Unbiased Analysis of Today's Healthcare Issues
Let’s say you’re the CEO of a health plan. A new drug just received approval to treat patients with lung cancer. The drug’s clinical trial examined how well the the drug worked on third line (3L) patients and patients with good funcional ability (e.g., performance status ECOG score of 0 or 1). FDA approved the…
In May 2025, CMS’s Center for Medicare & Medicaid Innovation (CMMI) unveiled it’s “Make America Healthy Again” vision. CMMI models focus on not only “protecting the federal taxpayer,” but also (i) promoting evidence-based prevention, (ii) empowering people to achieve their health goals, and (iii) driving choice and competition for people. CMMI has introduced a number…
The Peterson Health Technology Institute (PHTI) recently released a report titled: “Administrative AI: Current Use and Potential Impact.” The report was based on a workshop PHTI convened with senior leaders from health systems, health plans, technology developers, investment firms, and federal agencies in order to discuss how technology and policy can enable AI to reduce…
This is the question that a recent AJMCcommentary by William Shrank, Ellen Kelsay, and Mark Fendrick aims to answer. When talking about cell and gene therapies, the authors argue that cost sharing is not being used to avoid unnecessary use of low value care, but rather as a form of rationing that creates disparities in…
It turns out the answer is Medicare Advantage plans according to a KFF analysis released today. However the reason why Medicare Advantage is more profitable may not be obvious: At the end of 2024, gross margins per enrollee ranged from $608 in the Medicaid managed care market to $1,655 in the Medicare Advantage market. Gross…
That is the findings from a KFF Health Tracking Poll out this month. The survey examines which aspects of accessing care and health insurance are the biggest problem for insured adults. The survey finds that 69% of adults believe prior authorization is a burden. Specifically, the survey asks “When it comes to getting health care,…
While for years patient engagement has been seen as a valuable, starting in 2026 this will be a legal mandate. Plans offering essential health benefits must appoint at least 1 patient representative to their pharmacy and therapeutics (P&T) committees by the start of 2026.1 After July 10, 2026, every state Medicaid program must establish standalone Beneficiary…
That is the question a new paper by Chambers et al. (2025) aims to answer. The authors use data from the Specialty Drug Evidence and Coverage (SPEC) Database, which contains coverage policies related to specialty pharmacy for a large number of US health plans, to examine how n=25 cell and gene therapies are being covered…
Michael Cannon makes the convincing case that the answer is a resounding ‘no’. Those who say that private health insurance companies are evil entities that profit from denying health care to patients fail to appreciate that private health insurance companies are in fact a wondrous force for good.Outrageous? Not at all. Health insurance companies get…
How does formulary restrictions impact health outcomes for patients with multiple sclerosis (MS)? To answer this question, Blaylock, Van Nuys and Joyce (2025) use data 100% Medicare claims data from 2018-2022 covering patients with both prescription drug plans (PDPs) and Medicare Advantage Prescription Drug plans (MA-PDs). Individuals were categorized as above vs. below average formulary…