Anupam Goel on LinkedIn: Who profits most from America’s baffling health-care system? | 10 comments (2024)

Plan sponsors need transparent and intelligent data in order to pay fair market value for healthcare and prescriptions. Novo Connection delivers both. Transparency plus recommendations is the key to being a good fiduciary.

I can’t think of a state that has invested more and better health policy resources and infrastructure than Massachusetts. Yet, “The Bay State's total healthcare expenditures per capita increased by 5.8% from 2021 to 2022, well above the national rate of 4.1% and nearly double the 3.1% benchmark set by the Massachusetts Health Policy Commission (HPC) based on prior years’ compounded growth.” Strong health policy and data infrastructure alone will not stop the unabated march of healthcare cost increases. Employer purchasers MUST be part of the solution. Massachusetts in particular has some very strong domestic health plans and the state trails relative to self funding in the small and middle marketplace thereby making health services costs less transparent and actionable for plan fiduciaries. “Pharmacy has been the biggest contributor to health care spending growth for several years … underscoring the urgent need for targeted policy action and increased oversight to address pharmaceutical pricing and value,” HPC Board Chair Deborah Devaux said in a statement. “Even accounting for rebates, prescription drug spending grew more than 7% per year from 2019 to 2022 for those with private health insurance, 10 times faster than in previous years. The HPC continues to be concerned that, without action, these trends will continue and make care even more unaffordable and inaccessible.” MA is not alone. Something has got to give. Employers have to play their part. Unless and until plan fiduciaries take the time to evaluate what they’re paying and who they’re contracting with; we’ll continue to see these same sad headlines and results. #healthpolicy #healthcarecosts #pharmacy #valuebasedhealthcare #hospital Christine Arnold John Rodis, MD, MBA, FACHE, CPHQ Lisa Trumble Steve Schutzer, MD Paul Grady Chris Deacon Wyatt Bosworth Peter Hayes Ann M. Richardson, MBA Kathy McKeon, R.N., M.P.H.CSM Al Lewis 🇺🇦 Scott Haas Dave Chase, Health Rosetta-discovering archaeologist Doug Aldeen Stuart Sutley George Beauregard, DO Brian Klepper Patrick Long Jamie Greenleaf AIF, CBFA, C(k)P Julie Selesnick Darren Fogarty A. J. Loiacono Kristin Begley Mike Baldzicki Michael Brouthers Jay Kimmel Justin Leader

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"The senators...argue that health plans use copay accumulators not only to help control costs, but also as a 'profit-seeking tactic.'”https://lnkd.in/eStkSy4S#copayments, #hhs #cms #healthcareaccess #healthadvocate #healthcare #healthcarechallenges #csro #rheumatology #rheumatologist #barbknowsinsurance #healthinsurance #Copayaccumulator #medicare #medicareinsurance

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As many employers prepare for 2024 benefits open enrollment, two coverage offerings are showing rapid growth: newweight loss drugssuch as Wegovy and Ozempic andpersonalized medicine, which relies heavily on genetic testing.Nearly half of large employers (49%) expect to cover the new weight loss medications as part of their health plans, according to the2024 Large Employers’ Health Care Strategy and Plan Design Surveyby the Business Group on Health, which queried 135 larger employers. These are the medications, known as semaglutides, that have received so much attention this year for their high effectiveness but also for their high prices. Wegovy, for example, can cost more than $1,350 per month without insurance, according toCNBC.In 2023, 46% of major employers covered the cost of the semaglutide drugs for weight loss, up about 6 percentage points since 2015, according to areportinPharmacoEconomics.https://lnkd.in/g5Cdg23Y#health #weightloss #healthcare

U.S. health insurers have adequate ratings headroom to withstand the mounting cost pressures driven by growing drug shortages, rising #pharmaceutical and other input costs, and higher utilization.The structural advantages afforded to health insurers within the broader healthcare system, business model diversification and stable key financial metrics are key drivers supporting credit profiles.Learn more: https://ow.ly/isO250OXmn3#FitchRatings #Insurance #HealthInsurance

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YOUR PAIN IS THEIR GAIN.“. . . keeping healthcare costs in check might feel like trying to alter a law of nature. The sun rises in the east. Birds fly south for winter. Spending on healthcare outpaces inflation.”Unfortunately, this is a common perception, but the reality is that there are a variety of ways to address this situation. However, the Big Health insurance carriers, Pharmacy Benefits Managers, and Big Pharma, don’t want you to know that because it would cut into their profits.These 3 have built quite a profit driving business strategy under “managed care” with “negotiated” prices. What’s important to understand is that “negotiated” prices does not mean those prices are better for insureds. Over the last 30+ years they have been manipulated to be what’s best for the PBMs, Pharma, and Big Health insurance carriers, but not necessarily for insureds.Remember that most of these companies are for-profit businesses, and those that aren’t are still run like for-profit companies. Their duty is to shareholders first, then their clients, and manged care has created a health care system that is complex, confusing, and full of hidden prices.So, that prescription drug formulary that is supposed to be in place to ensure the best cost & best performing drugs in each therapeutic class are covered under your plan and the higher-cost lower performing drugs are excluded, no longer follows that goal. Today, pharmacy companies can buy their way onto your formulary by offering higher rebates.FYI – rebates are just a scheme to charge more and then give back a portion of the over-charge to make those getting screwed feel better about it.If your advisor hasn’t shown you ways to take control of your prescription drug spend, find one that will. Also, make sure you know whether your advisor, or broker, is benefiting from your current prescription drug program. Some will have an additional per-fill fee, or some other form of compensation, built into your Rx plan.Chapter 18 - Transparent Pharmacy Benefits in Dave Chase's book "The CEO's Guide to Restoring the American Dream", is a great resource for learning more about managing prescription drug costs.A well-managed Rx plan can cut 10%-40% off plans managed by the Big 3 PBMs.

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Interesting data on what drives health insurance premiums for 2023:https://lnkd.in/djjm__PzTop Factors:1. Inflation Driving Increased Provider Rates2. Shift in COVID-19 Vaccine and Testing Costs to Health Plans3. Uncertainty Surrounding Medi-Cal Redetermination4. Emergence of Expensive Weight-Loss and Specialty Drugs5. Misusing the Special Enrollment Period

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The hefty price tags are undermining the benefits of generics—a pillar of efforts to control Americans’ spiraling healthcare spending—while saddling patients, many on fixed incomes and insured by Medicare, with considerable deductible payments or other out-of-pocket costs. The reason, health researchers and industry officials say, is the very companies that are supposed to keep a lid on drug spending can maximize their profits by marking up the prices. Other companies in the drug-supply chain won’t stop them, because consolidation has swept many of the businesses under the same parent.https://lnkd.in/ghTTT8xU

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The hefty price tags are undermining the benefits of generics—a pillar of efforts to control Americans’ spiraling healthcare spending—while saddling patients, many on fixed incomes and insured by Medicare, with considerable deductible payments or other out-of-pocket costs. The reason, health researchers and industry officials say, is the very companies that are supposed to keep a lid on drug spending can maximize their profits by marking up the prices. Other companies in the drug-supply chain won’t stop them, because consolidation has swept many of the businesses under the same parent.https://lnkd.in/ghTTT8xU

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