Author Archives: Joseph Burns

Joseph Burns

About Joseph Burns

Joseph Burns (@jburns18), a Massachusetts-based independent journalist, is AHCJ’s topic leader on health insurance. He welcomes questions and suggestions on insurance resources and tip sheets at joseph@healthjournalism.org.

How to monitor the effects of insurance mergers

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InsuranceCompetition

Photo: Tyler via Flickr

When the American Medical Association publishes its next report on competition among health insurers, notice if Georgia makes into the top 10 among states with the least-competitive health insurance markets.

In the latest AMA report on competition, “The 2019 update to Competition in Health Insurance: A Comprehensive Study of U.S. Markets, Georgia had an overall score of 2,284, meaning the market for health insurers was below the highly concentrated level of 2,500 under the Herfindahl–Hirschman Index (HHI).

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Actuaries report on shortcomings of short-term, limited-duration health plans

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In a new study, Milliman actuaries compared costs under health insurance plans that comply with the requirements of the Affordable Care Act versus costs of short-term health plans that do not meet the ACA’s requirements.

Milliman actuaries compared costs under health insurance plans that comply with the requirements of the Affordable Care Act versus costs of short-term health plans that do not meet the ACA’s requirements.

New research about short-term, limited-duration health plans shows that none of the plans studied covered pre-existing conditions and all had coverage limits, according to a new report from Milliman, an actuarial consulting firm. Only one-third of the plans covered prescription drugs and only 42% covered mental health, according to the report.

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Facing increased scrutiny, PBMs will press case before High Court

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pharmacy benefit managers

Photo: FunGi_ (Trading) via Flickr

The U.S. Supreme Court recently agreed to hear a case that pits two groups on opposite sides of the debate over prescription drug costs: community pharmacists and pharmacy benefit managers.

In the case, Rutledge v. Pharmaceutical Care Management Association, the court will consider whether the federal Employee Retirement Income Security Act (ERISA) of 1974 pre-empts an Arkansas law regulating PBMs’ drug-reimbursement rates.

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FTC charges in Shkreli case shed light on need for new generic drug development

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The Federal Trade Commission and State of New York late last month filed a lawsuit against Martin Shkreli, charging that Shkreli and Vyera Pharmaceuticals raised the price of the life-saving drug Daraprim by more than 4,000% and worked to corner the market for such drugs.

“The joint action accused Shkreli and Vyera Pharmaceuticals, formerly known as Turing Pharmaceuticals, of scheming to ‘illegally’ prevent would-be generic competitors from selling a version of Daraprim,” as Stat’s Ed Silverman reported on Jan. 27. After acquiring the drug in 2015, Shkreli, dubbed the “Pharma Bro,” and Turing raised the list price of the medication from $17.50 per tablet to $750, he added. Continue reading →

In 2020, rebates from pharmaceutical companies deserve more scrutiny

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Source: 2018 Janssen U.S. Transparency Report. Reprinted with permission.This illustration from a Janssen Pharmaceutical Companies report shows how drug makers pay rebates across the pharmacy supply chain.

One of the big health care stories of the past few years has been how much money pharmaceutical manufacturers spend on rebates to promote prescription drugs. Pharmaceutical companies pay out rebates to just about every participant in the supply chain.

A report issued last year from the Janssen Pharmaceutical Companies (a division of Johnson & Johnson) showed that pharma companies give rebates to those companies that pay for health care (including health insurers, the government, and employers) and to PBMs, hospitals, physician groups, specialty pharmacies, wholesalers, government distributors, and to patients themselves.

Paying rebates to pharmacy benefit managers (PBMs) helps pharmaceutical companies keep medications on formularies, enticing health care purchasers to buy more drugs. Continue reading →

Report shows health insurers are failing to comply with mental health parity laws

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Source: “Addiction and Mental Health vs. Physical Health: Widening disparities in network use and provider reimbursement,” Milliman, November 2019.In a recent report on the level of parity between care for patients with mental health versus physical health conditions, actuaries from Milliman reported which states (shown in white and light blue) have the highest rates of parity and which states have the lowest rates (darker and deep blue). One of the strengths of the report is that it has data on parity for each state.

A recent report indicates that health insurers are failing to comply with mental health parity laws for people with employer-sponsored health coverage and their families.

In the report, “Addiction and Mental Health vs. Physical Health: Widening disparities in network use and provider reimbursement,” actuaries from the consulting firm Milliman document wide disparities in access to behavioral health care services for employees, family members and retirees with health insurance through an employer.

The report shows that disparities between physical and behavioral health care for both in-network access and provider reimbursement rates are making it harder for Americans to find affordable and available mental health care and addiction treatment. Continue reading →