • Medicare supplemental insurance plans, or Medigaps, will not be sold in the health insurance exchanges. • Beneficiaries who have Medicare Part A and Medicare Part B meet the ACA’s requirement that most adults have health insurance in 2014. • It is illegal for anyone to sell health insurance exchange policies to Medicare beneficiaries. However, people who are eligible for Medicare, and may have to pay for Medicare Part A, may be able to purchase a policy in the health insurance exchange. However, these people may be subject to a penalty should they decide to enroll in Medicare later. • People with Medicare do not need to re-enroll or get new Medicare cards as a result of the ACA. • Seniors shouldn’t ignore the exchanges; instead, they should talk about the health insurance exchanges with their family members who don’t have health insurance.

Medicare at the Center of Recent Budget Proposals

The Kaiser Family Foundation (KFF) recently updated an issue brief comparing Medicare cost-savings proposals in the budget plans provided by President Obama, the Senate and the House. In 2012 and 2013, Medicare had the lowest rate of growth in spending since 2000. Over the next 10 years, Medicare spending is projected to grow at a slower rate per capita than private insurance. Still, there is ongoing talk to reduce Medicare spending, including by shifting added costs to people with Medicare. In the issue brief, KFF looks at the most recent budget proposals and breaks down how each would address reductions in Medicare spending. The proposals include: • Raising in the age of Medicare eligibility; • Reforming private plan payment, including premium support and competitive bidding; • Increasing Part B and Part D premiums; and • Increase Medicare cost sharing for beneficiaries. In response to proposals that seek Medicare by shifting costs to beneficiaries, the Medicare Rights Center outlined several proposals to save costs, without worsening the economic and health status of people with Medicare. “Build on What Works: Medicare Cost Savers,” outlines solutions that eliminate wasteful spending and promote the delivery of high value care. The cost savers outlined in Medicare Rights’ latest fact sheet do not increase costs or decrease benefits for the 50 million older adults and people with disabilities who rely on Medicare. These cost savers include: • Restoring drug rebates for low-income Medicare beneficiaries; • Introducing a public Medicare drug benefit; • Maximizing the use of generic prescription drugs; • Creating a public Medicare supplement; • Eliminating wasteful overpayments to Medicare Advantage plans; • Expanding the competitive bidding program; and • Advancing innovative delivery and payment system reforms.

2013 Employer Health Benefits Survey

Annual premiums for employer-sponsored family health coverage reached $16,351 this year, up 4 percent from last year, with workers on average paying $4,565 towards the cost of their coverage, according to the Kaiser Family Foundation/Health Research & Educational Trust (HRET) 2013 Employer Health Benefits Survey. Source: Kaiser Foundation

Wednesday, October 23, 2013


According to a recent survey, 85% of responding physicians monitor online reviews about themselves, and 36% look at their competitors’ reviews. Source: "ZocDoc Releases Results of its First Annual Digital Doctor Survey, Benchmarking Technology Trends in Healthcare," ZocDoc Press Release, October 10, 2013,

Monday, October 21, 2013

Today's Datapoint

837 … out of a possible 1,000 points were earned by brick-and-mortar pharmacies in a recent customer satisfaction survey by J.D. Power and Associates, up 23 points from 814 in 2012. Customer satisfaction with mail-order pharmacies increased as well (from 792 to 797), but the gap between brick-and-mortar and mail-order pharmacies has widened.

Quote of the Day

The 42 outlier prescribers identified in a recent CVS Caremark study “are basically writing prescriptions illegally…like what you see on the television show 'Justified' where a doctor is set up in a trailer in rural Kentucky.” — Pat Gleason, director of health outcomes at Prime Therapeutics LLC, told AIS’s Drug Benefit News.

Wednesday, October 16, 2013


According to recent estimates from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS): • Health spending growth is projected to be 6.1% for 2014, with an average projected growth of 6.2 % per year after that • Over the 2012–22 period, national health spending is projected to grow at an average rate of 5.8% per year • By 2022 health spending financed by federal, state, and local governments is projected to account for 49% of national health spending and to reach a total of $2.4 trillion. Source: "National Health Expenditure Projections, 2012–22: Slow Growth Until Coverage Expands And Economy Improves," Health Affairs, abstract only, September 2013,

Monday, October 14, 2013

Key Statistics For The First Week of Open Enrollment at Covered California

Enrollment and Volume Statistics for October 1-5 at California Health Insurance Marketplace Unique visits to 987,440 Call volume 59,003 Average wait time 15:08 Average handling time 16:48 Applications 43,616 Partially completed 27,305 Applications completed with household eligibility determined 16,311 Number of Californians determined eligible for coverage 28,699 Small Business Health Options Program businesses registered as of 10/8/2013 430 Source: Covered California

Friday, October 11, 2013

What is At Stake If Congress Repeals The Medical Device Tax

By MARY AGNES CAREY KHN Staff Writer OCT 11, 2013 As Republicans and Democrats have battled over reopening the federal government and raise the federal debt ceiling, one idea that keeps coming up is a repeal of the 2010 health law's tax on medical devices. While the idea has drawn support from members of both parties, experts say it's still a heavy lift for the repeal's proponents. For starters, repealing the tax would create about a $30 billion revenue hole over the next decade. And supporters of the law fear that making such a change could start a stampede of demands for similar rollbacks from insurers and health care providers, who are also subject to new taxes and fees to help finance the health law. With that in mind, here are some frequently asked questions about the tax. Q: What is the medical device tax? A: Since the beginning of this year, medical device manufacturers and importers have paid a 2.3 percent tax on the sale of any taxable medical device. The tax applies to devices like artificial hips or pacemakers, not to devices sold over-the-the counter, like eyeglasses or contact lenses. Q: Why did Congress put the tax into the health law? A: The law created a package of new taxes and fees to finance the cost of the health law's subsidies to help purchase coverage on the online marketplaces, or exchanges, and the law’s Medicaid expansion. In addition to the tax on medical devices, an annual fee for health insurers is expected to raise more than $100 billion over 10 years, while a fee for brand name drugs will bring in another $34 billion. In 2018, the law also will impose a 40 percent excise tax on the portion of most employer-sponsored health coverage (excluding dental and vision) that exceeds $10,200 a year and $27,500 for families. That has been dubbed a "Cadillac" tax because it hits the most generous plans. Q: Why do proponents of the repeal suggest the medical device manufacturers should get a break over those other industries? A: Medical device makers say the tax will cost 43,000 jobs over the next decade and will increase health care costs. In a September letter to lawmakers, device manufacturers said if the tax were not repealed, "it will continue to force affected companies to cut manufacturing operations, research and development, and employment levels to recoup the lost earnings due to the tax." The device makers also assert that, unlike other health industry groups that are being taxed through the health law, they will not see increased sales because of the millions of people who will be getting insurance through the overhaul. "Unlike other industries that may benefit from expanded coverage, the majority of device-intensive medical procedures are performed on patients that are older and already have private insurance or Medicare coverage. Where states have dramatically extended health coverage, such as in Massachusetts where they added 400,000 new covered lives, there is no evidence of a device 'windfall,'" the group’s letter to Congress stated. The left-leaning Center for Budget and Policy Priorities has challenged industry assertions that the tax will lead medical device manufacturers to shift operations overseas and that it will reduce industry innovation. Since the tax applies to imported and as well as domestically produced devices, sales of medical devices in the U.S. will be subject to the tax whether they are produced here or abroad, the center’s analysis notes. Innovation in the medical device industry has slowed for reasons unrelated to the tax, the center said, noting that the health law may spur medical-device innovation by promoting more cost-effective ways to deliver care. Q: Who else is pushing for a repeal? A: Republicans and Democrats in both chambers – in particular those who hail from states with many device manufactures, such as Minnesota, Massachusetts and New York -- have sought to repeal the medical device tax. Most recently, Sen. Susan Collins, R-Maine, has pushed for a repeal as part of larger legislation to lift the debt ceiling and reopen the government. The Republican-controlled House has twice passed legislation to scrap the tax, including a recent measure that would have also delayed implementation of the health law by a year. In the Senate, 33 Democrats and Maine Independent Angus King voted earlier this year to repeal the tax, although the vote was a symbolic one, taken as part of a non-binding budget resolution. Q. Who opposes the repeal? The White House in the past has said the president would not support such a measure, although it has not commented about the issue in the current negotiations. In a statement issued last year about a congressional effort to get rid of the tax, the White House said, "The medical device industry, like others, will benefit from an additional 30 million potential consumers who will gain health coverage under the Affordable Care Act starting in 2014. This excise tax is one of several designed so that industries that gain from the coverage expansion will help offset the cost of that expansion." Senate Majority Leader Harry Reid, D-Nev., has said that the Senate will reject any attempts by Republicans to delay implementation of the law or to repeal the medical device tax as part of reopening the government or lifting the federal debt ceiling. But it is unclear if he would still oppose the effort if it was part of a major bipartisan compromise on the health law and budget issues. Meanwhile, other health care providers are watching closely. In a recent blog post, Chip Kahn, president and chief executive officer of the Federation of American Hospitals, an association of for-profit institutions, wrote that if Congress reopens the heath law "to reconsider the contributions of any one health care sector that benefits from ACA’s coverage expansion, it should simultaneously address the changed circumstances of hospitals and provide similar relief."

Monday, October 7, 2013

Today's Datapoint

16,000 ... hits per second were recorded by the California insurance exchange when it opened on Oct. 1, according to a Bloomberg article.

Thursday, October 3, 2013

Spending Inefficiencies in Healthcare Professional's Workplaces

According to the Coupa Software 2013 Healthcare Survey, 78 percent of healthcare professionals identified spending inefficiencies in their workplace. Top concerns included: • Wasteful spending (35%) • Insurance mandated process work (32%) • Late physicians (25%) • Useless tests (22%) Source: Coupa Software

Today's Datapoint

114 … health plans received a “Best Value” designation in 2013’s Consumer Reports Health Insurance Rankings, which means they met criteria for providing high-quality care without high costs.

Quote of the Day

“The government’s position [in Sept. 13 guidance issued by the Departments of Treasury and Labor] on stand-alone health reimbursement arrangements was expected. But their position on employer-payment plans is a real zinger. It effectively reverses IRS guidance that has been in place for over 50 years.” — Chip Kirby, a Washington, D.C., benefits attorney with the law firm Liberté Group LLC, told AIS’s Inside Health Insurance Exchanges.