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…
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…
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…
Patients hate narrow networks. Anything that limits their choice of physicians or hospitals is disliked. Americans love more choice. Payers, on the other hand, like narrow networks because they save cost–through the ability to negotiate lower rates–and potentially increase quality–if the contracted network has higher quality physicians. In fact, according to the KFF Employer Health…
How does Medicare Advantage market share impact skilled nursing facility (SNF) profitability? That is the question asked by Marr and Shen (2024). Using data from Medicare SNF cost reports, LTCFocus.org data, and county MA penetration rates, the authors use an ordinary least squares regression with SNF and year fixed effects examining how MA penetration impacts…
Medicare Advantage (MA) plans have a number of advantages and drawbacks over traditional Medicare (TM) (i.e., fee-for-service). One advantage of MA plans is that cost sharing is often lower. Another benefit is that enrollees may receive additional coverage benefits. One drawback is that enrollee provider choice may be restricted. Fewer provider options may be bad…
A CMS proposed rule would expedite the prior authorization approval process. CMS summarizes key provisions of the rule as follows: Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason…
Last month, ICER released their 2023 “Assessment of Barriers to Fair Access” . The report concludes the following regarding 18 drugs evaluated. ICER defines “fair access” based on the following criteria: Cost sharing Cost sharing based on net price. Patient cost sharing should be based on the net price to the plan sponsor, not the…