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 article talks about the challenges facing the FDA, especially those arising from the globalization of the pharmaceutical supply chain.

Description: This article provides the perspective of the Health Section's chairperson on Section activities, educational programs and the US healthcare environment.

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: The Health Section chairperson discusses the past year's activity, especially the Visions for the Future of the U.S. Health Care System essay contest, and an update on the Untapped Opportunities for Actuaries in Health initiative.

Description: An economics professor and a health care consumer advocate weigh in on the Patient Protection and Affordable Care Act, including implementation issues, directions for the future and what role actuaries shoudl take.

Description: This article summarizes 2012 AAA activities relating to the Affordable Care Act implementation, including work on the Amicus Brief for the Supreme Court Decision, MLR regulations, Actuarial Value, Rate Review, Essential Health Benefits and work with the NAIC.

Description: A new initiative, Commercial Health Care: What’s Next, will focus on education and research for health actuaries regarding issues that remain with the ACA.

Description: Part one of a two part series explores implementation issues for the Mental Health Parity and Addiction Equity Act of 2008 MHPAEA.

Description: A proposal to reform the health care provider payment system through: a national fee schedule, shifting more reimbursements to primary care providers, better integration of hospital & physician fees, evidence based care, pay for performance, and a better provider risk sharing mechanism.