The Industry Impact of Medicare Drug Price Negotiations
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
The Biden administration recently unveiled the first 10 prescription drugs subject to Medicare price negotiations. The Medicare Drug Price Negotiation Program—part of the Inflation Reduction Act (IRA)—is the Biden administration’s latest effort to combat rising health care costs. According to a Kaiser Family Foundation survey, more than 60% of the 65 million people on Medicare take prescription medication, and 25% take at least four prescriptions. Medicare drug price negotiation aims to lower out-of-pocket costs for millions of seniors and offer savings for taxpayers.
The first round of Medicare Part D drug negotiations will begin this year, with the new prices becoming effective in 2026. Over the next four years, Medicare plans to negotiate prices for up to 60 Part D and Part B drugs—and up to an additional 20 drugs every year after that. This article outlines the potential impacts of the Medicare Drug Price Negotiation Program on the health care industry.
Overview of Medicare Drug Price Negotiations
Under the IRA, the Medicare Drug Price Negotiation Program allows the federal government to negotiate directly with drug manufacturers to improve access to some of the costliest brand-name drugs. Many Medicare Part D enrollees depend on medications to treat life-threatening conditions, such as diabetes and heart failure, but may not be able to access them due to costs.
The following Medicare Part D drugs will be the first ones subject to these negotiations:
- Eliquis, for preventing and treating blood clots
- Jardiance, for treating diabetes and heart failure
- Xarelto, for preventing and treating blood clots; risk reduction for patients with coronary or peripheral artery disease
- Januvia, for treating diabetes
- Farxiga, for treating diabetes, heart failure and chronic kidney disease
- Entresto, for treating heart failure
- Enbrel, for treating rheumatoid arthritis, psoriasis and psoriatic arthritis
- Imbruvica, for treating blood cancers
- Stelara, for treating psoriasis, psoriatic arthritis, Crohn’s disease and ulcerative colitis
- Fiasp/Novolog, for treating diabetes
These 10 drugs are among the highest costs in total spending in Medicare Part D. In fact, Medicare enrollees taking these drugs paid a collective $3.4 billion in out-of-pocket costs in 2022 to obtain them. However, according to the Centers for Medicare and Medicaid Services’ (CMS) guidelines, if a biosimilar enters the market and finds substantial buyers, the agency will cancel or adjourn negotiations for the corresponding name-brand drug listed for negotiations. For example, two biosimilar versions of Stelara are set to launch in 2025. If they are successful, the CMS will no longer be able to negotiate a lower price for Stelara.
Pharmaceutical companies have until Oct. 2, 2023, to present data on these drugs to the CMS. The CMS will then make initial price offers in February 2024, which will start the negotiation process. Negotiations are scheduled to end in August 2024, with the new prices becoming effective in January 2026. However, several pharmaceutical companies have filed lawsuits to stop the Medicare Drug Price Negotiation Program. Some of these lawsuits argue that the IRA’s price negotiation process violates the U.S. Constitution by allowing the federal government to impose its preferred price unilaterally. According to legal experts, it’s unclear whether these lawsuits will be successful since Medicare is a voluntary program for drug companies. However, these lawsuits could delay the timing of Medicare drug negotiations.
Impact of Medicare Drug Price Negotiations
Medicare has been setting prices for services as well as physician and hospital payments but has not been allowed to be involved in pricing prescription drugs, which Medicare started covering in 2006. Therefore, allowing Medicare to negotiate drug prices could have a significant impact on the health care industry. While the first 10 drugs subject to price negotiations are used by only 9 million Medicare beneficiaries, the CMS plans to negotiate prices for 50 drugs by 2029. These 10 drugs include some of the most expensive for Medicare, costing a combined $50 billion in 2022; however, the impact of Medicare drug price negotiations may be slow at first but grow with time.
Short-term Impacts of Medicare Drug Price Negotiations
The initial impact of the Medicare Drug Price Negotiation Program may have muted financial impacts on manufacturers and the federal government, at least for the first round of negotiations, according to analysts. This is largely due to factors that impact the revenue and profits of the 10 drugs scheduled for negotiation. For example, many of these drugs currently face competition from other branded medications or patent expirations, which will allow generic alternatives to hit the market. Additionally, some of these drugs do not contribute significantly to pharmaceutical companies’ businesses, so any decline in drug sales may have little impact on a company’s overall business and profitability.
Moreover, Medicare Part D plans (prescription drug plans) and pharmacy benefits managers have already negotiated rebates for the first 10 drugs set for negotiation. Further, many of these drugs come with manufacturer discounts, decreasing their prices well below the list price. As a result, the negotiated prices for these first 10 drugs may not be significant or reduce what the federal government currently pays for them.
Long-term Impacts of Medicare Drug Price Negotiations
While the commercial impact of negotiations may be limited for the initial list of drugs, this could change in future rounds of negotiations. In 2028 and beyond, Medicare drug price negotiations will begin to target Medicare Part B drugs, which cover more specialized medications that are administered by health care providers rather than pharmacies. Many of these drugs offer fewer rebates than the ones currently listed for negotiation. Additionally, some of these drugs are biologics, which will likely have a more significant impact on drug companies because they are much more expensive and have a greater impact on the earnings and growth of these companies.
Pharmaceutical companies claim that the drug price negotiations will curb the development of new drugs. As a result, Medicare drug price negotiations may result in pharmaceutical companies altering their drug development strategies over time. However, according to the Congressional Budget Office’s estimates, only a few drugs would not be developed each year because of Medicare drug price negotiations.
Impact on Individuals
Due to the high costs of these prescriptions, many Americans are forced to choose between paying for vital medications or buying food and other necessities. While some individuals may save money on their prescriptions because of price negotiations, the Medicare Drug Price Negotiation Program aims to lower overall Medicare costs. By doing this, the Medicare program and taxpayers could see significant savings. Moreover, starting in 2025, the IRA will deliver further relief to Medicare beneficiaries by limiting their drug spending to $2,000.
However, the impact of drug price negotiations on individuals not receiving Medicare is currently unclear. Some experts believe that by reducing how much drug companies can charge Medicare beneficiaries, they will increase prices for privately insured individuals. Others believe that Medicare drug price negotiations may enable private health plans to negotiate for lower drug prices for the medications they cover. Additionally, Medicare drug price negotiations could incentivize pharmaceutical companies to lower listed gross prices for medications, which could lower out-of-pocket payments for privately insured individuals.
Employer Takeaway
Medicare drug price negotiations allow the federal government to negotiate prices for a limited number of drugs to lower out-of-pocket costs for millions of seniors and offer savings for taxpayers. While the drugs scheduled for negotiation are among the most expensive, it will likely be some time before the impact of these negotiations is seen. Even if the negotiated prices do not result in large savings for the federal government and taxpayers, Medicare beneficiaries may still experience some savings. The ultimate savings will likely depend on how successfully the federal government negotiates prices.
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Tailoring Benefits for a Multigenerational Workforce During 2024 Open Enrollment
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
Open enrollment is an opportunity for employers to educate their workforce about attractive benefits offerings that can help boost employee retention, satisfaction and engagement. However, with four or five generations in the workforce, finding a benefits plan that satisfies everyone can be challenging. A 2022 report by analytics and advisory company Gallup found that employees are postponing retirement, with over two-thirds (76%) of U.S. adults aged 65 to 69 still working. Additionally, Generation Z accounts for a growing percentage of the workforce. These generations and those in between have vastly different needs. This article provides guidance for how employers can balance the needs of an age-diverse workforce when developing competitive benefits offerings.
How Age Impacts Desired Benefits
Generations aren’t homogenous, and there may be variations between individual employee needs and desires within a generation. However, age often impacts the benefits that employees most desire. Here’s a traditional breakdown of the preferred benefits for each generation:
- The Silent Generation (1928-1945) generally wants traditional core benefits, retirement benefits and formal employee recognition programs.
- Baby boomers (1946-1964) typically value caregiving benefits, workplace flexibility, comprehensive health care plans, retirement benefits and ongoing training opportunities.
- Generation X (1965-1980) often wants remote work opportunities, flexible scheduling and caregiving benefits.
- Millennials (1981-1996) generally prioritize flexible scheduling, remote work opportunities, student loan repayment programs and ongoing training opportunities.
- Generation Z (1997-2012) typically wants flexible scheduling, remote work opportunities and comprehensive employee assistance program benefits.
Navigating Differences in Desired Benefits in Preparation for Open Enrollment
Creating a benefits plan that satisfies every generation in the workforce may seem daunting. However, employers should remember that they don’t have to meet the exact desires of every generation. Rather, a successful multigenerational benefits plan will contain something of value for everyone. Therefore, choosing benefits for a multigenerational plan may be similar to what employers are already doing. The following steps can help employers create benefits plans that meet their budget and their employees’ needs:
- Determine the primary goal (e.g., reducing costs or improving employee attraction and retention).
- Survey employees about their benefits preferences.
- Decide on a budget.
- Select benefits that align budget requirements with employee desires.
- Communicate the offerings.
Considerations for Educating a Multigenerational Workforce About Open Enrollment
Employers should remember that there are understandable differences in the way different generations view open enrollment. Older generations with more experience selecting benefits are often more confident and prepared to make educated benefits decisions than younger generations who are new to the workforce. Thus, employers should present information about open enrollment and benefits plans in a way that’s accessible to all generations. This may include the following:
- Create a multichannel approach. Unsurprisingly, different generations prefer to obtain information from varying sources. For example, baby boomers are generally more likely to want information via a pamphlet or brochure than younger generations. For this reason, open enrollment and benefits information should be provided to employees via numerous channels (e.g., emails, webinars, pamphlets and in-person conversations).
- Find ways to connect virtually. These days, an organization’s workforce can be widely dispersed across geographic locations. Depending on an employee’s age, they may also be making benefits decisions with their parents, a partner or a spouse. Therefore, employers must find ways to connect with employees virtually about open enrollment. This may include creating videos, sending emails and providing access to interactive virtual tools.
- Target communications. A survey by software company Jellyvision found that 35% of employees only want to learn about benefits that impact them personally. This means that helping employees connect with the benefits they want and need may include targeting benefits communications to employees based on demographics and benefits preferences. For example, employers should consider providing Medicare information and guidance to older generations of workers. Meanwhile, younger generations of workers might prefer to be directed toward employee assistance programs and student loan repayment benefits.
- Make information accessible. It’s important to remember that workforces aren’t just age-diverse. Employees’ families today may look different than the “typical” family did decades ago. Employers should be inclusive in their messaging to ensure employees from all types of households (e.g., single-parent families and LGBTQI+ relationships) feel there are benefits for their families.
Conclusion
Benefits offerings are a primary factor that impacts employees’ decisions to stay at their current jobs or search for new positions. Employers who tailor benefits to the needs of their employees and successfully communicate open enrollment information across all generations in the workforce may experience improved employee retention and engagement.
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Virtual Second Opinions
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
There may be a time in employees’ lives when they receive a medical diagnosis or feedback they feel uncertain about. Second opinions allow patients facing medical challenges to seek additional medical information on their condition, which can provide clarity and other treatment options available. With the increase in the popularity of telehealth, there is even the option of virtual second opinions, which can provide convenience by saving employees time and travel.
A virtual second opinion can help ease some of an employee’s stress after a serious diagnosis or when looking for a diagnosis for ongoing symptomatic issues. It can be difficult for a patient to find an appointment, especially if they need specialty care. Therefore, offering health coverage that includes virtual care gives a more accessible and efficient option for care. This article explains the additional benefits of receiving second opinions virtually.
Benefits of Virtual Second Opinions
Access to a second opinion can help relieve worry about diagnosis or treatment uncertainty. A virtual second opinion can provide easier access to different opinions, creating peace of mind for a patient. Additional benefits to this virtual care option can include:
- Improved patient care—The most significant benefit patients find from seeking a virtual second opinion is an improvement in overall care. This is due to having access to a large library of doctors nationwide. No matter where a patient is located, they may potentially receive access to any specialist they need.
- Increased timeliness—Receiving a virtual second opinion is often more efficient than going in person to receive one. The virtual process may allow patients to receive in-depth care and a treatment plan from a physician in about two weeks; in contrast, in-person visits are booked months out in most cases.
- Individualized care—It’s easier to make informed health decisions when all the facts are present. With a virtual second opinion, doctors can take the facts and ease patient anxiety by answering questions and creating a clear plan.
- Expanded care—Offering the benefit of virtual second opinions to employees helps those who live in areas of the country that do not have adequate access to health care.
- Eased anxiety—Virtual second opinions can ease the anxiety and stress of employees that may have received a diagnosis or care option they’d like analyzed in-depth. It can also empower an individual to take charge of their health and increase overall health literacy.
It’s important to note that there are different virtual second opinion program levels available. For example, these programs can include quality care for cancer and musculoskeletal disorders. Other programs offer care from specialists and subspecialists, such as surgeons and oncologists, that may be required for a patient’s care.
Summary
The level of care offering needed at each organization will vary, so it’s important to survey the needs of employees to find out which coverage options will receive the most use. Providing the option of virtual second opinions can give employees comfort in knowing they have access to additional care when they need it most. For more information on virtual second opinions, contact RISQ Consulting today.
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A Primer on Medical Stop-loss Insurance
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
Catastrophic and unexpected health care claims are on the rise. This increase in catastrophic claims is, in part, the result of medical and pharmaceutical advances, such as specialty drugs and cell and gene therapies, as well as medical price inflation. As a result, many employers with self-funded health plans are actively looking for ways to minimize their financial exposures to potentially catastrophic claims. A common strategy these employers have leveraged is purchasing stop-loss insurance.
This article provides a general overview of stop-loss insurance and outlines some considerations for employers to keep in mind when deciding whether to purchase this coverage.
What Is Stop-loss Insurance?
Generally speaking, stop-loss insurance helps self-funded employers protect themselves from higher-than-anticipated health claim payouts by limiting their exposure to employee medical claims that exceed a predetermined amount. In other words, such coverage can prevent abnormal claim frequency and severity from draining employers’ financial reserves.
Stop-loss insurance plays an important role in helping employers manage their health care costs and protecting against unexpected or catastrophic claims, as it sets a ceiling for the amount they pay in health claims. This coverage is not a form of medical insurance, but rather a policy employers can purchase to manage their financial risks.
How Does Stop-loss Insurance Work?
Under a stop-loss insurance policy, an employer’s claims liability is limited to a certain amount (also called an attachment point), therefore ensuring abnormal employee health claims do not drain the employer’s financial reserves. An employer can add stop-loss insurance to an existing plan or purchase it independently.
If an employer’s health claims exceed a predetermined amount, their insurer will usually reimburse them for all additional claims. For example, if an employer has a stop-loss insurance policy with an attachment point of $500,000, their insurer will typically begin providing reimbursement after the plan’s claims exceed $500,000. It’s worth noting that since stop-loss coverage only reimburses an employer for claims that exceed their policy’s attachment point, the employer is initially responsible for paying employee claims before they reach the established cost ceiling.
Types of Stop-loss Insurance
There are two types of stop-loss insurance: individual (or specific) and aggregate (or total claims). Understanding the difference between individual and aggregate stop-loss insurance can help self-funded employers evaluate and determine which coverage best meets their needs and reduces their financial exposures. Because health plan usage can be unpredictable, some employers choose to purchase both individual and aggregate stop-loss insurance to provide their organizations with maximum financial protection.
Individual Stop-loss Insurance
Individual stop-loss insurance limits an employer’s liability when an individual employee’s medical claims exceed the attachment point. As such, this coverage can protect employers against unexpectedly high claims from individual employees.
Aggregate Stop-loss Insurance
Aggregate stop-loss insurance can help safeguard employers from the total sum of health claims for an entire group of employees rather than any one individual. Under this coverage, an employer is usually reimbursed when their expenses for all employees’ medical claims exceed the attachment point for the plan year.
Stop-loss Insurance Considerations
Each organization is unique. Deciding whether stop-loss insurance is necessary depends on an organization’s specific needs, workforce characteristics and risk tolerance. Reviewing all relevant factors (e.g., rates, policy terms and potential exposures) can help employers decide whether purchasing this coverage makes sense. Employers can consider the following factors when evaluating whether to purchase stop-loss insurance.
Understanding the Attachment Point
The attachment points for individual and aggregate stop-loss insurance differ. Generally, the attachment point for an individual stop-loss policy is a specific dollar amount. As a result, an employer is only responsible for an individual employee’s claims up to that amount.
For aggregate stop-loss insurance, the attachment point is usually a percentage of expected claims. The typical attachment point for aggregate stop-loss insurance tends to be between 120% and 125% of expected health claims. In any case, a stop-loss insurance policy’s attachment point can vary depending on factors such as the employer’s size, employee demographics and overall risk profile.
Evaluating Coverage Limitations
Stop-loss insurance plans are medically underwritten; therefore, an insurer may refuse to cover certain conditions or require higher claim thresholds for those conditions. For example, if a plan enrollee consistently has high-cost claims, a stop-loss insurer may refuse to continue to cover that enrollee or require a higher claim threshold for the enrollee. This practice is known as lasering.
Additionally, since stop-loss contracts typically last for one year, an employer’s high-cost claimants may only be covered for a few months before the insurer excludes them from the policy upon renewal. Thus, the employer will likely be financially exposed to those claims the following year.
Monitoring Increasing Costs
While stop-loss insurance can help employers reduce their financial exposures when health claims are higher than anticipated in a given year, the cost of such coverage can increase annually. Rising claims can also make it more difficult to obtain rates from other providers.
Ensuring Stop-loss Coverage Aligns With Health Plan Provisions
Some stop-loss policies may exclude certain medical treatments or classes of individuals covered by employers’ health plans. Consequently, employers may be on the hook for expensive claims that aren’t covered under their stop-loss policies. Therefore, employers should consider reviewing their stop-loss policies and health plan provisions to ensure they align to limit their potential financial exposures.
Summary
Selecting the right insurance policies can have major financial repercussions for employers. Having sufficient coverage can lower employers’ insurance costs, reduce their risks and keep their workers healthy. Stop-loss insurance can make all the difference in helping employers mitigate their financial risks, especially as catastrophic health claims are increasing. Understanding stop-loss insurance will allow employers to make the best policy decisions for their respective organizations.
For more health care resources, contact RISQ Consulting today.
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High Deductible Health Plans
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
Enrolling in a high deductible health plan (HDHP) allows you to place pre-tax earnings in a health savings account (HSA). Then, you can use these saved funds to pay for medical, dental and vision care, and most medications.
The Basics of HDHPs
Many people enroll in an HDHP, a health insurance option that does not cover your first dollar of medical expenses. Instead, these plans have a high deductible that must be met before most services are covered at 100 percent. In general, the deductible must apply to all medical expenses (including prescriptions) covered by the plan. However, plans can pay for “preventive care” services on a first-dollar basis (with or without a copay), including routine prenatal and well-child care, child and adult immunizations, annual physicals, mammograms, pap smears, etc.
HDHPs and HSAs: Their Connection
An HSA is an account that can be funded with your tax-exempt dollars, by your employer, or by both, to help pay for eligible medical expenses not covered by your insurance plan.
Anyone who meets the following criteria is eligible for an HSA:
- Covered by an HDHP, and not covered by any other plan that is not an HDHP
- Not entitled to Medicare benefits
- Not eligible to be claimed on another person’s tax return
After visiting your physician, health care facility or pharmacy, your medical claim will be submitted to your HDHP for payment. Then, you can use your HSA to pay for out-of-pocket expenses that were not covered by your plan. Or, you can simply save your money in your HSA for future medical costs.
For more information on HSAs, ask RISQ Consulting about their HSA flyer!
Why Enroll in a HDHP and Open an HSA?
- Once your deductible is met, most medical costs are covered at 100 percent.
- Contributions to and withdrawals from HSAs for qualified expenses are tax-exempt
- Ability to save for future medical expenses
- Funds roll over from year to year
- If the account is through your employer and you leave, you take it with you.
- You control and manage your health care expenses.
Contributions Are Easy!
Once enrolled in an HDHP, you (and your employer if the account is through your job) can make contributions to your HSA. Remember though, your total contributions are limited annually.
If you make contributions, you can deduct them (even if you do not itemize your deductions) when filling out your income tax return.
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