Unbiased Analysis of Today's Healthcare Issues
In 2020, spending on specialty drugs was $265 billion; this constituted 49.6% of total prescription drug expenditure. To combat rising costs, payers have turned to white, brown and clear bagging as well as approaches to restrict the site of care where patients receive specialty drugs. What are these “bagging” policies, what are the pros and…
According to a recent paper by Wallace (2023), the answer is ‘yes’, but it does so in a highly inefficient manner. Using 2008-2012 Medicaid data from the New York State Department of Health, the author find that: Leveraging the random assignment of over 50,000 Medicaid enrollees in New York, I present causal evidence that narrower…
Part of the Affordable Care Act mandated a medical loss ratio (MLR) for health plans in the individual and small group markets. What this means is that if the MLR is 80% and insurers charge $100 in premiums, plan enrollees must receive $80 in services on average. If they do not (say they only receive…
How does ICER plan to determine whether health plans offer fair access to pharmaceuticals? I summarized their approach last year as outlined in their white paper titled “Cornerstones of ‘Fair’ Drug Coverage: Appropriate Cost-Sharing and Utilization Management Policies for Pharmaceuticals.” Last month, final protocol for their “Barriers to Fair Access Assessment“. While the approach follows…
Prior authorization is a pain. A paper by Howell et al. (2021) found that the total cost of various utilization management schemes is $93.3 billion of which physicians devote $26.7 billion worth of time to navigate utilization management systems. Payers would argue that prior authorization helps to control costs and stop the prescribing of unnecessary…
Medicare Part D plans have begun using preferred pharmacy networks in order to steer their beneficiaries to lower cost pharmacies. A key question is, does this work? A paper by Xu et al. (2022) aims to answer this question using 2011-2016 data. that compares Low Income Subsidy (LIS) Medicare beneficiaries and non-LIS beneficiaries. LIS beneficiaries…
Many countries allow private plans to administer health insurance benefits but with restrictions on premiums and with the potential for risk adjusted government payments based on the health of a health plan pool For instance, Belgium , Germany, Israel, the Netherlands and Switzerland all have mandatory health insurance schemes; Ireland and Australia have voluntary health…
Are narrow networks a good thing or a bad thing? The first thing you need to know is what is a “narrow network”. Narrow networks is an informal terms which basically means that your health plan either places restrictions over the providers you are able to see and/or you certain providers that are out of…
Specialty drugs have delivered significant improvements to patient health, but oftentimes they pay be expensive. To try to insure that these treatments are used appropriately, some health plans impose a utilization management tool known as “prescriber requirements” where only certain types of physicians may prescribe a drug. While this may be useful for some complex…
Last fall, ICER published a white paper titled “Cornerstones of ‘Fair’ Drug Coverage: Appropriate Cost-Sharing and Utilization Management Policies for Pharmaceuticals.” To paraphrase, ICER’s goal is to limit access restrictions (e.g., cost sharing, coverage limitations, prescriber restrictions, step therapy) when a drug is deemed to be cost effective. How will they do this? Their Barriers…