The Wall Street Journal reports that pharmacy benefits manager Express Scripts is seeking new payment deals with pharmaceutical companies for some cancer drugs based on their effectiveness.
The common practice for PBMs is to pay the same per-unit rate for a cancer drug regardless of the type of cancer it is being used to treat. Express Scripts Chief Medical Officer Steve Miller said in an interview that the company has proposed changing the pricing structure based on how well a drug worked against different types of tumors.
“One of the big frustrations has always been people paying top dollar for drugs that aren’t always giving them the best response,” Dr. Miller said. “If pharma is truly sincere about wanting value-based reimbursement, we now have the sophistication to do that.”
Miller cited as an example Tarceva, a drug that has shown a smaller benefit in pancreatic cancer than in lung cancer. In an “indication-specific pricing” model, the per-pill cost of Tarceva, which currently costs about $6,850 a month per patient, would be lower for pancreatic-cancer patients than for lung-cancer patients, given the reduced efficacy.
A Business Insurance editorial calls on Congress to repeal the Affordable Care Act's "Cadillac" tax, which will penalize group health care plans premiums that exceed $10,200 for single coverage and $27,500 for family coverage:
"One justification for the tax has been that it will encourage employers to redesign their health care plans to better control costs to avoid, or at least delay, being hit with the tax.
"To that we say: nonsense. Employers have all the incentives they need — chiefly the need to earn a profit and stay competitive — to design their health care plans to keep cost increases under control.
"Indeed, it was the spiraling health care costs of a decade ago, not the threat of a federal excise tax, that led to the revolution in plan design that is helping employers keep the lid on cost increases.
"A key part of that revolution is the employer move to consumer-driven health care plans, whose key feature is greater participant cost-sharing through higher deductibles and coinsurance requirements.
"There is no question that CDHPs have made employees better consumers of health care services by, for example, moving them away from brand-name prescription drugs to less costly but identical generics, or going to urgent care centers rather than expensive hospital emergency rooms."
Read more at businessinsurance.com.
The staff of MedBen want to wish you and your family a happy and safe Memorial Day!
Our home office will be closed on Monday, May 25 in observance of the holiday. We will reopen at 8:00 a.m. Tuesday, May 26, 2012.
During this time, please remember that clients can use the online services of MedBen Access to check on benefit coverage and the status of any pending claims. Simply go to www.medben.com and select “MedBen Access". For those who use Pharmacy Data Management (PDM) as their pharmacy benefits manager, you can check on prescription claims and find lower cost drug options through MedBen Access by clicking on the “Rx” button located in the “My Claims” section of this website.
If you’re a MedBen Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA) participant in addition to having other coverage, you also can use MedBen Access to see your FSA/HRA balances, claims submissions and payments. When you log in to MedBen Access, you’ll find an “FSA/HRA Online Inquiry” option (visible only to groups offering MedBen FSAs/HRAs) under the “My Plan” section located on the left sidebar. By selecting this option, users are automatically taken to the MedBen FSA/HRA Online System.
Plan members who still wish to log in directly to the MedBen FSA/HRA Online System can do so by going to the Online Client Services area of medben.com and selecting “FSA/HRA Employee Online System". Login requires a separate User ID and PIN.
MedBen is pleased to announce the promotion of Andrea Corn to Director of Data Services and Special Investigation Unit (SIU). Corn has served customers of the health benefits management company since 1990.
The promotion was made in recognition of Corn’s continued dedication to ensuring quality and cost savings to clients, said Doug Freeman, MedBen’s Chairman of the Board and CEO. “Andrea has played a vital role in our efforts to maintain consistent work processes while reducing inefficiencies and unnecessary spending,” Freeman said.
Corn started at MedBen as a claims examiner trainee, eventually working her way up the ranks to a management position in the Claims Department. In 2006, she joined the company’s Data Services Department as Manager of Benefit Configuration, Quality Auditing and SIU.
As the Data Services Director, Corn will manage the operation of MedBen’s benefit configuration, which maps each plan within the claims processing system so that claims will be paid accurately. Additionally, she will oversee the auditing team that reviews claim payment accuracy, and direct the department's client and provider network data processes.
“The duties performed by Andrea’s team set the foundation for a variety of work processes companywide, from claims processing and payment to customer service,” said MedBen Vice President of Information Systems Rose Gribble-McEntire. “Ensuring that the content of our database is accurate is critical to everything we do.”
Corn also heads the Special Investigation Unit, which monitors claims to protect against waste and abuse, such as “unbundled” medical services that should be grouped together or charges for non-essential treatment. “By being vigilant about appropriate claims payment, the SIU greatly reduces the risk of improper reimbursements, saving clients even more money,” Gribble-McEntire said.
Andrea is a graduate of Heath High School and has earned industry designations as a Health Insurance Associate and Associate of Life and Health Claims.
Corn assumes her new role following the recent retirement of Director of Claim Operations Vicki Annarino. A three-decade veteran of the health care benefits industry, Annarino served MedBen clients since 2008.
“As much as we’ll miss Vicki’s exceptional talents as we move forward, we all wish her our best for a long and happy retirement,” Freeman said.
Apparently, Obamacare has not given employers sufficient confidence to release their employees into the wilds of the public insurance marketplace. According to a new survey by the International Foundation of Employee Benefit Plans, 98.2% of benefit professionals said businesses will continue to offer coverage in 2016.
Business Insurance reports that just 1.6% of respondents said their employers will provide coverage in 2016 but will encourage some employees to seek coverage through the public health insurance exchanges created by the health care reform law. Only 0.2% said they would drop coverage and direct employees to the exchanges.
As to why employers wil continue to offer coverage, 78.7% of benefit professionals survey said that employer use health care benefits to attract top talent, and 74.8% said it helps to retain current employees.
MedBen University offered timely and practical worksite wellness advice at its First Annual Wellness Roundtable on May 14. Held at the C. Arthur Morrow Conference Center in Newark, Ohio and co-sponsored by MedBen and Sun Life Financial, the event explored wellness programs from multiple perspectives and provided a wealth of information on ways that employers can improve workplace health while saving money.
Leading the presenters was MedBen President and COO Kurt Harden, speaking on "The Painful Truth About Wellness." Prefacing his comments with the statistic that "preventable, chronic diseases make up about 70% of deaths in American," Harden analyzed the results of a 2013 Rand study of worksite wellness programs -- specifically, its finding that such programs have mixed success.
Harden emphasized that short-term success shouldn't be the goal of a wellness program. "In fact, if you're doing it right, it will cost you money in the first year," he said, noting that the programs are designed to detect plan members with chronic conditions that require immediate attention.
As for what leads to "mixed success," Harden cited such factors as poor participation, lower incentives and unclear objectives. Only through a "targeted approach" -- one in which a majority of the employees are engaged, management is fully invested, and progress can be accurately measured -- will a worksite wellness plan succeed in the long term.
In an effort to clear up confusion about the range of free prescription birth control that insurers and self-funded health care plans must provide to members, the Obama administration earlier this week released a clarification to the Affordable Care Act contraceptive mandate, Kaiser Health News reports.
“Today’s guidance seeks to eliminate any ambiguity,” the Health and Human Services Department (HHS) said. “Insurers must cover without cost-sharing at least one form of contraception in each of the methods that the Food and Drug Administration has identified... including the ring, the patch and intrauterine devices.”
HHS released the ruling following reports that many insurers were not offering complimentary birth control for all prescriptions. The administration said that insurers may have misinterpreted the original language to mean that they only had to offer certain types of contraception without cost-sharing.
Health care plans may still charge fees to encourage individuals to use a particular brand or generic, so long as free alternative of that type is available.
Plans have until July to implement the policy, which will generally not take effect until a new plan year begins. That means for most people the new rule will start in January.
MedBen clients with questions regarding this ruling are welcome to contact Vice President of Compliance Carline Fraker at email@example.com.
Health care plans spend, on average, $10,000 more per person annually to treat individuals with diabetes than those who don't have the chronic disease, a new analysis reveals.
According to Forbes, a review of large insurance company claims data by The Health Care Cost Institute found that for people under age 65, spending per capita on health care for people with diabetes was just shy of $15,000 in 2013. By comparison, $4,305 was spent in the same year on people who didn’t have diabetes.
Expensive new brand name insulin and other prescription medications was a key driver in rising diabetes costs, the analysis says. Costs per capita for people with diabetes jumped from $14,404 in 2012 to $14,999 in 2013, compared to an increase from $4,146 to $4,305 for people without diabetes.
Over 12% of Americans 20 and older have diabetes, either diagnosed or undiagnosed, and another 37% have pre-diabetes. The vast majority of those individuals -- more than 9 out of 10 -- have type 2 diabetes, which is largely caused by obesity and physical inactivity. Fortunately, the condition is largely treatable.
MedBen WellLiving helps plan members diagnosed with type 2 diabetes take the proper steps toward better health. With our Specialty Care program, an RN Health Consultant will contacts patients to offer customized counseling. Members who choose to use the service will get individualized, confidential disease monitoring on a scheduled basis
Specialty Care is just one element of MedBen WellLiving, however. Our total wellness strategy promotes awareness of personal health, as well as the importance of the doctor-patient relationship in preventing long-term complications from unmanaged health conditions.
To learn more about how MedBen WellLiving can help your employees stay healthy and save money, contact Vice President of Sales & Marketing Brian Fargus at firstname.lastname@example.org.
In a recent interview by Employee Benefit Advisor, a representative from a national employee business service company says that fully-insured employers with as few as 50 employees "are seriously considering self-funding."
At MedBen, our experience is different. Smaller employers aren't simply considering it... rather, they've been buying our self-funding services for some time now.
Over the past two years, 78% of our new self-funded clients have come from fully insured plans... some with even less than 50 employees. And considering the advantages self-funding offers, it's hardly surprising that more mid- and small-sized businesses are making the switch:
Additionally, MedBen offers a variety of self-funded solutions, from captive programs that allow employers the chance to get part of their reinsurance premium back, to plans that provide total design independence and maximum savings opportunities. Whether you've got 25 employees or 2,500 (or more), we can help you create a health care benefits package that addresses your group's unique needs.
Arthritis is considered the leading cause for disability in America, with more than 53 million adults and 300,000 children suffering from its symptoms. “Arthritis” is a loose term, referring to over 100 different types that are related to joint inflammation and pain. Each one is unique and usually requires some form of treatment – otherwise, it could become a chronic condition.
Degenerative arthritis, the most common form of the condition, occurs when excess weight, genetics, or previous damage causes the cushions on the end of the bones to deteriorate leaving bare bones to grind against one another. But regardless of type, all share such similar characteristics as swelling, inflammation and pain if not treated.
Arthritis has been proven to get worse or become more likely as a person gets older, but it is possible to start seeing symptoms at an earlier age. Swollen joints or pain may be a sign that you need to see your family doctor for more assistance.
To check for possible arthritis, a physician may run a blood test, perform a physical examination, or require an X-ray. Patients who have chronic or inflammatory arthritis may be referred to a rheumatologist. No matter what causes arthritis, one thing is for sure: the earlier it is caught, the more likely it is for successful treatment.
On Monday, the IRS announced its annual cost-of-living adjustments affecting health savings accounts (HSAs) for calendar year 2016. The HSA contribution limits will increase for families, but stay the same for self-only coverage.
High-deductible health plan (HDHP) out-of-pocket maximums will also increase, while the HDHP minimum required deductibles remain unchanged.
MedBen clients with questions regarding these adjustments are welcome to contact Director of Administrative Services Sharon A. Mills at (800) 423-3151, Ext. 438 or email@example.com.
Obamacare problems, continued...
Straight on the heels of last week's report that multiple states are having difficulty financing their insurance marketplaces, Monday saw the release of a poll showing a spike in emergency room visits since the Affordable Care Act took effect.
According to USA Today, the American College of Emergency Physicians poll found that 28% of 2,099 doctors surveyed nationally saw large increases in volume, while 47% saw slight increases. By contrast, fewer than half of doctors reported any increases last year in the early days of the ACA.
Obviously, this finding flies directly in the face of one of the stated goals of health care reform -- to give individuals greater access to primary care, thus reducing the need for costly ER visits. Trouble is, the influx of newly insured patients has far exceeded the current supply of family doctors.
"They don't have anywhere to go but the emergency room," said ACEP President Mike Gerardi. "This is what we predicted. We know people come because they have to."
The refusal by some physicians to accept Medicaid patients has also contributed to the surge in ER activity.
"Nearly half of the 17 insurance marketplaces set up by the states and the District under President Obama’s health law are struggling financially," reports The Washington Post today.
Uncooperative technology and expensive customer-call centers contribute to rising costs, exacerbated further by less-than-hoped-for enrollment numbers. Marketplace officials are looking for ways to cut costs and raise funds, such as raising insurer fees, sharing costs with other states and appealing for additional funds.
One other possible solution: Dropping state marketplaces in part or altogether and folding them into HealthCare.gov, the federal insurance exchange used by the majority of states. But simply washing their hands of the marketplaces may not be an option of the Supreme Court rules next month that states using HealthCare.gov cannot receive subsidies to buy insurance.
Based on a preliminary federal estimate of economic activity in the first quarter of 2015, health care spending will continue to increase at a higher rate than in previous years, Modern Healthcare reports.
Data released on April 29 by the U.S. Department of Commerce's Bureau of Economic Analysis estimates that, when adjusted for inflation, health care spending in the first three months of 2015 rose 5.5% compared with the same quarter last year as well as the fourth quarter. By contrast, real gross domestic product in the first quarter increased only 0.2% compared with the fourth quarter.
While this analysis is only a first draft based on incomplete data, the information is consistent with recent health care spending reports, particularly within the hospital setting. Moreover, the measurement does not calculate prescription drugs and other goods, so spending may be even higher.
Estimates like this demonstrate the importance of having a dedicated benefits managers as an ally, to help your business keep its health care spending in check. At MedBen, we combine forward-thinking administration of your medical claims with some common-sense concepts we’ve developed to make group health coverage more efficient, while saving employers money in the process.
MedBen offer actionable reporting tools that let you see where your health care dollars are going, and why. And we find clients quality, low-cost health care backed up with the most verifiable savings.
In the matter of the Affordable Care Act, Democrats and Republicans in Congress have seldom seen eye-to-eye on its various regulations, responsibilities and penalties. But a looming tax could conceivably bring both sides of the aisle together.
The so-called "Cadillac tax," set to take effect in 2018, will impose a 40% excise tax on individual health plans worth more than $10,200 and family plans worth more than $27,500. The tax has met strong resistance from Congressional Republicans -- and recently, several Democratic representatives joined the opposition, introducing the Middle Class Health Benefits Tax Repeal Act to repeal the Cadillac tax.
On Forbes.com, Robert W. Wood argues that the growing concerns about the tax's impact are well-founded:
"Whatever else it is, the Cadillac tax name is a misnomer. It will apply to many benefits that are not elite. Company provided health benefits have not been taxed for generations. And that is exactly what the Cadillac tax does. It is broad too, applying to health savings and flexible spending accounts, supplemental insurance plans, and more.
"Even plans that are not hit by the 40% tax in 2018 soon could be. After all, the Cadillac tax is linked to the consumer price index plus 1%. Medical and insurance costs are growing far faster, so more and more plans will be hit with the 40% each year. A survey by Mercer anticipates that one-third of employers will be hit by the tax in 2018, growing to 60% by 2022. It could be worse still."
MedBen clients that have questions about the Cadillac tax are welcome to contact Vice President of Complaince Caroline Fraker at firstname.lastname@example.org.
It may not be riveting reading, but the DOL's latest report to Congress regarding the state of self-funded plans in still important. As you may recall, the Affordable Care Act (ACA) requires the Department of Labor to report general information on self-funded plans to Congress each year and this is its fifth such report. To generate its findings, the DOL reviewed the most recent compilation of IRS Form 5500 tax returns, which means the DOL reviewed 2012 group health plans filings for this report. Bear in mind that, because the DOL is creating this report from 5500 filings, they are missing a large segment of self-funded group health plans - those maintained by public employers not subject to the 5500 filing requirements.
But, while the data is limited to private employers, it is still valuable. Note the following: Of the 2012 5500 filings reviewed, 40% of the participants in new health plans were covered under a self-funded group health plan, while 26% were covered under mixed insurance plans and 34% were covered by a fully-insured plans. In addition, in 2012 there were 20,600 self-funded group health plans that filed Form 5500s; those plans covered approximately 32 million participants. These numbers don't include the large number of public employers that self-fund.
What does this mean? First, it means that self-funding is alive and well. Employers continue to self-fund because they can provide meaningful benefits to their employees while maintaining financial control over the cost of those benefits. But it also means that Congress and the DOL continue to keep a watchful eye on the growth of self-funding and how such growth may affect the continuing implementation of the Affordable Care Act.
Simple changes can make a major difference in a person's well-being -- and for employers looking to promote a healthier workplace, the American Heart Association has seven messages that are words to live by.
According to Reuters Health, the association has released "Life's simple 7" -- guidelines by which a worksite wellness program can encourage heart health. The messages are: stop smoking, get active, lose weight, eat better, manage blood pressure, control cholesterol and reduce blood sugar.
The messages are targeted specifically to employers because “There are about 155 million working Americans today, that’s about half of our population,” said AHA president Dr. Elliott M. Antman.
“We want to inform people about what heart-healthy living involves and have companies recognized for promoting heart health,” Antman told Reuters Health by phone. “We hope the lessons learned from that environment will be carried home so workers’ spouses and family will benefit as well.”
Businesses often advertise that they "cut out the middle man and pass the savings on to you." And indeed, sometime that's an effective money-saving strategy. But not always.
Case in point: A new report on cost management for Medicaid pharmacy benefits demonstrates that keeping the "middle men" -- in this case, managed care organizations -- actually resulted in lower costs.
The report by trade association America’s Health Insurance Plans (AHIP) determined that in states in which an MCO manages Medicaid pharmacy costs (that is, benefits are "carved in"), the net cost per was 14.6% lower than the average net cost per prescription in states not carving in pharmacy ("carved out").
Other key findings in the report:
Hat tip to the NCPA Health Policy Blog.
“Lift with your legs, not with your back.” We’ve all heard it said a hundred times... and for good reason. It’s a smart bit of advice for anyone interested in avoiding a back injury.
Roughly 65 million Americans suffer from back pain, ranking it among the top reasons for physician visits. In addition to muscle strain caused by improper lifting, you can throw your back out of whack through accidents or sports injuries, or simply by carrying excess body weight.
Back pain can take multiple forms, from a steady aching along the spine to a sharp, localized pain. But fortunately, 95% of cases can be treated without surgery.
There are a variety of remedies for back pain available, ranging from heat wraps and massages to adding more vitamin D to your diet. Often, rest and exercise can provide relief, but for more severe cases, physical therapy may be necessary. Opioids, or “painkillers,” are also an option, but such drugs can be highly addictive, so caution must be taken if used.
If you suffer from persistent back pain, review the symptoms with your family doctor and discuss potential fixes. (If you also have numbness in your arms or legs, seek immediate medical help.) Hopefully, together you’ll find a solution that will have you “back” to your healthy self soon!
Government business representatives gathered on April 16 at the C. Arthur Morrow Conference Center in Newark, Ohio for the 9th Annual MedBen Municipality Roundtable. Through multiple presentations, current MedBen clients were able to see how their plan costs compared to that of other groups in the MedBen municipality block, while clients and non-clients alike were offered proven tips on the best ways to keep their medical and pharmacy plan spending in check.
Among employer groups, municipalities traditionally offer some of the most benefit-rich coverages. Union contracts can mean much lower out-of-pocket costs (and by extension, more frequent use of medical care) for plan members than those in the private sector, which make it a challenge for public employers to keep costs.
Fortunately, by following MedBen recommendations, municipality clients have on average kept their costs well under the national norms. Total MedBen municipality block costs only rose 2.5% from 2013 to 2014. Moreover, the block's five-year trend from 2010 to 2014 was just a 0.5% increase overall.
MedBen University will continue to offer additional roundtable and educational sessions throughout 2015. The following upcoming MBU sessions will also be held at the Morrow Conference Center:
Wellness in the Workplace Thursday, May 14
With client worksite wellness programs in place for nearly a decade, MedBen has gained expertise on how an increased focus on preventive care and lifestyle changes can benefit workplace health and productivity, as well as the employer’s bottom line. We’ll produce useful advice for businesses thinking about implementing a wellness program and share success stories that current wellness clients can adapt to their own programs.
Business Roundtable Thursday, May 28
At this premiere session, employers from a wide range of specialties will get a “big picture” look at the current state of health care planning and learn about the distinctive challenges employers in other fields face. You'll see how plan costs can vary among different industries – and discover how the savings strategies other companies use can benefit your business, too.
For additional information about these upcoming MBUs or to reserve a seat for one, please contact MedBen Sales Analyst Sally Wood at (800) 423-3151, Ext. 502 or email@example.com.
Additionally, MBU will continue to tour the Midwest, co-sponsoring benefits management sessions with MedBen brokers. These are typically invitation-only events for employers in the respective region... so if we haven't made it to your neck of the woods yet, keep an eye on your mail. Chances are good we'll be around there in the near future!