2,005: The number of drugs excluded from the Big 3 PBM’s 2024 formularies. Caremark and Express Scripts both added more drugs while OptumRx’s list decreased slightly. CVS reported that 1.4% of its members will be affected by 2024 exclusions, which sounds like a small number, but in 2023 that number was only 0.28%. The other PBMs haven’t reported any numbers around patient impact.
History of the Pre Auth: Pre-authorization seems to be disappearing faster than phone chargers in my house, but are the range of laws and policies to push insurers to curtail the practice really a big change at all? Many probably don’t remember the long-history of gold carding. In 2007, in the heyday of MRI utilization in physician offices, doctors could get a so-called gold-card for having a 97% or higher authorization approval rate, allowing them to skip the authorization process but, like today, there is still a “retro” authorization that audits the providers work every 6 months. Even commercial insurers who have been halting pre-authorization regularly for years have shifted attention to the back end, adding “re-authorizations” and “pre-pay review” systems to manage spend.
Direct To Consumer: Mailman Newman once told his girlfriend that zip codes are meaningless on an episode of Seinfeld, but they matter a great deal for drug manufacturers like Eli Lilly who will be shipping medicines directly to people’s homes under a new business called LillyDirect. The telehealth platform will allow the company to cut out middlemen like PBMs, only using a third-party service to ship drugs at no cost to consumers. The patient will also have access to independent telehealth providers if they don’t already have a prescription from their own. Lilly recently had a new weight loss drug approved which will be sold via the platform, along with treatments for other conditions like migraines and diabetes.
OutFusion: The shift to alternative infusion sites continues and the decision by Anthem (now Elevance) to acquire infusion provider Paragon is the latest out-of-the box move. The acquisition will help deepen the plan’s specialty pharmacy operations after its 2023 acquisition of BioPlus. For independent companies, the threat of vertically integrated operations is not a new one. In 2024, a bigger question for these infusion operators is more likely the impact of policies to promote self-administered drugs and biosimilars, as well as the realignment of plans, PBMs, hospitals and mail-order pharmacies. Patients also may have something to say - 72% of people aged 50+ in a recent poll we did would like their infusions at a hospital compared to 39% of those under 50.
Habit Change: Constanza once famously started doing the exact opposite of his usual behavior in a last-ditch effort to lift himself from being a self-prescribed loser. George was ahead of his time as healthcare companies like Newtopia are working on habit changes to help employers prevent disease. They tout savings of 70% or more under an Aetna study. The program includes genetic testing and 1-on-1 coaching with a focus on keeping people healthy and changing behaviors in those who have signs of potential disease. These employer programs aren’t new, per se, but they are evolving, with more focus on mindfulness and yoga and use of test results to guide habits and avoid disease onset. But they have the same challenge - they get a PMPM for a period with a goal of bending the cost curve and ultimately need to show ROI quickly up.
Therapist Reimbursement Expands: Beginning February 1, Horizon BCBS will expand the behavioral health practitioners eligible to receive reimbursement to include associate marriage & family therapists practicing under a licensed marriage & family therapist (LMFTs), along with psychology permit holders practicing under a licensed psychologist. The supervising providers must be licensed in NJ, contracted with Horizon, and have an approved Plan of Supervising Clinical/Counseling Experience in place.
New Reimbursement Tier: In case you missed it, Aetna expanded their Mid-Level Practitioners policy to include a new reimbursement tier for certain practitioners. The Mid-Level Practitioners policy now includes audiologists, genetic counselors, massage therapists, nutritionists, respiratory therapists, and registered dietitians, allowing reimbursement at 75% of the negotiated fee or recognized charge for covered services. This only applies for Commercial business. Other companies are corralling these practitioners – such as midwives – and packaging services that can be available to employers, commercial plans and Medicaid plans, largely as part of an effort to improve women’s healthcare.
Covid (Don’t) Comeback: The Covid variant known as JN.1 is spreading quickly and represents approximately 62% of current Covid variants. Covid hospitalizations increased 20% during the last week of 2023 and despite evidence showing JN.1 does not cause more severe disease, Covid related deaths rose 12.5% in that same period.
Extra Point (From The Archives): All this talk about the cost to pre-authorize and whether more health insurers and doctor groups can figure out a way to stop getting in the way of care and remove authorization has me questioning my own authorization behavior. In my house, I’ll admit there are times I just go ahead without so much as a heads up. Take Thursday – I went to play hoops to burn off some energy. Didn’t get pre-approval, didn’t pre-notify, and while it was generally no big deal I missed a college prep meeting I agreed to 3 weeks ago. Then last night I ate the Key Lime Pie Bridget’s friend had made for her. I mean, it looked lonely in the fridge at 10 o’clock, even if it wasn’t mine to devour. So, here I sit on a Friday morning, my so-called Gold Card revoked, and a corrective action plan likely coming. And much like an oncology practice that needs to give the insurer’s case manager Sandy a heads up since she has a wider lens into the patient’s recent medical history, I suppose at 51 I too still have a few things to learn about the merits of authorization. I need to be managed sometimes.