AM News Cycle: April 26


More PBM legislation, Medicaid work requirements are a hot topic, low-value care's main culprits

More heat on PBMs

Another day, another hearing, piece of legislation or investigation targeting pharmacy benefit managers (PBMs). Sen. Bernie Sander of Vermont, chair of the Health, Education, Labor and Pensions Committee, and Sen. Bill Cassidy, of Louisiana, announced yesterday that they reached an agreement on a several drug price-related pieces of legislation, including one they are calling the Pharmacy Benefit Manager Reform Act of 2023. Sens. Patty Murray, a Washington state Democrat, and Robert Marshall, a Kansas Republican, are co-sponsors. The 91-page bill would ban spread pricing and impose a variety of disclosure requirements on PBMs, including one that require the PBM to disclose any “benefit design parameter” that encourages or requires beneficiaries to use a mail-order, specialty or retail pharmacy that is owned by the PBM. A markup is scheduled for next Tuesday, May 2. Sens. Mary Cantwell, a Washington state Democrat, and Chuck Grassley, an Iowa Republican, have introduced the Pharmacy Benefit Manager Transparency Act of 2023,and the Senate Finance Committee is also working on legislation. Meanwhile, Rep. James Comer, a Kentucky Republican, announced in March that he was launching an investigation of PBMs, and the Federal Trade Commission voted to launch inquiry last year,

Debate over Medicaid work requirements is heating

The Trump administration approved over a dozen Section 1115 waivers that allowed states to impose Medicaid work requirements, but court challenges and the Biden administration have blocked them in many states (Georgia and Arkansas are exceptions). But some House Republicans have been pushing hard to have work requirements included in the debt ceiling legislation that may be voted on this afternoon. It was unclear as of this writing whether the work requirements survived all the wheeling and dealing that occurred within the Republican caucus last night and into the wee hours this morning. Yesterday, the Department Health and Human Services put out a press release about an analysis that it said shows that approximately 21 million people’s health coverage would be threatened “if the draconian Medicaid work reporting requirements proposed by Congressional Republicans were implemented.” The Kaiser Family Foundation held one of its Health Wonk Shop virtual discussion on work requirements yesterday and the 43-minute video is available here.

These 7 are the main low-value care culprits

Using the Milliman Health Waste Calculator and pre-pandemic 2019 claims data from people with employer-sponsored health insurance, the Health Care Cost Institute (HCCI) issued a report yesterday that identified seven low-value services that were responsible for 70% of all low-value use and spending. Although inappropriate opioid prescribing for noncancer chronic pain was the most commonly used low-value service in HCCI’s tally, cardiac screens for asymptomatic patient was associated with the highest spending, accounting for 23% of all spending on low-value services. Other low-value culprits on HCCI’s list include vitamin D deficiency testing among low-and average-risk patients, prostate-specific antigen testing, general health checks for asymptomatic patients, preoperative baseline laboratory tests and preoperative cardiac tests.

From JAMA: Using IQVIA database, University of Michiganresearchers found that from January 2016 through October 2022, the monthly buprenorphine initiation rate increased, then flattened and that the leveling off occurred before the COVID-19 pandemic. Buprenorphine is used to opioid use disorder. “These findings suggest that recent clinical and policy efforts to increase buprenorphine use have been insufficient to meet the need for this medication,” they wrote.

From the FDA: The regulatory agency announced yesterday that it had granted accelerated to Qalsody (tofersen) for treatment of amyotrophic lateral sclerosis (ALS), sometimes referred to as Lou Gehrig’s disease. But the drug is only for people with a mutation in the superoxide dismutase 1 (SOD1) gene (SOD1-ALS). The FDA announcement cites a Centers for Disease Control and Prevention estimate that between 16,000 and 32,000 Americans are currently living with ALS but says approximately only about 2% of ALS cases are associated with mutations in the SOD1 gene, which the agency says works out fewer than 500 patients with SOD1-ALS in the United States.

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