What’s New in Health Care Reform: July 27

a-young-woman-with-her-arm-around-the-shoulders-of-an-elderly-woman-walking-outside-facing-away-from-the-camera-original-1024x693What's New in Health Care Reform provides an overview of the past week’s news, updates, and commentary in health care reform and utilization management.

Obama Signs into Law Opioid Addiction Bill to Protect Newborns

President Barack Obama on signed into law a measure that pledges greater efforts to protect drug-dependent newborns and assist their parents. The Comprehensive Addiction and Recovery Act also stresses drug treatment and overdose prevention to help stanch the nation’s heroin and opioid drug epidemic. Via Reuters.

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Humana Pulling out of Many Obamacare Markets

Humana will stop marketing Obamacare exchange plans in several states next year and will exit many off-exchange individual markets as well, the company announced today. The decision means the company will only offer individual plans in 156 counties in 11 states, down from 1,351 counties across 19 states this year. It had sold plans on Affordable Care Act exchanges in 15 states this year. Via Politico. 

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Most Insurers Lost Money in First Year of Obamacare

Only about one-third of health insurers came out ahead in their first year in the Obamacare marketplace, according to a study by the Commonwealth Fund released. While insurers made nearly twice as much money from health care premiums in 2014, overall profits “diminished noticeably” because of higher payouts, according to the expansive new analysis on companies participating in the exchanges. Via The Hill.

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ACA Exchanges Getting Even Worse for UnitedHealth

Government-run health insurance exchanges became an even bigger source of financial losses during the second quarter at Minnetonka-based UnitedHealth Group. The nation's largest health insurer said that it saw higher medical costs once again on the exchange marketplaces, and increased projected losses for the year by $200 million. Via Star Tribune.

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Medicaid Spends a Lot on Outpatient Drugs, but Which Cost the Most?

With more than 70 million beneficiaries, Medicaid spent more than $27 billion on outpatient drugs two years ago. But which medicines have cost the program the most money? Not surprisingly, many of the drugs topping the list carried high price tags. Between January 2014 and June 2015, the costliest medications were the Abilify antipsychotic pill; the Sovaldi and Harvoni hepatitis C treatments; the Vyvanse attention deficit medicine; and the Truvada HIV drug, according to a new analysis by the Kaiser Commission on Medicaid and the Uninsured. Via Stat News.

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Are Premiums Lower Than We Think?

Insurance premiums for Affordable Care Act individual policies may not be as expensive as presumed when compared to rates before the law took effect, a recent analysis suggests. The analysis, released last week by Health Affairs, argues that though premiums are increasing, they’re actually lower than they would have been before the Affordable Care Act was implemented in 2010. That’s because the “average premiums in the individual market actually dropped significantly upon implementation of the ACA,” the analysis says. Via Morning Consult.

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State Health Exchanges Wrestle with Budgets

State-based marketplaces survived startup problems with botched technology and political threats but continue to grapple with a fundamental challenge: financial sustainability. The 13 states that run their own exchanges face challenges in raising enough money, through user fees or state funding, to maintain their operations now that about $5 billion in early federal grants has largely run out. As states establish those budgets, they are testing decidedly disparate approaches to investments in priorities like marketing, technology and operations. Via Roll Call.

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Medicare Proposes Fixed Payments for Treating Heart Attacks

Medicare wants to pay hospitals fixed amounts for treating heart attacks, following a move to offer set reimbursements for hip and knee replacements rather than letting providers bill for every service provided to older Americans, the Obama administration said. The proposal represents the most significant extension of the Obama administration’s efforts to curb costs and improve quality of care funded by Medicare. Under the plan, hospitals that take in patients for cardiac care will ultimately be offered a target price for all of the services provided in hospital and within 90 days after discharge. If they bill for less, they will be allowed to keep the savings, but if they bill for more, they will have to repay Medicare. The proposal would also introduce target prices for hip and femur fractures. Via Wall Street Journal.

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One Court Case That Could Really Hurt Obamacare Insurers

There’s been a lot of bad news about rising Obamacare exchange premiums over the past few months. But things could get much worse for insurers (and consumers) if a court ruling brought by House Republicans against the administration prevails. At issue in House v. Burwell is whether the administration has been illegally paying cost-sharing reduction subsidies to insurers. This issue was also the subject of a Republican House investigation, which resulted in a recent report concluding that the administration knowingly made the payments without a congressional appropriation, which is illegal. Via Morning Consult.

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Health Plans Slow to Take up Value Frameworks

Most health insurers don’t use value frameworks to when deciding which pharmaceuticals to cover and how much to pay for them, an analysis released by Avalere Health shows. Value frameworks, which are used to determine the value of a prescription drug based on its costs, as well as its benefits and how it improves a patient’s quality of life, were introduced by four high-profile organizations last year: the American Society of Clinical Oncology, the Institute for Clinical and Economic Review, Memorial Sloan Kettering, and the National Comprehensive Care Network. Most payers told Avalere it was unlikely they would be using the framework initiatives to make decisions in their coverage a year from now. Via Morning Consult.

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Andy Tofilon

Andy Tofilon is a Marketing Segment Manager at Mayo Medical Laboratories. He leads strategies for corporate communications, public relations, and new media innovations. Andy has worked at Mayo Clinic since 2003. Outside of work, Andy can be found running, hiking, snapping photos, and most importantly, spending time with his family.