Topic: Clinical

Azar Testified on Drug Pricing. Industry Yawns.

John Gorman

Health and Human Services (HHS) Secretary Alex Azar  was in front of the US Senate Health Committee for a hearing today on drug pricing. His prepared remarks freaked out the market open saying the US “fundamentally may need to move toward a system without drug rebates, where PBMs and drug companies just negotiate fixed-price contracts.”

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Integrated OTC Benefits: A Prescription for Customer Satisfaction

Convey Health Solutions

Most over-the-counter products and medications like pain relievers, allergy medications, heartburn drugs and topical antimicrobials were once available only by prescription. In OTC form, these drugs are FDA approved and often equally effective as prescription drugs at a fraction of the cost. Yet their OTC status has long meant these drugs are not covered under prescription drug plans for Medicare Advantage, Medicaid or commercial health plans. As a result, consumers with limited incomes may simply forgo needed medications while others may opt for more expensive prescription drugs that are covered by their health plans.

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Reading the “Blurred Lines” of the Cigna/Express Scripts Merger

John Gorman

The Wall Street Journal reported last night (Cigna Nears Deal to Buy Express Scripts) that Cigna is in final talks to acquire Pharmacy Benefit Manager (PBM) Express Scripts (ESRX) for a whopping $67 billion. ESRX was the last truly independent major PBM, and the deal signals the end of an era…and ushers in a new one, further blurring the lines between insurers, providers, and their primary vendor. The combined entity will reach over 250 million people and will have a ripple effect on many of their competitors.

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CMS Releases Part II of the Medicare Advantage Advance Notice & Draft Call Letter

Olga Walther

On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Advance Rate Notice (Part II) and Draft Call Letter. CMS estimates an expected increase of 1.84% to payments in 2019. CMS says its estimates do not reflect underlying coding trend, which it expects to increase risk scores by 3.1% in 2019.

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HEDIS Deadlines Approaching

Anita Green

It’s HEDIS® time again! Health plans should have data collection and audit activities in full swing for Healthcare Effectiveness Data Information Set (HEDIS®) 2018. High-performing plans will have started the hybrid chart collection and medical record review.

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Ring in the New Year with a Revised MOC

Mayling Naputi

We all know this is the busiest time of the year – or so it seems. As we wrap up (pun intended!) end-of-year requirements, it intensifies the need to streamline efforts in completing priority projects. This should, of course, include re-evaluation of your Model of Care (MOC). Time spent NOW re-evaluating your organization’s most current Centers for Medicare & Medicaid Services (CMS)-approved Special Needs Plan Model of Care (SNP-MOC) will pay off later in the new year. This instantly becomes tangible when faced with a CMS audit in 2018, where CMS will take a step-by-step review of your organization’s operations as it relates to plan processes and performance outlined in your MOC.

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Influencing Your 2019 Star Ratings: Every Day Matters

Melissa Smith

With the recent release by the Centers for Medicare & Medicaid Services (CMS) of 2018 Star Ratings to health plans, the now-annual “4th quarter Star Ratings fire drill” is officially underway.  Whether you dropped below the 4-star threshold required to earn quality bonus payments, or you hit 4 stars and are hoping to sustain it, the next six weeks are critical to your success. But with only about 90 days remaining to connect members with the care they need for your success, every day and every decision matters.

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