Showing posts with label California. Show all posts
Showing posts with label California. Show all posts

Wednesday, January 29, 2025

Neglect and Cover-Up: Kaiser's Research Ethics Fail Examined

Kaiser Permanente in Northern California conducted a study that breached numerous patient protection rules. The study was meant to explore if a fish oil-derived drug could help reduce complications from respiratory illnesses like COVID in high-risk cardiovascular patients.

  • Researchers' Misconduct: Two leading researchers, Dr. Alan Go and Dr. Andrew Ambrosy, were disciplined for failing to adhere to research compliance and patient safety protocols. They withheld critical information and attempted to cover up these lapses.
  • Study Termination and Suspension: The study was halted in December 2022, and eleven other studies by these researchers were suspended. An internal audit by Kaiser's Institutional Review Board (IRB) found "persistent failure" in following regulations.
  • Patient Safety Compromised: Notably, an elderly man with a known shellfish allergy, which should have excluded him from the study, was pressured to participate and subsequently experienced health issues potentially linked to the drug. The study also included participants with other exclusion criteria like cognitive impairments or language barriers.
  • Inadequate Oversight: The FDA criticized Kaiser's oversight, highlighting that their system for monitoring research safety and ethics was inadequate. The IRB lacked the authority to act swiftly due to delays from Kaiser leadership in providing necessary information.
  • Audit Findings: The audit revealed numerous violations including:
    • Enrollment of ineligible participants with allergies, cognitive issues, or language barriers.
    • Undue influence on participants to join or continue in the study.
    • Improper management of study protocols, leading to poor documentation and data handling.
  • Corrective Actions: After complaints and the audit results, Kaiser implemented corrective action plans, but specifics were not detailed. The researchers' appeal to continue the study was denied.
  • Broader Implications: This incident not only questions the integrity of the research conducted but also casts a shadow over Kaiser's research oversight, potentially affecting its reputation and the trust of its large patient base in California.

Full story.   

Monday, November 4, 2024

One Mom’s Nose for Savings

Exorbitant Hospital Pricing in the U.S. Undermines Morale, Employee Compensation, and Employer Profits — It Must Stop

As the sun dipped below the horizon on a brisk spring evening, a young mother crouched behind home plate, catching for her daughter.  Already showing signs of a future softball superstar, Gisele unleashed a wicked rising fastball.  It clipped the edge of the glove and smashed into her mother’s face, cracking bone and pushing her nose sharply to the left. 

In a display of savage tenacity, Mom wiped the blood away, grimly reset her nose with a crackling snap, and resumed her catching duties for the evening.  Despite her efforts, the misshapen lump and the nose’s noticeable leftward slant gave her the hardened appearance of a seasoned mob enforcer.

Doctors told her she’d almost certainly require surgery but wanted to let the swelling subside and see how her breathing progressed before they intervened. 

Months later, she couldn’t breathe through her left nostril; she wanted her beak fixed. Luckily, she found herself on a Mahoney Group plan backed with Reference-Based Pricing and Cash-Pay options at recognized centers of excellence.

  • So no, UHC and Adventist, her plan isn’t going to pay $74,000. 
  • Nor will she pay the $58,000 sought by Cigna and El Camino Hospital. 
  • Not going to pay $73,000 either, Western Health and John Muir. 
  • And we say nay nay to the $73,000 Santa Rosa Memorial wants from EVERY commercial payer.  (Hat tip to the late, great John Pinette.)
  • She’ll pass on the $51,000 Stanford and Blue Shield want.
  • And UCSF and Aetna can only dream about that $69,000 they lustily crave.  

At 140% of Medicare, we will pay $7,811 for this surgery.  If circumstances such as geography, timing, or specialized surgeons demand a higher price, we can negotiate.  But that is seldom required.  In this case, Gisele’s Mom is getting her nose fixed up for a voluntary cash price of $7,750. 

Plus, since Mom agreed to use the cash-steerage option, her employer is paying 100% of the cost of the procedure and waving all deductibles and coinsurance

And from now on, Mom’s going to wear a catcher’s mask. 

Monday, October 28, 2024

The 5 Forces of Justice - 5 Different Forms of RBP

This ain't yo grandpappy's RBP!  Five different ways employers are installing RBP to save millions on healthcare costs.


Wednesday, July 24, 2024

Wednesday, December 20, 2023

On Armstrong and Getty for a Couple Hours This Morning

7 AM Hour - Just a Wee Bit Less Dynamic: features our guest, Craig, the Obamacare Guru, who joins Jack to discuss...

  • The escalation of Christmas...
  • The Trump/Colorado ruling...
  • Jack's confrontation conundrum...
  • Immigration...
  • Those magical family moments! 



8 AM Hour - Just Eat Your Cotton Candy! features Craig, the Obamacare Expert, who joins Jack to discuss...

  • The Trump/Colorado decision...
  • Weight Loss Drugs...
  • The Ukraine/Russia War.
Plus...
  • Expert military analyst Mike Lyons joins the show to talk about the Israel/Hamas war.

  

Friday, September 15, 2023

Healthcare's Final Frontier: Navigating the Wild West of RBP with Industry Renegades

Omar Arif of ClaimDOC & Scott Schnaidt of HST on All Things RBP




Ever imagine healthcare could feel like the Wild West? Welcome to the untamed lands of Reference-Based Pricing (RBP), the sizzling frontier where a select few employers unleash radical savings while giving the traditional PPO system a stiff arm.

Unveil a world where only 3-4% of employers dare to tread, but where jaw-dropping 30-40% savings rain like gold and concierge-level service is the sheriff in town.

Curious about RBP's magic? This isn't just healthcare. It's "Health-FAIR!" Here, employers "price-match" medical costs against benchmark prices, slicing their claims in half compared to big insurers.

Projections say employer healthcare costs will shoot up another 7-9% in 2024. Yet Medicare Part D Premiums are projected to decrease by 1.8%. All major insurers participate in both markets. The lesson? Employers with private insurance are subsidizing Medicare. But hold your horses. With RBP, brace yourself for a 0-2% trend that turns the tables on traditional care.

Jump into this roller-coaster ride of a podcast with your guide through this maze, joined by two titans of the trade—Omar Arif of ClaimDOC & Scott Schnaidt of HST. They've both cracked the code, each in their unique ways, and the results? Nothing short of spellbinding.

🎯 What's on Tap:
  • The gears and levers behind RBP
  • Navigating the legal minefields
  • Secrets from Third-Party Administrators (TPAs)
  • RBP's performance across the geographical board
  • The art of handling balance bill claims
  • Litigation: When & How Often
  • Co-fiduciaries: The real deal or just smoke and mirrors?
  • Show Me the Money: Their pay structure dissected
  • Year-end Report Cards: The Good, the Bad, and the Profitable
And just when you think it couldn’t get any cooler—did one of these guys actually play pro baseball in a global tourney, while the other rocked the stage with NIRVANA? 🎸⚾

Lock in your earbuds. Prepare for a mind-bending journey. You’re entering "The Repricers"—Healthcare’s Final Frontier! 🌌🛸


Tuesday, August 8, 2023

It's A Government Healthcare Complex: Craig Gottwals Talks To A&G

Your health insurance costs and premiums have skyrocketed compared to the rate of inflation since Obamacare passed. Meanwhile, insurance carrier stock prices have grown by 1900% in the same timeframe.

"They're making unimaginable amounts of money... off of you." -Joe Getty

Craig Gottwals, aka "Craig the Healthcare Guru,” talks about that and more in a new episode of A&G's Extra Large Podcast.

Listen to the Armstrong & Getty Extra Large Podcasts featuring Craig.

Originally posted here


Saturday, July 15, 2023

Required Leave for Any Reason, Ozempic, and Coverage for Gender Affirming Care

Tools & Webinars:


Compliance News:

Pharmacies are Sharing Sensitive Health Data with Facebook - "Looking for an at-home HIV or Plan B test on CVS’ website is not as private an experience as one might think, and CVS is not the only pharmacy sharing this kind of sensitive health data, according to a KFF Health News investigation. We found trackers collecting browsing- and purchase-related data on websites of 12 of the U.S.’ biggest drugstores, including grocery store chains with pharmacies, and sharing the sensitive information with companies like Meta (formerly Facebook); Google, through its advertising and analytics products; and Microsoft, through its search engine, Bing."

The IRS recently issued Notice 2023-37 to update its guidance for high deductible health plans (HDHPs) on expenses related to COVID-19 testing and treatment. The notice also clarifies whether certain items and services are treated as preventive care under the tax rules for HDHPs, and confirms that for plan years ending after Dec. 31, 2024, an HDHP is not permitted to provide benefits for COVID-19 testing and treatment without a deductible. 

Open Issue: Employer-Sponsored Health Plans and Coverage of Gender-Affirming Care

June 28, 2023 – Jackson Lewis P.C.

Whether an employer-sponsored health plan must cover gender-affirming care is often dependent on whether the employer’s health plan is fully-insured or self-insured; fully-insured plans must provide gender-affirming care to the extent required by applicable state and federal law, while the law on categorical exclusions for gender-affirming care in self-insured plans continues to develop. 


Talk about an FMLA leave headache! This one was a migraine

June 27, 2023 – HR Morning

A federal appeals court rejected claims filed by terminated employees who sought FMLA leave along with many others, ruling that the employer had good reason to believe the employees acted dishonestly and sought leave for an improper purpose. Employers can also take away from this article a few tips to curb FMLA leave abuse.  


July Is the New January: The Pace of New State Laws Heats Up

June 26, 2023 – Littler Mendelson P.C.

This article offers insight into an array of labor and employment laws and ordinances from across the country, state by state, that take effect mid-year and will implicate employers’ compliance obligations. 


New Trend in State Laws, Paid Leave for Any Reason - "In May 2019, Maine became the first state in the nation to require private employers to provide paid leave for any reason when Gov. Janet Mills (D) signed LD 369. Nevada followed a month later, in June 2019, when then-Gov. Steve Sisolak (D) signed SB 312, which also granted paid leave for any reason. Illinois is poised to join their ranks on January 1, 2024. In March 2023, Gov. J.B. Pritzker (D) signed SB 208, which says that beginning on January 1, 2024, private employers must offer their workers five days paid time off for any reason after they’ve completed a 90-day probation period."

  • In Nevada, for example, Employers may limit the use of paid leave to 40 total hours per benefit year and may prevent an employee from using any accrued paid leave until the employee reaches their 90th day of employment. Employers may also set minimum increments of paid leave which an employee may elect to use, so long as that limit does not exceed 4 hours.


Benefits News:

A Couple Retiring in 2023 Needs $315,000 in Retirement Savings Just to Cover Medical Expenses in Addition to Medicare - "The after-tax cost for medical expenses throughout retirement for a single, 65-year-old retiree held steady at $157,500 ($315,000 for the average retired couple at the same age), according to the new 2023 Retiree Health Care Cost Estimate, which tracks retiree healthcare expenses annually."

Renewals Not Looking Good for UHC Clients: "UnitedHealth Group extended its streak as the most profitable company among major national insurers in the first quarter of 2023, reporting $5.6 billion in earnings. By comparison, fellow healthcare giant CVS Health reported the second-highest profit in the quarter at $2.1 billion, less than half of UnitedHealth's haul. CVS' profit also declined year over year, as it posted nearly $2.4 billion in the first quarter of 2022. UnitedHealth also takes the top spot on revenue for the quarter, reporting $91.3 billion. That's up from $80.1 billion in the prior-year quarter. CVS again lands at No. 2 on revenue, posting $85.3 billion."

Will the Doctor See You Now? The Health System's Changing Landscape - "About 48% of primary care physicians currently work in practices they do not own. Two-thirds of those doctors don’t work for other physicians but are employed by private equity investors or other corporate entities, according to data in the “Primary Care Chartbook,” which is collected and published by the Graham Center.... it now takes an average of 21 days just to get in to see a doctor of family medicine, defined as a subgroup of primary care, which includes general internists and pediatricians. Those physicians are many patients’ first stop for health care."


Health and Wellness:

Watch The Truth About Weight Loss Drug Ozempic with Dr. Peter Attia - a one-minute short.

Trusting The Science: The following is a list of the 20 largest settlements reached between the United States Department of Justice and pharmaceutical companies from 1991 to 2012 - Pfizer claims the largest criminal fine in U.S. history, while GlaxoSmithKline holds the largest pharma-fine in history when combining civil and criminal penalties.

What you need to know about Ozempic & Mounjaro - "But I want all my patients and the public to know that the appetite and weight loss effects do not last forever. Effects on hunger, cravings control, sweet cravings, mood & fullness are TEMPORARY and return to baseline between years 1 & 2. This was shown in surveys taken from patients using the medication over the long term."

Just 3% of adults show no major health risk factors linked to death - "Overall, most of us have something wrong with us, and we’re more likely to have a lifestyle health-risk factor now than in the ’80s and that’s actually associated with even greater mortality risk now than before."

Ozempic, Weight-Loss Drugs Probed Over Reports of Suicidal Thoughts - "Novo Nordisk A/S’s weight-loss medications are under investigation by the European Union’s drugs regulator after a small number of reports of suicidal risks were referred to the watchdog. The European Medicines Agency is looking at adverse events noted by the Icelandic Medicines Agency, including two cases of suicidal thoughts linked to the drugs Saxenda and Ozempic, the EMA said in a statement Monday." 


Monday, May 22, 2023

HR’s Porta-Potty Predicament: California Compliance Chaos

From Armchair Lawyer to Bathroom Auditor. A Peculiar Friday at the Office

In the late afternoon on Friday, at the brim of the weekend, my phone shrieked with a call of urgency. It was from a client named Nancy, who, with an audible eye-roll, launched into an account of her current predicament. Here's a condensed retelling of our dialogue.

“Craig, we have a pressing compliance concern that needs an immediate solution. Regrettably, it's not tied to benefits, but I’m betting you might be of assistance.”

“Consider it done, Nancy. I'm all ears.” ...

The full story is on my Substack



Thursday, April 13, 2023

1 in 5 California Hospitals is in Danger of Closure


California hospitals are in serious trouble due to:
  • The misguided government prohibition against non-COVID care during the pandemic;
  • Overall inflation;
  • And chronic underpayment from Medicare and Medicaid (only covering about 75 cents on the dollar of actual costs).
The underpayment then forces employer plans to pay absurdly high prices (224% of Medicare in last year's study) to make up for the fact that many hospitals can't survive on government reimbursements.

When Medicaid (Medi-CAL) first passed, it was designed to cover the lowest 2% of wage earners. It now makes up 80% of patient volume at many of these rural hospitals, and about four in ten Californians are born into it. That's what you call mission creep at its finest.

As Patty Maysent, the CEO of UC San Diego Health, explains, "[t]here are hospitals all around the state ... that are two, three or four months away from running out of cash."

There are answers! Employers need not suffer through this. I've written about this extensively. Here are a couple of good starting points:
  1. The fiduciary imperative of reference-based pricing: A legal and financial analysis; and
  2. America will dramatically change the way it provides health care by 2030

Saturday, March 25, 2023

1.2 Million Canadians Are Waiting for Care They Desperately Need

According to the Canadian Institute for Health Information (CIHI), the median wait time for priority procedures in Canada in 2020 was 16.8 weeks, up from 10.9 weeks in 2019. Priority procedures are defined as procedures that are clinically necessary, but their delay could result in the patient's condition becoming more serious.

However, wait times vary widely depending on the province or territory and the specific medical facility. In 2020, the median wait time for priority procedures ranged from 10.6 weeks in Quebec to 32.9 weeks in Prince Edward Island. Even the median wait time for cancer-related surgeries was 4.8 weeks. 

Patients are often forced to travel to a different province to try and get care more quickly. 

This is a summary of the current situation from the Mises Institute

Currently, there are approximately 1.2 million Canadians stuck on a government waiting list for healthcare that they need. This is a death sentence for many of them, as it has been for thousands of patients who have gone before them. ...

Patients who endure considerable suffering as they languish on a waiting list—where many of them die—cannot be seen to have been given reasonable access to health services in the government’s Medicare system. The government also prevents them from having reasonable access to a private healthcare option.

Thus, reasonable access is an obvious deception, with benefits flowing to highly paid, power-hungry politicians, bureaucrats, and administrators wanting to maintain control over massive, inefficient healthcare bureaucracies at the federal and provincial levels. This deceitful behavior fits the definition of fraud and should be prosecuted as such.

Thousands of Canadians die while they wait for the care that the government promised to deliver when they needed it. ...

If politicians were personally accountable for the damage they caused, guess what? They wouldn’t cause any damage! However, we cannot hold them personally accountable because equality under the law does not exist in a democracy.

In the private sector, you are accountable for your own actions. If you break your neighbor’s window, you pay for the replacement. If you are a politician and you break the window in the course of performing your official duties, you can charge the cost of the new window to taxpayers....

When citizens demand better service, politicians respond by saying, “Okay, but that means we have to take more of your money.” So, taxes are raised, more bureaucrats and administrators are hired, and the inefficient Medicare bureaucracies that politicians and bureaucrats regard as their personal fiefdoms grow ever larger. That’s why healthcare is the single largest item in many provincial budgets. ...

Saturday, March 4, 2023

Rackets, Rods, Radio Ranches & BOR Letters

After losing to Jimmy Conners sixteen times in a row, Vitas Gerulaitis finally broke through and beat his relentless tormenter. In the post-match press conference, Gerulaitis said, "And let that be a lesson to you all. Nobody beats Vitas Gerulaitis 17 times in a row.”

Rods, Insurance, and Racquets


When the original partners of Liberty Benefit Insurance Services of Los Gatos, California, Dixon Greer and Ryan Kennedy, began selling insurance together in the early 1990s, they failed to make one sale in their first 23 prospect meetings. When I started in insurance, I went nine months and made over 10,000 cold calls before closing a sale. In 2011, Greer, Kennedy, and the rest of the Liberty Benefit team sold the business to BB&T (now Truist) for more than we ever imagined possible back in our winless days. 

... this one is more about perseverance, grit and passion than insurance, per se. Head on over to my Substack to read the full story.  




Thursday, October 20, 2022

New CA Employment Laws, Trends in Rx Spending, Telemedicine Challenges and More

Benefits in Brief

Employees can put an extra $200 into their health care flexible spending accounts (health FSAs) next year, the IRS announced on Oct. 18, as the annual contribution limit rises to $3,050, up from $2,850 in 2022. The increase is double the $100 rise from 2021 to 2022 and reflects recent inflation. 

Compliance News

A Group Health Plan Without a Public Website may satisfy the new transparency and price disclosure requirements if the plan’s TPA posts the required information on its public website - (Q 11, pg. 12) Federal regulators have now made it clear that self-funded employers can rely on their administrator (TPA) to make the necessary price disclosure files publicly available so long as there is a written agreement in place. One original federal interpretation was that employers had to provide that on their websites, and if they did not have a public website, they had to create one for that purpose. Of course, that seemed ludicrous. And thankfully, regulators now agree it was.

California Expands Who an Employee Can Care for Under the CFRA and California Paid Sick Leave Law - "Beginning January 1, 2023, employees throughout California will be able to use sick leave or take leave under the California Family Rights Act (CFRA) to care for a 'designated person' ... defined as any individual related by blood or whose association with the employee is equivalent to a family relationship. An employee can designate this person at the time they request leave." 

California Unleashes Last-Minute Onslaught of New Employment Legislation - California Governor Newsom recently signed several pieces of employment-related legislation into law including: Supplemental Paid Sick Leave Extension, an expansion of the California Family Rights Act and California Paid Sick Leave, Unpaid Bereavement Leave, Emergency Working Conditions, Reproductive Health Decisionmaking, and Cal/WARN Act Enforcement for Call Centers.  

Benefit News

Trends in Prescription Drug Spending, 2016-2021 - This HHS Issue Brief presents the Agency’s findings on prescription drug spending trends between 2016-2021. 

  • In 2021, the U.S. health care system spent $603 billion on prescription drugs, before accounting for rebates, of which $421 billion was on retail drugs. 
  • Spending growth on drugs was largely due to growth in spending per prescription, and to a lesser extent by increased utilization (i.e., more prescriptions).
  • Expenditure growth was larger for non-retail drug expenditures (25%) than for retail expenditures (13%). 
  • Between 2016 and 2021, the location where people received their drugs changed. Americans increasingly received their drugs from mail order pharmacies (35% increase), clinics (45% increase), and home health care (95% increase). During the same time period, there were decreases in drugs received through independent pharmacies (5% decrease), long term care facilities (17% decrease), and federal facilities (9% decrease). 
  • Drug spending is heavily driven by a relatively small number of high-cost products. The cost of specialty drugs has continued to grow, totaling $301 billion in 2021, an increase of 43% since 2016. Specialty drugs represented 50% of total drug spending in 2021. While the majority (80%) of prescriptions that Americans fill are for generic drugs, brand name drugs accounted for 80% of prescription drug spending in both retail and non-retail settings, with little change over time. The top 10% of drugs by price make up fewer than 1% of all prescriptions but account for 15% of retail spending and 20%-25% of non-retail spending.
  • Prescription drug spending trends have been less affected by the COVID-19 pandemic than health care services. 
  • Several provisions in the Inflation Reduction Act address drug pricing, including allowing the Secretary of HHS to negotiate prices in Medicare Parts B and D for selected medications and introducing Medicare rebates for drug prices that rise faster than inflation. These provisions may impact future drug spending trends.
  • There were 1216 products whose price increases during the twelve-month period from July 2021 to July 2022 exceeded the inflation rate of 8.5 percent for that time period. The average price increase for these drugs was 31.6 percent.

Telemedicine was made easy during COVID-19. Not any more - "Over the past year, nearly 40 states and Washington, D.C., have ended emergency declarations that made it easier for doctors to use video visits to see patients in another state, according to the Alliance for Connected Care, which advocates for telemedicine use. Some, like Virginia, have created exceptions for people who have an existing relationship with a physician. A few, like Arizona and Florida, have made it easier for out-of-state doctors to practice telemedicine. Doctors say the resulting patchwork of regulations creates confusion and has led some practices to shut down out-of-state telemedicine entirely. That leaves follow-up visits, consultations or other care only to patients who have the means to travel for in-person meetings."

Health and Wellness

Sore Throat, Now the Most Common Sign of COVID - "where once a fever and loss of taste or smell were early warning signs of the bug, the symptom tracking app has revealed the most common symptoms have changed."

People who sleep 5 hours or less a night face a higher risk of multiple health problems as they age - "The study, published Tuesday in the journal PLOS Medicine, took a closer look at a group of nearly 8,000 civil servants in the United Kingdom who had no chronic disease at age 50. Scientists asked the participants to report on how much sleep they got during clinic examinations every four to five years for the next 25 years. For those whose sleep was tracked at age 50, people who slept five hours or less a night faced a 30% higher risk that they would develop multiple chronic diseases over time than those who slept at least seven hours a night. At 60, it was a 32% increased risk, and at 70, it was a 40% greater risk."

Monday, October 3, 2022

Compliance and Benefit News, October 3, 2022

Compliance Updates

CA Legislature Expands Pay Transparency and Data Reporting Requirements; Extends COVID Supplemental Paid Sick Leave - "If signed into law by Governor Newsom, the current amended version of SB 1162 would increase employers’ pay transparency obligations as follows: 1) upon request, all employers will be required to provide the pay scale (i.e., hourly rate or salary range) for the position in which the employee is currently employed; 2) employers will be required to maintain records of job title and wage rate history for all employees for the duration of employment plus three years; and 3) all employers with 15 or more employees will be required to disclose pay scales in all job postings.


SB 1162 also expands California employers’ current pay data reporting requirements, which were initially passed into law in 2020 as part of the nation’s first such state-imposed obligations. The current requirements mandate that private employers with 100 or more employees report annually the number of their employees by race, ethnicity, and sex in specified job categories to the Department of Fair Employment and Housing (recently renamed the Civil Rights Department (CRD))."

California Slated to Usher in New Era of Pay Transparency in 2023: What California Employers Need to Know - "The Act expands pay data reporting to all California employers with 100 or more employees regardless of whether or not they are exempted from the EEO-1 filing requirement. The Act also significantly expands the types of pay information employers must report each year. The first deadline to report is the second Wednesday of May 2023 (May 10, 2023). Covered employers must now also provide the “median and mean hourly rate” within each job category (discussed above), for each combination of race, ethnicity, and sex."

Benefit News

The Cost Of Long COVID To Employers Is Skyrocketing -"two types of claims were sorted out: those labeled long COVID, and those attributed to diabetes. When the numbers were crunched, here’s what came up: Per-member employer spend on long COVID was on average $2,654.67, more than 26% higher than the average diabetic spend....The study also finds that long COVID patients reported a 3.6 times greater likelihood of missing work for medical reasons than plan members without the symptoms. ... [T]he average predicted cost of long COVID to patients is nearly $9,500 within the first six months following a diagnosis."

Segal Trend Survey, 7.4% Plan Increases in 2023 - "The projected annual cost trend for outpatient prescription drugs is expected to be approaching double-digit levels, the highest rate observed since 2015. Double-digit specialty Rx cost trend, mostly driven by price increases and new-to-market specialty drugs, continues to be a major driver of Rx cost trends. Survey respondents project per-person cost trends for open-access PPO/POS plans to be 7.4 percent."

Yet Another Reason to Look at Reference-Based-Pricing (another hidden cost shift against employers) - Employer plans pay an average of 224% of what Medicare pays for the same hospitalizations. This cost shift away from Medicare and onto employers has led to growth in employers moving away from traditional insurance and reverence-base-pricing their plans. I spoke about it with Armstrong and Getty in September here. And I wrote about it becoming a growing trend in the 2020s hereA new study now shows that the same hidden tax/cost shift is happing with Obamacare Exchange plans.

‘Gaming’ Of U.S. Patent System Is Keeping Drug Prices Sky High, Report Says - Four pharmaceutical companies have filed hundreds of patents to keep their drugs out of the hands of generic competition and prolong their “unprecedented profits,” according to a report published Thursday. The excessive use of the patent system — by drugmakers Bristol-Myers Squibb, AbbVie, Regeneron and Bayer — keeps the prices of the medications at exorbitant levels, often at the expense of American consumers, according to the report from the Initiative for Medicines, Access & Knowledge, or I-MAK, a nonprofit organization that advocates drug patent reform. ... The U.S. patent system is meant to reward innovation by permitting drug companies to sell new medications on the market and barring other manufacturers from making generic versions for a set period of time — usually 20 years. Once the patent expires, generics are allowed on the market, often at a lower list price than the brand-name drug. But drugmakers often extend their patents by making small tweaks to the drugs, sustaining their monopolies for several years. Legal experts refer to this tactic as “evergreening...”

Health care spending for mental health disorders increases between 2013 and 2020 -

  • Overall spending on mental health services increased from 6.8% to 8.2% between 2013 and 2020, according to a new study published by the Employee Benefit Research Institute (EBRI).
  • The percentage of the population under the age of 65 with employment-based health coverage diagnosed with a mental health disorder increased from 14.2% in 2013 to 18.5% in 2020.
  • Among enrollees with a mental health diagnosis, average annual spending on mental health care services increased from $1,987 to $2,380 between 2013 and 2020 — an average of 3% per year.

Physician Burnout Has Reached Distressing Levels, New Research Finds - "Results released this month and published in Mayo Clinic Proceedings, a peer-reviewed journal, show that 63 percent of physicians surveyed reported at least one symptom of burnout at the end of 2021 and the beginning of 2022, an increase from 44 percent in 2017 and 46 percent in 2011. Only 30 percent felt satisfied with their work-life balance, compared with 43 percent five years earlier."

The perks that work to retain employees now - "Among employed adults, 56% say that the work schedule attracts them most in their current role ­— a factor valued more by women (61%) than men (51%). Almost half of the workers surveyed say that colleagues (48%), fair pay (46%), and work-life balance (43%) are most appealing, with 34% also appreciating their health benefits. In fact, 58% of Gen Z are attracted to their job because of colleagues and work friends, while men (52%) are more likely than women (39%) to be drawn to their job because they are paid fairly."

Health and Wellness

Antidepressants Work Better Than Sugar Pills Only 15 Percent of the Time - "Five years ago Mark Horowitz seemed an unlikely skeptic of psycho-pharmaceuticals. He had been taking the popular antidepressant Lexapro virtually every day for 15 years. He was so fascinated by the drugs that he spent three years hunched over a dish of human brain cells in a laboratory at King's College London, measuring the effect of human stress hormones and drugs like Prozac and Zoloft. Then, when he tried to wean himself off the medication, he suffered panic attacks, sleep disruptions, and depression so debilitating that he had to move back to his parents' house in Australia—symptoms that he says were far worse than anything he experienced prior to going on the drugs. He went online and found thousands of others in a similar pickle. They had been unable to kick one of the psychiatric drugs known as Selective Serotonin Reuptake Inhibitors, or SSRIs, which include Lexapro, Zoloft, and Prozac, among others. Since withdrawal symptoms were thought to be mild and temporary, many of them, like him, had been told by doctors that they were experiencing a relapse of their depression. ..."

How to maintain peak brain health: Scientists say it comes down to these 3 factors - "The three identified keys to strong brain health are:

  1. Physical exercise
  2. Social activity
  3. Strong, passionate interests and hobbies

Simple, right? Let’s break down each factor a bit further. ..."

CDC no longer recommends universal masking in health facilities - "The Centers for Disease Control and Prevention no longer recommends universal masking in health care settings, unless the facilities are in areas of high COVID-19 transmission. The agency quietly issued the updates as part of an overhaul to its infection control guidance for health workers published late Friday afternoon [Sept. 23rd]. It marks a major departure from the agency’s previous recommendation for universal masking."

Being unhappy or lonely speeds up aging — even more than smoking - "Being unhappy or experiencing loneliness accelerates the aging process more than smoking, according to new research. An international team says unhappiness damages the body’s biological clock, increasing the risk for Alzheimer’s, diabetes, heart disease, and other illnesses. The team reports that they detected aging acceleration among people with a history of stroke, liver and lung diseases, smoking, and in people with a vulnerable mental state. Interestingly, feeling hopeless, unhappy, and lonely displayed a connection to increasing a patient’s biological age more than the harmful impact of smoking."

Tuesday, September 20, 2022

Compliance and Benefit News Updates, Sept. 20, 2022

Tools You Can Use

How Employers Should Handle MLR Rebates - The Affordable Care Act (ACA) established medical loss ratio (MLR) rules to help control health care coverage costs and ensure that enrollees receive value for their premium dollars. The MLR rules require health insurance issuers to spend 80-85% of premium dollars on medical care and health care quality improvement rather than administrative costs. Issuers that do not meet these requirements must provide rebates to consumers. Rebates must be provided by September 30 following the end of the MLR reporting year. For the 2021 reporting year, issuers are required to pay rebates by Sept. 30, 2022. Employers that expect to receive rebates should review the MLR rebate rules and decide how they will administer the rebates. For assistance with rebates, please contact your Fantastic McGriff representative.

The affordability percentage for “Pay or Play” purposes under the Affordable Care Act will be decreased for 2023 to 9.12% of household income (from 9.61% in 2022). As a result, some employers will have to contribute more heavily toward the cost of individual coverage in order to avoid penalties. 

Compliance Updates

California Set to Extend COVID-19 Supplemental Paid Sick Leave Until End of Year - California is expected to extend COVID-19 Supplemental Paid Sick Leave (SPSL) through the end of 2022, but the leave-extending bill does not require employers to provide a new bucket of leave and establishes a relief grant for small businesses and non-profits who incur costs for SPSL. 

Court Allows GINA Claims to Proceed Against Wellness Program Sponsor - A recent case should remind employer plan sponsors that the Genetic Information Nondiscrimination Act may limit the information they are allowed to request from employees as part of a wellness program.  

How A Facebook Messenger Chat Can Become a “Usual and Customary” FMLA Notice Procedure For a Company - A Fourth Circuit case highlights the importance of abiding by the company’s written absence policies and call-in procedures. "Because the terminated employee’s manager accepted previous messages regarding absences via Facebook Messenger, the Company’s position that using Facebook Messenger was not its “usual and customary” notice practice for reporting FMLA absences was called into question. The Court found that previous utilization of Facebook Messenger to communicate absences raised a question of material fact for a jury to determine if a Facebook Messenger Chat satisfied the FMLA’s notice requirements."

California Passes Bill Protecting Employees’ Off-Duty Marijuana Use - California’s legislature recently passed AB 2188, a bill that would “make it unlawful for . . . employer[s] to discriminate against a person in hiring, termination, or any term or condition of employment . . .” for cannabis use while off the job and away from the workplace. 

Benefit News

Employers Project 7.5% Rise in Health Care Costs for 2023 - "As industry experts predict that organizations should brace for increased health care costs in 2023, the International Foundation of Employee Benefit Plans launched a survey of U.S employers to identify the considerations they are contemplating for the coming year. Results show that corporate employers project a median increase of 7.5% for medical plan costs."


Healthcare Pricing Protected So Far From Inflation, BLS Data Shows - "In July 2022, overall prices grew by 8.5% from the previous year, while prices for medical care increased by only 4.8%. While that’s a reversal from the typical trend, the relatively high rate of inflation seen in the rest of the economy may eventually translate to higher prices for medical care, the analysis found. This may lead to steeper premium increases in the coming years.... Since 2000, the price of medical care, including that of services provided, insurance, drugs and medical equipment, has risen faster than prices in the overall economy. Medical prices have grown 110.3% since 2000, while prices for all consumer goods and services rose by 71% in the same period."

The FDA Is Helping Millions Of Americans Hear Better. Finally - "The FDA finalized a rule that would allow people with mild to moderate hearing loss to buy hearing aids over the counter — no prescription, no haggling with insurance, which usually does not cover the devices, and no audiologist visit. This move will also allow people to bypass complex and unnecessary state-level restrictions, which often limit who can sell hearing aids and when, inhibiting patients from shopping around for the best products and discouraging manufacturers from competing on cost and quality."