Unbiased Analysis of Today's Healthcare Issues
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…
From the Peterson-KFF Health System Tracker: Most ACA Marketplace insurers are requesting premium increases in the 10-20% range for 2026. But more than a quarter (27%) of insurers are proposing premium increases of 20% or more for 2026. What individuals will pay for this insurance, however, is much higher because of the expiration of the…
Myself and Kristy Piccinini, PhD from FTI Consulting published a new commentary in The Evidence Base titled “Perspectives from the Healthcare Economist: Why CMS/AHIP’s prior authorization changes won’t hurt payers.” Dr. Shafrin and Dr. Piccinini share their insights in this Guest Column examining the implications of recent CMS/AHIP prior authorization reforms and why these changes are unlikely…
AHIP (formerly America’s Health Insurance Plans) released a statement yesterday saying that their health plan members “announced a series of commitments to streamline, simplify and reduce prior authorization.” 48 US health plans signed off on the statement. What were AHIP’s 6 commitments? Standardizing Electronic Prior Authorization. Participating health plans will work toward implementing common, transparent submissions…
Recently, I published a paper noting that the risk of using prior authorization and step edits may vary by the disease to which this type of utilization management is applied. States are starting to pass legislation to limit how health insurers can use prior authorization rules. According to the American Medical Association (AMA), 10 states…
That is the question asked in a new paper by Enright, et al. (2025). The authors use the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) database current as of August 2023. This database contains publicly available specialty pharmacy coverage decisions as issued by 18 large US commercial health plans, which—collectively—cover 200m people (i.e.,…
This is a question I can’t answer with certainty. Patients often believe that since I’m part of the health-care system, I would know. But I don’t, not as a doctor — and not even when I’m a patient myself. In the United States, health insurance is so extraordinarily complicated, with different insurers offering different plans,…