Description: Two years ago, before COVID-19 changed everything about how we provide and receive health care, telehealth was largely provided by third-party vendors to treat a narrow range of acute one-and-done conditions. The value proposition was simple: a fast and easy member experience would drive satisfaction and engagement; high member satisfaction and engagement would drive health plan savings and member retention. Clearly, from the perspective of utilization, telehealth—as a viable alternative to in-person care during a pandemic—worked. And with COVID-19’s nudge—or was that a push?—toward cultural acceptance, the health care system is in a better position to capitalize on telehealth’s original promise of expanded access, lower cost and better outcomes than it was two years ago. But in the wake of the pandemic, it is just as clear to us that if telehealth is to live up to its full potential, some changes are needed. The rest of this article presents five ideas for improving the delivery of telehealth going forward.

Description: This article is an update on the No Surprises Act, which is a U.S. Act aimed to reduce the risk that a person unexpectedly receives out of network charges for their health care visits.

Description: This article on IPV focuses on IPV during the COVID-19 pandemic

Description: This article details the medical stop-loss coverages purchased by HMOs, small insurers and providers taking delegated financial risk in payor agreements. Along the way we will identify strategies purchasers often use to save money on medical stop-loss.

Description: The coming wave of biosimilars could dramatically affect prescription drug costs and benefit strategies over the next several years. The launch of many Humira biosimilars in 2023 is the Big Event that will largely determine the impact of the biosimilar wave. Payers have many decisions to make about coverage and formulary tiers. What factors will drive payer decision-making?

Description: PBMs are positioned in the healthcare delivery system as the only entity that is not regulated for profitability. The Commercial Fully Insured Health Insurance Plans are heavily regulated by the State Insurance Commissioner who allows only 2%-3% profit margin. The self-funded Health Plans are regulated by ERISA fiduciary responsibility that prohibits excessive compensation. PBMs are classed as a service provider and are not regulated by either. This allows PBMs to implement large, unreasonable mark ups for profit. PBMs are massive commercial entities, states are trying to sue under antitrust law. PBMs found a sweet spot in the regulation. Large Insurance Carries understood that and either acquired large PBMs or merged with them. It is likely that a combination of measures will be needed to regulate PBMs. The most direct approach would be for Congress to pass a law establishing PBM as a fiduciary under ERISA just like an “investment advisor” providing advice for a fee. Establishing PBM as a fiduciary will help Courts and other Federal Agencies ensure that PBMs do not unfairly retain rebates and inflate the prices of Rx drugs sold to employer health plans, and the US population in general.

Description: This is Part 2 of 2 on changes affecting Medigap insurers. It focuses on marketing and regulatory differences between Medigap and Medicare Advantage that affect the competitiveness of Medigap plans.

Description: When designing and pricing a healthcare product, it is not only important to know how to model frequency and severity, but it is essential to understand human behavior. Of course, the issue of anti-selection in medical insurance is well known as individuals know more about their health and prior expenditures than an insurer does. This type of behavior is certainly rational, and to be expected.

Description: What are Biosimilar drugs? Are they the same as generic drugs? What potential impact might Biosimilars have in the United States prescription drug landscape and it’s economics? This article explores those questions as well as exclusivity and interchangeability.

Description: This article attempts to make a modest contribution to the dialogue on the potential and risks associated with novel treatments such as cell & gene therapies. With a fast-expanding roster of what are believed to be one-time treatments at ever increasing price points aimed at curing a wider swatch of the population, they are as much a source of relief for patients stuck in medical limbo, as they are a source of anxiety for payers.