We Thrive Together Medicare Agency’s Post

https://lnkd.in/eewPx87b Takeaway: Medicare is prohibited under current law from covering drugs used for weight loss, but Medicare Part D plans can cover GLP-1s for their other medically-accepted indications, including to treat diabetes, and now to cut cardiovascular risk based on a recent memo from the Centers for Medicare & Medicaid Services (CMS). While the potential cost of authorizing Medicare coverage of anti-obesity drugs has presented a barrier to enacting legislation to lift the prohibition, covering these drugs under Medicare for authorized uses has already catapulted these drugs to rank among the top-selling drugs covered by Part D, Medicare’s outpatient drug benefit program.

Its tragic that this is the best message is to 'shame' and grand stand. Bernie is a self proclaimed socialist, so we expect this, although government programs - Medicare, Medicaid and ACA products cover these drugs. However Biden should understand that that price is driven by demand. While its certainly an expensive drug, there are alternatives for diabetics. As an obesity drug there are any number of alternatives - some are free lifestyle changes like diet and exercise. I think we can expect more of our leaders in understanding and promoting a free market economy. These two proponents of the ACA clearly made the problem worse with Medicaid expansion and government subsidized premiums.

Thanks to the Inflation Reduction Act, one of President Biden’s signature achievements, prescription drugs are set to become substantially more affordable for seniors. Yet many Americans seem unaware of just how monumental these changes will be. My latest Washington Post column is on the 6 policy changes to look for. The most notable is the cap on out-of-pocket costs. In 2025, everyone with Medicare’s prescription drug benefit, called Part D, will pay no more than $2,000 per year out of pocket for medications. The Center for Medicare and Medicaid Services projects that nearly 19 million seniors will save an average of $400 per year. But this number alone does not tell the full story. CMS Administrator Chiquita Brooks-LaSure shared with me that she recently met a woman with leukemia. “She’s spending $12,000, which was 13 percent of her gross income, just for one drug,” she said. I myself have treated patients who chose not to fill medications because out-of-pocket costs were too high. I’ve met spouses who delayed retirement and caregivers who worked extra jobs just so they could cover their loved one’s prescription costs. This should not happen. The $2,000 maximum will be a huge step toward health-care affordability. https://lnkd.in/eJbz_CRH #prescriptiondrugpricing #medicare #CMS #medicationcosts #healthcare #IRA #healthpolicy

Some American seniors will see reduced out-of-pocket costs for over 60 drugs, including treatments for osteoporosis and cancer, as part of the White House’s effort to control rising pharmaceutical prices. This will apply to 64 drugs administered in doctor’s offices and hospitals from July to September. Seniors and those with disabilities who have met their annual deductible will benefit from a lower coinsurance rate. These drugs were chosen because their prices rose faster than the rate of inflation. We are seeing significant changes to Medicare drug prices. These are all welcome changes to the clients I work with. It all so means that a Medicare review is vital this year as drug prices fall and premiums are expected to increase. Make sure you do a full review of your entire Medicare program. 🗝 Over 60 drugs, including osteoporosis and cancer treatments, will see reduced out-of-pocket costs for seniors due to a White House initiative targeting rising pharmaceutical prices. 🗝 The price reductions will apply to 64 drugs administered in doctor’s offices and hospitals from July to September, benefiting seniors and those with disabilities who have met their annual deductible. 🗝 These drugs were selected because their prices increased faster than the rate of inflation. 🗝 The effort is part of President Biden’s Inflation Reduction Act, aiming to address rapid drug price increases, affecting over three-quarters of a million Medicare enrollees. 🗝 The administration estimates this initiative will save taxpayers approximately $237 billion over the next decade. #medicare #retirmentplanning https://lnkd.in/gKMYTv-H

Insightful article about the Centers for Medicare & Medicaid Services #cms #inflationreductionact #ira drug price negotiation program and how it may offer a chance to actually improve #healthequity published in Health Affairs today. The key take-aways for me: we have a unique opportunity to advance #comparativeeffectiveness methodologies that more appropriately capture and consider #heterogeneity of treatment outcomes, and further the adoption and use of #subgroupanalyses to ultimately improve #healthequity. As the authors succinctly state, we all know that there is no 'average' patient. #CMS's #ira mandate incudes an appropriate consideration of all relevant patient population subgroups (including #raredisease patients as well as patients at increased risk of adverse health outcomes due to age, sex, race/ethnicity, various other social determinants of health #SDOH, etc. and for whom specific 'therapeutic alternatives' may not be appropriate choices). #CMS failing to do so effectively can hamper access in particular if the clinical benefit of a drug for specific population subgroups is underestimated. The authors are right that clear evidence standards, including for real-world data, and meaningful stakeholder engagement - through patient listening sessions and beyond! - will be key... and although #CMS's efforts to date are admirable there is considerable room for further progress and improvement!

🚀 Big News for Heart Patients with Obesity: Medicare & Medicaid to Cover Anti-Obesity Drugs for Additional Medical Conditions🚀 In a groundbreaking move, the Centers for Medicare and Medicaid Services (CMS) have announced a pivotal shift in their coverage policy, significantly expanding access to anti-obesity drugs for US government health program beneficiaries. Here are the key takeaways: 1. Expanded Coverage: CMS has issued guidance to Medicare Part D plans, indicating that anti-obesity medications that have received FDA approval for additional medically accepted indications, such as reducing the risk of major cardiovascular events, will now be covered. 2. Specific Criteria for Coverage: It's crucial to note that while this expansion is significant, the coverage for anti-obesity drugs is not for the treatment of obesity alone. Drugs like Wegovy and Eli Lilly’s competitor, which are under study for multiple new indications (from heart health to joint damage), will be covered when prescribed for additional conditions like heart health. 3. FDA's Role & Recent Developments: The FDA’s recent expansion of Wegovy’s label to include the prevention of cardiovascular events is a testament to the evolving understanding and acceptance of the multifaceted benefits of these medications. 4. Future Implications: This decision may be a harbinger for further changes, including Congressional efforts to mandate CMS coverage for weight loss indications. This could open doors to comprehensive care options for patients struggling with obesity and associated health conditions. 5. Health Plans’ Autonomy & Prior Authorization: Despite this advancement, it’s anticipated that health plans will implement prior authorization requirements to ensure that these medications are used precisely for their approved indications, especially focusing on patients with cardiovascular diseases who also have obesity. This move by CMS marks a significant milestone in the journey towards integrating comprehensive and preventive healthcare solutions for chronic conditions, reflecting a broader recognition of the interconnectedness of obesity with other serious health issues. #HealthcareInnovation #CMS #MedicareMedicaid #ObesityTreatment #CardiovascularHealth #Wegovy #FDA #HealthPolicy Check out the fullstory from Endpoints News https://lnkd.in/efnQdwA5

STAT on a wild approach from researchers at Yale University – buying Novo Nordisk might not be Medicare’s worst option. Medicare spending on GLP-1s increased from $57 million in 2018 to $5.7 billion in 2022; for Medicaid, spending increased from $383 million to $1.8 billion in that period. Treating half of Medicare and Medicaid beneficiaries with obesity would cost $166 billion per year; the cost of total spending on all prescription drugs in 2022 was $175 billion! The authors state ‘…Medicare and Medicaid must secure a fair deal on Wegovy.’  Medicare can negotiate prices, develop outcomes-based agreements, contract a biosimilar company to manufacture GLP-1 drugs, or… buy Novo Nordisk for its current market capitalization of about $600 billion. The cost of buying Novo Nordisk could be recouped in 22 months through GLP-1 purchases alone. But again, the authors are just talking about the price, the initial outlay – the impact to reduce chronic disease burden is far greater, from a humanitarian and economic perspective. https://lnkd.in/eDkwa8vE

🗞️ Extra, Extra! The Centers for Medicare & Medicaid Services, CMS, in the US announced their Maximum Fair Prices. Boy, did it make interesting Friday night conversation among the economists I call friends (vice versa). https://lnkd.in/gMMfbWas Healthcare payers the world over struggle with meeting seemingly unlimited needs with finite resources. Economics 101. Countries and systems have tried to solve this puzzle in various ways and like watching someone set a bouldering route, it is fascinating to observe. The CMS makes two statements, “𝘔𝘦𝘥𝘪𝘤𝘢𝘳𝘦’𝘴 𝘯𝘦𝘸 𝘢𝘣𝘪𝘭𝘪𝘵𝘺 𝘵𝘰 𝘯𝘦𝘨𝘰𝘵𝘪𝘢𝘵𝘦 𝘱𝘳𝘪𝘤𝘦𝘴 𝘧𝘰𝘳 𝘴𝘦𝘭𝘦𝘤𝘵𝘦𝘥 𝘥𝘳𝘶𝘨𝘴 𝘸𝘪𝘭𝘭 𝘪𝘮𝘱𝘳𝘰𝘷𝘦 𝘥𝘳𝘶𝘨 𝘢𝘧𝘧𝘰𝘳𝘥𝘢𝘣𝘪𝘭𝘪𝘵𝘺 𝘧𝘰𝘳 𝘱𝘦𝘰𝘱𝘭𝘦 𝘸𝘪𝘵𝘩 𝘔𝘦𝘥𝘪𝘤𝘢𝘳𝘦, 𝘪𝘮𝘱𝘳𝘰𝘷𝘪𝘯𝘨 𝘢𝘤𝘤𝘦𝘴𝘴 𝘵𝘰 𝘪𝘯𝘯𝘰𝘷𝘢𝘵𝘪𝘷𝘦 𝘭𝘪𝘧𝘦-𝘴𝘢𝘷𝘪𝘯𝘨 𝘵𝘳𝘦𝘢𝘵𝘮𝘦𝘯𝘵𝘴 𝘧𝘰𝘳 𝘱𝘦𝘰𝘱𝘭𝘦 𝘸𝘩𝘰 𝘯𝘦𝘦𝘥 𝘵𝘩𝘦𝘮.” “…𝘵𝘩𝘦 𝘯𝘦𝘨𝘰𝘵𝘪𝘢𝘵𝘦𝘥 𝘱𝘳𝘪𝘤𝘦𝘴 𝘸𝘰𝘶𝘭𝘥 𝘩𝘢𝘷𝘦 𝘴𝘢𝘷𝘦𝘥 𝘢𝘯 𝘦𝘴𝘵𝘪𝘮𝘢𝘵𝘦𝘥 $6 𝘣𝘪𝘭𝘭𝘪𝘰𝘯 𝘪𝘯 2023 𝘢𝘤𝘳𝘰𝘴𝘴 𝘵𝘩𝘦 10 𝘥𝘳𝘶𝘨𝘴, 𝘸𝘩𝘪𝘤𝘩 𝘸𝘰𝘶𝘭𝘥 𝘩𝘢𝘷𝘦 𝘢𝘮𝘰𝘶𝘯𝘵𝘦𝘥 𝘵𝘰 𝘢𝘱𝘱𝘳𝘰𝘹𝘪𝘮𝘢𝘵𝘦𝘭𝘺 22% 𝘪𝘯 𝘴𝘢𝘷𝘪𝘯𝘨𝘴.” While this seems like a great party, two less-than-fun guests that could be on the invite are Middlemen and Counterfactuals. Margins that rack up as healthcare changes hands from provider to patient will dilute any savings on paper and take teeth away from price negotiations. My first exposure to counterfactuals was in my time doing policy analysis work. What a delightful science. They allow us to explore what-ifs. Much like rewinding time, changing a decision and seeing what happens. If done right, we can differentiate causation from correlation, and coincidence. Would prices have dropped otherwise? 🤷🏻♀️ Maybe somebody somewhere knows. I hold out hope that these read positively as they should, for the patients who deserve good treatments and the good outcomes that come with them. #healthcarefinancing #healthcare #healtheconomics 

Are you keeping an eye on your company's 👀🔎 Medical and Pharmacy Claims Data? Fully insured members: Take control of your healthcare costs by actively reviewing and managing your company's medical and pharmacy claims data. BCBSM's Wake-Up Call: $544 million operating loss 📉 $36.3 billion in revenue in 2023 (they call it revenue, employers call it PREMIUM) Year-Over-Year Cost Increases: $1.4 billion increase in #CLAIMS costs 📈 $1.8 billion increase in #PHARMACY costs 📈 What's Driving the Increase? High-priced #specialtydrugs #GLP-1s impact: Largest contributor to pharmacy costs Cost Blues $350 million more than in 2022 #GLP-1s for diabetes, which BCBSM will continue to cover, constitute a large share of that figure

Medicare's Plan to Lower Drug Prices: Helping Seniors Afford Medications and Saving Billions #bipartisansupport #CMSplan #highdrugprices #inflationrebatepenalty #lowerdrugprices #Medicaredrugpricenegotiations #outofpocketcosts #pharmaceuticalresearchanddevelopment #prescriptiondrugaffordability #risinghealthcarecosts