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: On December 21, 2018, the Centers of Medicare & Medicaid Services (CMS) released the final rule for Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program. 'Pathways to Success' makes sweeping changes and will push ACOs to assume financial risk more quickly. This session will discuss the key changes in the final rule, reasons why providers would remain in the program while being forced to downside risk, and how actuaries can add value to providers who will be taking on millions of dollars of risk in the coming years.

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

Description: An overview of health care history and privatization developments in four Latin American countries: Mexico, Chile, Colombia, and Brazil.

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

Description: A list of acronyms for the names of the agencies, unions, and other organizations and entities involved in the French social insurance, health policy, and long-term care environment.

Description: Centers for Medicare & Medicaid Services (CMS) launched the GUIDE model, which represents a significant step forward in improving dementia care nationwide. Those with deep expertise in dementia recognize that family caregivers are the most powerful frontline defense to improve care for people living with dementia. It is thus not surprising that the GUIDE model specifically requires the inclusion of the family caregiver in the care team.

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: 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.