Blaine Lindsey JD, MPH

This weekend #CMS issued a #Medicare Final Rule with new #PartD technical requirements. In addition to regulatory updates, this rule itself is a crucial reminder for #MA plans:  ✅ This FR codifies previous Proposed Rules which remained unfinalized. ✅ This FR reminds plans that unadjudicated #MedicareAdvantage #StarRatings proposals (including increase of #Improvement measure #HoldHarmless from 4 to 5 stars and removal of cutpoint guardrails from non-CAHPS measures) remain alive and can be finalized by CMS without additional rulemaking. From a technical perspective, among other things, this FR:   1️⃣ Requires Part D plans, prescribers and dispensers to to exclusively use NCPDP Formulary & Benefit standard for electronic transmission of formulary/benefits info (including ePA) by 1/1/2027. 2️⃣ Requires RTBTs to comply with RTBT standard v13 (adopted by ONC) by 1/1/2027. 3️⃣ Codifies many technical/technological details to align CMS and #ONC. If you’re not in the pharmacy space, why should you care? Here are 4 reasons: ⚠ This illustrates that pending high-impact #Stars changes can still be codified. ⚠ CMS admits this FR is needed because recently-codified RTBT requirements were created in absence of industry-wide standards, and as ONC catches up to policy needs, new regs will be established despite impact to providers, plans and vendors. ⚠ Last week’s restated Star Ratings to correct #Tukey errors may increase 2025 Medicare spending by up to $1 billion. CMS may seek methods by which to make that change budget neutral, which the proposals to remove guardrails and change the Improvement measure Hold Harmless provisions could achieve. ⚠ January's #Interoperability FR was complex and TL;DR for many, but it will trigger more #HHS Interagency alignment and regulatory adjustments sooner rather than later. Here are a few things insurors, providers and vendors outside of Part D should consider in response to this FR: ✔ How ready are you for January’s Interoperability FR? ✔ What gaps exist between your current status and looming Interoperability requirements? ✔ How might greater CMS/ONC alignment impact your organization? ✔ What strategic investments do you need to consider to ensure your readiness? With #PartDRedesign and the #IRA about to kickstart the most disruptive pharmacy changes since Part D launched in 2006, early adopters of these new requirements will lead the way in #CAHPS and #memberexperience. This is a great time for Stars teams to continue reminding executives that ambiguity and uncertainty is exactly what CMS wants! They want free markets to force us to strive as high as we're willing in order to reap #QBP rewards. Whether you are seeking corporate or personal leadership development and growth, our Reality-Based Improvement Institute has been designed to drive success amidst uncertainty. Reach out if you’d like to learn more. #WhatGotYouHereWontGetYouThere #LetsRoll ⭐ ⭐ ⭐ ⭐ ⭐

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CMS’ “Year 2” IRA Guidance Concedes Agency Patient Engagement Has Been a Bust A number of patient groups have quietly expressed frustration with #CMS’ “listening sessions” on the #InflationReductionAct “fair price” negotiations. If you read CMS’ “year 2” guidance carefully, it effectively admits the patient complaints are real and legitimate. The Complaints: Patient groups sat on the sidelines in the litigation challenging the constitutionality of the IRA, at least in part, because they believed that they could shape IRA implementation through agency engagement. But some groups are now expressing frustration. They expected CMS to explain how it was approaching negotiation and the underlying evaluation of the selected drugs. With that context, they expected to be able to provide meaningful feedback to CMS’ plans and preliminary assessments. According to the groups I have spoken to, that is not how things have gone. CMS is tight-lipped—in “listen only” mode. Unclear what CMS is considering and how it sees the “value” question, “patient interaction” on the IRA has devolved into CMS and patient groups staring at each other blankly. Confirmation: When you read the “year 2” guidance, it confirms the patient complaints. Deploying diplomatic “regulatory speak”, CMS says it “intends to improve upon the design of the patient-focused listening sessions”. Note the reference to “listening sessions”—confirming the agency has been in “listen only” mode. CMS admits the need for change, saying it “is soliciting comments from interested parties on event format, scope, and logistics”; it then indicates it “is considering events where there is discussion among speakers and in which CMS may ask clarifying questions”. But even this proposal isn’t getting to the core of the problem—patient groups shouldn’t have to be expert mind readers regarding CMS’ intent based on a few interspersed “clarifying questions”. CMS offers some other alternatives, too: “CMS is also weighing different event formats, such as round table sessions on broader topics with a mix of speaker types (e.g., patients, providers, and health data experts) or focus groups on targeted topics with one speaker type (e.g., patients or caregivers)”. But all that doesn’t commit CMS to doing any speaking. Just that others—patients, providers, and “experts” will be asked to speak. Patient groups can’t react in, or to, a vacuum. No Time: The guidance concedes that they can’t fix the problem for “year 1”. After all, July 31, 2024 is the deadline for manufacturers of selected drug to accept or reject CMS's final MFP offer. Indeed, CMS acknowledges that its proposed changes in patient engagement will be effective only “for…price…year 2027”. So, in another words, at least for “year 1”, we are going to get “fair prices” that don’t reflect meaningful patient input. #drugdevelopment #drugpricing #Medicare #managedcare #rarediseases #patientsfirst #lifesciences

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The Double Standard that Protects #CMS, #MAPlans, and #PBMs In 2007, 17 years ago, Judge Saris, in the #AWP case, took #drug makers to the watershed for EXACTLY what #CMS, #MedicareAdvantage plans, commercial payers, and #PBMs do to patients EVERY day. What was bad for the goose (manufacturers) is perfectly fine for the many ganders out there. It’s time to throw a flag on this ridiculous double standard. The Case: I’m rereading In re: AWP for the law school course I’m teaching in the Fall, and, as happens each time I read it, my head explodes. Judge Saris was merciless in her criticism of how Average Wholesale Price, because it did not reflect rebates and other discounts, affected patients. “Disturbingly”, Saris wrote, “the patient was a vulnerable victim” of AWP as the means to peg both #reimbursements and #copays. This was so, she said, because the “inflated” AWPs that did reflect rebates and discounts, meant that “the Medicare patient was required to make a co-payment” that was itself “inflated”. With obvious disgust, she concluded her rant by intoning that ”manufacturers understood well the harmful impact that publishing inflated AWPs had on the elderly cancer patient” through the inflated copays they paid. I wish that some of Judge Saris’ outrage could now be turned towards #Congress, #HHS, #CMS, MA plans, and their #PBMs. All of these “ganders” are responsible for inflated Part D “negotiated prices” that impose the very same kind of inflated #costsharing “percentages” on vulnerable patients. The “ganders” know that—but they have enshrined inflated prices in Part D “negotiated price” and profit of off it. The same dynamic exists in the commercial insurance market. The ganders don’t care. #InflationReductionAct supporters will say: “Ah ha—but that is the beauty of the the IRA. It will mean truly negotiated prices where a net price will be the basis of the cost share.” Well, I fear that is doubly wrong. First, that only applies, if it applies at all, to #IRA “selected drugs”. So many patients using so very many other #drugs are necessarily subjected to exactly the kind of inflated copays that Judge Saris decried under the #PartD statute’s “negotiated price” deception. Second, I’m skeptical that patients even get the benefit, at least in the early years of the IRA, of “select drug” copay rates, which, on paper, will be lower. Why’s that? As I have said before, I’m not understanding why plans and PBMs won’t push patients using those select drugs to high list/high rebate alternatives—forcing patients to continue to pay the inflated copays Judge Saris found “[d]isturbing”. Lower copays on paper that aren’t actually accessed don’t mean nothin’. Why hasn’t 17 YEARS been sufficient to systematically fix this #patientharm? Senator Sanders, let’s stop the finger pointing exercise, and just fix this problem. #lifesciences #drugpricing #managedcare #healthcare

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Risk adjustment ensures providers are paid fairly in capitated payment models, allowing them to deliver appropriate care to all patients. However, if done poorly, it can worsen health inequities by misallocating resources. In my work, I've seen the importance of accurately predicting future healthcare costs to ensure providers can care for healthier and sicker patients. Risk adjustment modifies payments based on patients' characteristics and health conditions. This method uses statistical models to assign risk scores, adjusting payments accordingly to reflect the expected cost of care. One challenge we face is inconsistent data and coding practices, which can affect the accuracy of these adjustments. Traditionally, risk adjustment focuses on factors like age and chronic conditions. However, incorporating social determinants of health—such as housing stability and food security—is essential for fair compensation. These factors impact health outcomes but are often excluded due to data standardization issues. To better support providers and reduce inequities, it’s crucial to design and implement risk adjustment models carefully, incorporating comprehensive data and considering social factors. This approach ensures we can continue to deliver high-quality care to all patients, regardless of their health needs. #Healthcare #Hospitals #doctors #hospitals #CommunityHealth

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#340b Issues Left All Kinds of Fuzzy in the #IRA Draft Guidance Rich Daly’s 340B Report article charts a course through the 340B aspects of the “Year 2” #CMS #Medicare “fair price” guidance. I’m quoted. As Rich’s article explains, the guidance leaves stakeholders with more questions than answers. The article, which is definitively worth a read, makes the following 3 points: 1) There’s no provision for reliably identifying 340B duplicates. The use of 340B identifiers is “voluntary”, meaning that the #MTF data won’t be able to serve as a meaningful “screen” for 340B duplicates. 2) 340B #coveredentities, #contractpharmacies, and other #pharmacies are deeply concerned about the lack of details explaining how they will be paid the “fair price” by manufacturers. Well, manufacturers are equally concerned—in part because of CMS’s repeated threats, sprinkled throughout the guidance document, to subject #drug makers to #enforcement if their payments are inaccurate or untimely. The guidance’s vague and ill-formed provisions increase the enforcement risk, exponentially. 3) The guidance is marred by the agency’s lack of understanding of how distribution and data flows currently operate—and what can and needs to change to effectuate “fair price”. Ignorance and naïveté never lead to clear, dependable guidance. Implications: #Drug makers, if they have not already done so, need to partner ASAP with a contractor to do what the MTF won’t be capable of doing. You can’t rely on the MTF, and you don’t have much time to implement your own solution. One last note: I’ve expressed concerns about the timeline to get the MTF stood up. Comments to this proposed guidance are due July 2. Realistically, to review those comments and to address the gaping holes in the draft guidance, we may not get final guidance until October or November. After that, an RFP and contracting process would follow. This could mean that work would not begin, in a meaningful way, until November or December, with the holidays in full swing. That means just about a year, maybe less, of actual work time to get an MTF designed, implemented, and tested. I’m not saying that’s impossible, but it sure ain’t going to be easy. https://lnkd.in/eXvd2J-X

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Sooner than You Think: When Will the #340B Program Be the Largest #Drug Program in the Country? The IQVIA 340B report is chock full of great info on what is happening in 340B. But, with some other data, it points to how fast 340B will be the largest drug program in the country—bigger, even, than #Medicare #PartD. Main Takeaways: The report tells us that: • In 2023, 340B sales were $124.1B. • 2022 to 2023 growth was an astonishing 16.5%. • 5 year growth was a more astonishing 129.4%. • Those growth rates were (can we be more astonished?) more than 3x the growth rate of non-340B sales. • #Hospitals and #clinics increased 18.9% year-over-year and retail and mail channels was up 10.2%, “despite ongoing #contractpharmacy restriction[s]”. • The average 340B discount was 55%. • 2023 340B profits/subsidies were $56.1B. But Where Are We Headed?: Good question. I applied the current growth rate of 16.5% to the current 340B sales of $124B and compared that result to Part D gross spend by the government in 2021, marked up by the average growth rate for Part D from 2016-2021. Based on the current rate of increase in the 340B program, the 340B program--already the second largest drug program in the country--will be the largest program, eclipsing even Part D, in just 6 years. At that point, 340B sales will be in excess of $310B a year. Applying the current relationship between 340B sales and 340B profits/subsidies ($124.1B to $56.1B), that would mean that, in 6 years, 340B profits/subsidies would be in excess of $145B. In any program that even approaches that size, patients should receive drugs without any #costsharing where their income is less than 300% of the federal #poverty limit, all patients should have cost-sharing determined based on net (not inflated) gross prices, and 340B hospitals should have a set obligation to provide a designated percentage of revenue to charity care, without fail. It is unconscionable that federal reform proposals and state contract pharmacy laws fail to include these basic patient protection provisions. The 340B program must put the #patientfirst, beginning with that patient at the #pharmacy counter, whether they seek #medication for a #chronicdisease or a #raredisease. It’s the right thing to do, and we should do it now. #managedcare #charitycare 3charities #financialneed #allcopayscount #copays #costsharing #fpl #access #affordability #rarediseases #lifesciences

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Updated Questions Questions Questions: Lequembi and CMS (with two answers) Here is what CMS said to STAT: "Medicare’s actuaries expect the drug Leqembi, made by the Japanese drugmaker Eisai and sold in partnership with Biogen, to cost the traditional Medicare program around $550 million in 2024, and the entire Medicare program $3.5 billion in 2025, a spokesperson for the Centers for Medicare and Medicaid Services confirmed to STAT. That projection forecasts a large increase in uptake over the next year and a half." As usual I just have questions: 1) Is this the actuarial contingency margin or actual expected expenditures? Answer expected expenditures (OACT) 2) Does that estimate include the cost of diagnosis and checking that patients do not have ARIA? Answer The PMPM estimates include the cost of the drugs themselves, the cost for administration of the drug, and the costs of associated diagnostic testing and office visits. (OACT) 3) If just the drug, did the actuaries consider the primary site of service is the HOPD where drugs are part of the overall budget neutrality equation? Its not like physician fee schedule where drugs were separated from the other fees. 4) Are rural hospital proponents examining Medicare hospital outpatient payments shift away from smaller urban and rural facilities to large urban due to the addition of these and similar highly complex services. (I note the cost of the "340B" fix demonstrated the link clearly for all to see in the HOPD final rule for 2023* I'll put the shift at the bottom.)) Example of budget neutrality shift: "As required by statute, CMS implemented a 3.09% reduction to the payment rates for non-drug items and services to achieve budget neutrality for the 340B drug payment rate change for CY 2023." #lequembi #CMSOACT #ruralhospitals

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In the face of ongoing challenges, such as the recent shortages of FDA-approved GLP-1 medications (eg, Ozempic, etc), compounding pharmacies like Empower Pharmacy are stepping up to fill critical gaps. 💪 Our compounded medications are not only tailored to meet individual needs like allergies and dosage adjustments but also ensure that patients continue to receive essential treatments without interruption. Also, compounded medications are way more affordable. 💰 We're committed to personalizing healthcare solutions. By providing alternative forms and custom dosages, we make sure that everyone has access to the medications they need, exactly how they need them. Learn more about what we do --> https://lnkd.in/g_XRaHcM If you want to chat about it, DM me! #medicationshortage #healthcareinnovations #GLP1s #weightloss #diabetes #healthcaresolutions #houston #integrativehealth #access

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Join me at our live webinar on May 15 to learn more about the newly defined standard Part D benefit. 

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New 2024-2025 #PBM Report identifies and profiles nearly 70 PBMs - market leaders, mid-market, non-traditional http://bit.ly/4dbITVU #pharmacybenefit #transparency #pharmacy #drugpricing #CVS #OptumRx #ExpressScripts #report

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Also don’t outsource your hospital’s core services to a GPO ran by foreign PE… I do find it so odd that Vizient’s own contracts couldn’t stand on their own so they had to create a aggregation group with Mayo Clinic called Capits. (https://lnkd.in/gpiVDKvn) Which by the way Mayo Clinic is being sued because not only does Mayo control pricing on supply chain contracts for Vizient, but guess who controls pricing on their self insured insurance plan. (https://lnkd.in/guvx5mqr) Oh and as of November of last year Mayo Clinic lead their state in adverse healthcare events. (https://lnkd.in/gXsPi2sw) Should I go on or have I made my point clear on why Oklahoma hospitals should not blindly follow Vizient, Captis, and the Mayo Clinic?

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If you build it, will they come? I’ve heard countless organizations - #MA plans, #Medicaid plans, risk-bearing providers, vendors, PBMs, and retail players - say “we need to build the capabilities to XX”. Many are looking to vendors for solutions, but few vendors are ready to invest in new capabilities without contracts.  Anyone else sensing this (problematic) new conundrum? Here’s my quick take and a few ideas to break through this barrier. Many sales meetings are often held with functional departments, and often do not include the #MedicareAdvantage #StarRatings, #RiskAdjustment, #HEDIS, IT or P&L owners. We must collaborate to get those departments’ urgent needs integrated into new vendor purchases in order for new activities to meet new and emerging needs, remembering that: 🌟 Vendors are vital to your success.  🌟 Vendors operate in a more volatile environment than plans. 🌟 Vendors have smaller budgets than plans. 🌟 Vendors need signed contracts to make significant investments.   🌟 Vague RFPs waste vendors’ time and resources. Collaboration creates win-win contracts which expand capabilities of both parties. I encourage plans to: ✅ Ask vendors about their roadmap; including timing and certainty of planned enhancements. ✅ Include the #Stars, Risk Adjustment and #PartD teams in new vendor discussions. ✅ Consider adding a vendor's roadmap capabilities to contracts. ✅ Co-create with trustworthy vendors. I encourage vendors to: ✔ Ask about the customer’s unmet needs. ✔ Offer to co-create solutions to new and emerging needs with willing customers. ✔ Offer to accelerate roadmap capabilities with willing customers.   ✔ Articulate the things you would be willing to do if a customer would be willing to contract for it. This is a #MarketMakingMoment as #CMS has thrown down the gauntlet with #NewNeedsOfStars and #NewNeedsOfMA. This is a stellar time for vendors to review current and planned capabilities with a broader lens on new and emerging MA, #Compliance, Stars, #ECDS, #Interoperability, #HealthEquity, Medicaid & #SNP Aligment, and Risk Adjustment needs. If you need help, reach out to us.  #WhatGotYouHereWontGetYouThere  ⭐ ⭐ ⭐ ⭐ ⭐

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Now that the health plans have all submitted their Medicare Advantage bids for the 2025 calendar year, I thought it would be worth bringing up a recognized problem in the CMS Benchmark calculation (United States Per Capita Cost or USPCC) that falsely lowers the benchmark. If you aren’t familiar with how these benchmarks are calculated, I wrote a simplified explanation last month which you can find here: https://lnkd.in/gSmvq9mB The first step in calculating this benchmark is for CMS to add up the risk-adjusted monthly total fee-for-service spend for all Traditional Medicare beneficiaries and get an average spend per beneficiary per month. The thing is, they include beneficiaries that only have Part A (institutional expenses) but not Part B (professional expenses) as well as those that only have Part B and not Part A. Obviously, that means they’re counting people where a meaningful portion of their medical expenditures are not included as if they’re the same as people where all of their spend is included. In effect, this lowers the average monthly cost per beneficiary. Yet, this is the benchmark that is used to represent the cost to manage the combination of all Part A and Part B expenses for a population. That is, the MA bids have to cover both Parts A and B for their whole population but it is being compared to a benchmark where some of the people only have one or the other. Even MedPAC has recognized this issue and calculated in 2017 that if they were to only include beneficiaries with both Parts A and B, it would raise the benchmarks by about 1%. This fact tends to be ignored in the news articles decrying the higher spending in MA when compared to Traditional Medicare. #MA #MedicareAdvantage #Benchmarks #ManagedCare #Medicare

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Don’t Believe #Optum When It Professes a Commitment to #Value As a #raredisease patient, my bs meter has gone off. This article illustrates the core problem with the “value” debate: people mean vastly different things when they use the word. But this little bit of finger wagging pontification from Optum illustrates the ugly core of that core—when some people bandy that word about, they don’t actually want to pay for value at all. Disclaimer: I haven’t done a value analysis of the current and future possible indications of #GLP1s, which, I’ll note, Optum hasn’t done either. So, unlike Optum, which appears to have already come to a conclusion, i won’t speak to whether any use of any #GLP-1 has the value to support a price increase. As an aside, this drug class is right at the edge of a global #drugshortage. I have a vague recollection from college (when I attended it in the Middle Ages) that there’s some sort of connection between “supply” and “demand”. I forget exactly how that goes. Please message me with a tutorial. My Point: But my point is more fundamental than any particular GLP or its indications. This executive is speaking for Optum, which controls a huge swath of #healthcare, with enormous impact on the lives and well-being of millions and millions of people. It’s pretty critical that when he and his organization talk about paying for value, they mean it. Because if they don’t, the inevitable effect is that people like me, who pray every day for #druginnovation, aren’t going to get it. And there are things said here—complete with an air of moral superiority—that tells me that Optum doesn’t really want to pay for value. They want to use the word, but the perspective, at its root, is anti-value. Here’s the part that just set me off: “I think the concern is when you look at those 4 or 5 indications where data is going to be available over the next couple of years, well those drugs would also be introduced with yet another brand, same drug, and yet another price increase for the same drug. In theory, volume should translate [to lower costs]. If this were purely about manufacturing cost, volume should translate to lower cost. But it's not. That’s irresponsible or irrational pricing behavior.” That is a wonderfully direct rejection, in the most fundamental way possible, of any consideration of value. He’s rejecting the notion, in advance, of paying even one penny more for the possibility of multiple new indicators, without even seeing a lick of evidence on their value. He’s angling instead for the proposition, a la #SenatorSanders, that champion of #innovation, that greater volume use, without regard to “value”, should result in lower prices. And then, moral sage that he is, he concludes that any other perspective is “irrational” and “irresponsible”. It’s a sweeping and yes, I’ll say it, “irresponsible” thing for a #pbm executive to say. Shame on you. #drugpricing #reimbursement #pharmacy #drugs #diabetes #weightloss

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CVS Health's CFO made a striking confession: "The goal next year is margin over membership". He then explicitly acknowledged the potential loss of up to 10% of their Medicare members to bolster financial margins. What does this mean? In plain terms, one of America's largest healthcare giants, with projected annual revenues nearing $360 billion (still 10% more than last year), is considering reducing its patient base—yes, **patients** (aka members)—under its #MedicareAdvantage plans. This decision comes as a result of growing "utilization pressures"- a payer euphemism indicating that more people are seeking the care they desperately need. And what were those "utilization pressures"? Increased outpatient services, outpatient pharmacy, and behavioral mental health services (healthcare). Big Picture: CVS Health isn’t just any company. It's a behemoth with sprawling operations, including Aetna, a CVS Health Company (a major insurer), CVS Caremark (a leading pharmacy benefit manager), and a vast healthcare workforce through CVS MinuteClinic and Oak Street Health. Despite these extensive resources and their near-monopolistic vertical in the healthcare industry, the focus turns to profits over patients (aka margins over members). The Problem: Incentives. Medicare Advantage insurers and administrators love the upfront capital from Centers for Medicare & Medicaid Services (aka taxpayers), but really dislike it when patients actually need to use their services (which drains their capital) or CMS cuts their reimbursement due to quality concerns. To maintain profitability, they have three options: 1) shed members or 2) make it even more difficulty for patients to use services or 3) all of the above. And here's the problem, all options are bad for patients. Folks, it's beyond time to question the incentives embedded within our profit-drive health insurance system and in Medicare Advantage. We have to critically evaluate how business decisions by CVS (or United Healthcare or Humana) ultimately affect patient outcomes and #provider practice. To be clear, margins are necessary because it's true "no margin, no mission", but when a company can openly prioritize margins with potential repercussions for vulnerable, senior populations, it highlights the profound misalignments between healthcare needs and business strategies. #Healthcare #CVS #MedicareAdvantage #BusinessEthics #PatientCare ABIG Health Matthew Raffa MBA Meroka UNC Kenan-Flagler Business School MBA@UNC ESCP Business School

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🌟 Exciting Insights from the Latest Harvard-Inovalon Medicare Study! 🌟 As professionals in the Medicare Advantage space, we’re always on the lookout for data that underscores the efficacy and efficiency of MA plans. A recent study by Harvard and Inovalon has brought some compelling findings to light, showing that Medicare Advantage not only reduces healthcare expenditures but also maintains high levels of care compared to traditional Medicare Fee-for-Service. Here are some key takeaways: - MA enrollees experience over 50% fewer inpatient stays and 22% fewer emergency visits compared to FFS, with no significant reduction in primary care or prescription drug services. - Overall, MA shows a 12% reduction in health expenditures, highlighting its efficiency in managing healthcare resources. At Sonder Health Plans, we're proud to say that we're already implementing many of the strategies that make Medicare Advantage so beneficial. Our focus on care coordination and preventive care isn’t just about keeping costs down—it's about providing a foundation for healthier, happier lives for all our members. This study reinforces the value of the Medicare Advantage program and the potential for more innovative, cost-effective care models. Let’s continue to push forward, driving improvements that matter. #MedicareAdvantage #HealthcareInnovation #SonderHealthPlans

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I was approached recently by someone begging me to help a patient afford a GLP-1. The person asked me to weigh in on whether the patient should take the Facebook offer for a price that approximated a tenth of the Novo price or use a compounding pharmacy at approximately 30%. I appreciated today's Vanity Fair article describing the potential problems with "grey market" pharmaceuticals. I know many groups need help with the price of pharmaceuticals and end up importing medications without FDA pathways. As a patient, I know how much these drugs cost me, and I've seen how much they cost my plan. I want lower costs as much as the next person. However, employers are importing through grey channels; I hope they consider the a) risk of an ineffective medication being provided that drives up costs, b) an adulterated drug harming their employee, and c) the potential liability for using non-FDA channels. *I'm not a lawyer, but I hope that if you or your plan is suggesting importation or other grey channels, you address these questions with counsel.* We can push the FDA for better importation pathways, and we can push for different approaches to drug pricing as better solutions. My Three takeaways. #1 Don't buy drugs on Facebook marketplace. #2 If you are an employer considering an importation pathway, consider how to verify the safety and efficacy before providing them to your employees. #3 Consider working with your state legislature to create a legal importation pathway rather than relying on the pharmaceutical grey market that can put people at serious risk.

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I'm sure everyone is aware of this news, but just to make it clear: The payers are in trouble. Profitable growth will not return until they find ways to reduce operating, back-office, and administrative costs, because high Medical Cost/Care Ratios are here to stay. As someone who has been privy to large payer operations, I can say there is significant room for improvement. However, bureaucracy and slow technology adoption continue to be major impediments. Luckily, the document-based, fax-oriented healthcare business model has the potential to overcome some of the most manual and mundane back-office problems by utilizing GenAi and LLMs, resulting in 200-400 basis points of additional profits. Yet, the inclination to develop their own solutions, or the desire to align with big brands like OpenAI, Microsoft, and Google, will likely result in nothing more than press releases and superficial market strategies. I worry that their natural tendency to cut costs by reducing headcount will perpetuate the inefficiencies, create backlogs, and ultimately reduce quality of care. #healthcare #healthinsurence #cvs #aetna #genai #llm #artificialintelligence #ai #technology #deeplearning #tech #innovation #data #dataanalytics #business #datascientist #automation #analytics #medicare #carequality #backoffice https://lnkd.in/g9Dbqacs

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AccendoWave - A Pain #Data Company More recently, the federal government has begun using the QIS program and QRS parameters to advance health equity. Federal rules now require all marketplace insurers to adopt a strategy for reducing health disparities and to stratify certain clinical data by race and ethnicity. While state-based marketplaces (SBMs) have authority to supplement these federal minimum QIS and QRS standards with state-specific quality rules, most have hewed closely to the federal default approach. California and Washington are notable exceptions. Each has implemented a customized QIS program and robust data collection standards to identify and reduce racial and ethnic health disparities. Time to Focus on - #Pain not being Believed. A Root Cause Health Equity Problem. A Top 4 Global Health Equity Solution and Top 15 Global Remote Monitoring Company, AccendoWave, benchmarks objective brain wave pain data (specialty, gender, age) and has nine #pain databases: Emergency Department, Maternal Health, Oncology, MSK, Medical Surgical, ICU, #Women, Adults, #Seniors to eliminate bias, improve outcomes and reduce health care costs. If desired, AccendoWave can also create customized pain databases for partners that can be accessed on the Datavant platform.

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