HIX market enrollments declined in 2017 and 2018 due to decreased enrollment among unsubsidized individuals; CMS cites rising premiums as a reason.

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Aug. 16, 2019


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2014: Good Times Never Seemed So Good (Compared to HIX in 2016–2018)


On Monday, the Centers for Medicare & Medicaid Services (CMS) reported overall declines in individual health insurance exchange (HIX) market enrollments in 2017 (10%) and 2018 (7%). This decline followed an enrollment peak in 2016.

Enrollment decline over the 2 years is due almost exclusively to a drop in enrollment among unsubsidized individuals. CMS cites rising premiums as a reason for the decline: in 2017 and 2018, premiums increased 21% and 26%, coinciding with an overall decrease in unsubsidized enrollment of 40%. Looking across the entire history of the program, average monthly premiums have increased from approximately $350 in 2014 to just under $600 in 2018 (a 71% increase).

Consumers who earn too much to qualify for a subsidy but who don’t have an employer plan are caught in the middle. Premiums for those not subsidized are typically higher than those offered through employer plans.

For folks wanting to do away with the Affordable Care Act, this could add fodder to their argument, given that those consumers who don’t qualify for help often have difficulty affording a HIX plan’s premiums and its cost-sharing requirements. On the flipside, those in support of the program point the finger at Trump Administration actions like the decrease of funding for enrollment outreach and abbreviated enrollment periods.


Live Webinar: Achieve Better Patient Outcomes With Clinically Supported, Tech-Enabled Adherence Programs


Thursday, August 29 | 11:00 AM ET / 8:00 AM PT

At Lash Group, we believe keeping the patient at the center of a support program is essential to improving adherence.

Join Lash Group leadership—Michael A. Craig, Vice President, Market Development and Strategy, and Dale Hanna, Product Director, Adherence Services—to discuss why clinical expertise and teams trained in empathy are critical components of tech-enabled support solutions—and how this combination can transform outcomes.

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Legislative Bytes


Note: Congress is on recess and will reconvene after Labor Day (unless Senate or House leadership calls back their chambers).

  • Rep. Eliot Engel (D-NY) introduced HR 4178 that would require manufacturers of certain single-dose vial drugs under Medicare Part B to pay rebates for the amounts of discarded drugs.
  • US Senate Budget Committee and House Committee on Oversight and Reform sent letters to 3 pharmaceutical companies—Heritage, Mylan, and Teva—again requesting information regarding generic drug pricing for an investigation initiated in 2014.
  • Senate Committee on Finance Chairman Sen. Charles Grassley (R-IA) sent a letter to Novartis AG requesting information about data accuracy on ZOLGENSMA, its gene therapy product to treat infants with spinal muscular atrophy.

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Global Value Stories: Then I Know It’s Growing Strong


Last week, the Institute for Clinical and Economic Review (ICER) announced plans to assess the comparative clinical effectiveness and value of crizanlizumab, a P-selectin inhibitor, and voxelotor, an HbS polymerization inhibitor, which are currently in the pipeline for the treatment of sickle cell disease. ICER is accepting stakeholder comments during the Open Input Period for this topic through August 27. The final evaluation will be discussed during a public meeting of the New England Comparative Effectiveness Public Advisory Council (CEPAC) in March 2020.

On Monday, the Scottish Medicines Consortium (SMC) announced a decision to not cover 2 new cystic fibrosis therapies, ORKAMBI and SYMKEVI. Despite testimony from patient and clinician groups on the drugs’ therapeutic benefits, SMC determined there were uncertainties in the manufacturer’s estimates around the long-term health benefits in relation to their costs. ICER previously reviewed ORKAMBI, and SYMKEVI is on its list of potential topics for 2020.

Additionally, BMC Health Services Research recently published a systematic review on value assessment frameworks (VAFs), which highlights inconsistencies in how value is defined and measured in developed countries. Among the 22 methods identified, 18 considered a multiple-criteria approach, with 17 of these focusing on outcomes-oriented criteria, and 12 using data-driven performance measures. Furthermore, 12 of the identified VAFs were disease specific and, thus, not generalizable across a range of interventions.
The National Comprehensive Cancer Network (NCCN) is now accepting abstracts for its Annual Conference General Poster Session, which will be held March 20–21, 2020. Abstracts will be accepted from academia, teaching and community hospitals, and industry and are due by October 23.

As always, if you need assistance with all things ICER or value-related, please contact Kristen.Migliaccio@xcenda.com.

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GAO Looks at Role of PBMs: They Are Reaching Out, Touching Me, Touching You


On Wednesday, the Government Accountability Office (GAO) released a report that examines the role of pharmacy benefit managers (PBMs) and Medicare Part D plan sponsors. The report comes at the request of the House Ways and Means Committee and looks at the role of PBMs, contracts with Part D plan sponsors, utilization of rebates, discounts, and other price concessions, and impact on the price of Part D drugs.

Specifically, the report found:

  • Medicare Part D plans provide 26% of drug benefit management services and use PBMs to provide 74% of services.
  • From 2014 to 2016, gross expenditures on drugs (including amounts paid to pharmacies by PBMs, plan sponsors, and beneficiaries) increased 20%, to ~$145 billion; rebates and other price concessions increased 66%, to $29 billion, during the same time. Consequently, net expenditures increased 13%.
  • Rebates and other price concessions accounted for 20% of gross expenditures in 2016.
  • In addition to fees paid by plan sponsors, PBMs earned revenue through rebates negotiated with manufacturers on Part D drugs, which accounted for $18 billion of the $26.7 billion in rebates in 2016.
  • PBMs retained less than 1% of these rebates as revenue and passed the rest to plan sponsors. Most service agreements included provisions that require the PBM to pass through all rebates to the plan sponsor.

The Pharmaceutical Care Management Association (PCMA) supported the report’s findings, claiming they provide conclusive evidence that PBMs actually curb the rising price of prescription drugs for patients. Other organizations, like the National Association of Chain Drug Stores (NACDS), dispute the accuracy of the report’s findings, claiming the study relies on self-reported data.

It will be interesting to see how and if the report’s findings will be taken into consideration by the current Administration, particularly with the recent scrutiny of PBMs, pharmaceutical manufacturers, and plans—as well as the recent surprise with the Administration taking the rebate rule off the table. Findings of studies like the GAO research and others may influence policymakers on how they view the supply chain and changes they are considering for drug pricing and reimbursement.


Information Buffet (AKA, Other Stuff That Caught Our Attention)


We kept running into stories we wanted to bring to your attention, so here’s a quick hit list of other news we thought you should know:

  • Quality matters. While CMS has had staff dedicated to HIX health plan quality metrics for a decade, CMS announced that, when 2020 Open Enrollment begins, HIXs will be required to publish quality ratings using a 1- to 5-star scale similar to federal ratings to help consumers decide on a plan.
  • John Brooks will replace John O’Brien as the Department of Health and Human Services’ Senior Advisor for Drug Pricing Reform, in addition to his current role, Principal Deputy Director of the Center for Medicare.
  • Pretomanid, a drug to treat a highly resistant type of tuberculosis of the lung, was the second to be approved by the Food and Drug Administration under the Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD), created under the 21st Century Cures Act to help patients who are without effective therapies.
  • The Office of the Inspector General (OIG) released a report comparing average sales prices (ASPs) with average manufacturer prices and will send CMS a list of 11 drugs for review to consider substitution of the ASP for a lower calculated amount.
  • The OIG also reported that New York reached program goals for enhancing its drug monitoring program after the state experienced a significant increase in drug overdose deaths in 2016 and 2017.


How Digital Innovation Drives Improved Market Access Strategies


Just as R&D innovation can drive the development of new therapies from manufacturers, Xcenda recognizes that digital innovation can enhance the market access journey for those new therapies.

Read about 4 key areas where manufacturers can leverage digital solutions to optimize their product’s access strategies in the marketplace.

Read article


“We agree that Mr. Mucus is thoroughly annoying—after all, he is the personification of your most annoying cold. Far from being our mascot, though, it is our sole goal to help get rid of him whenever he tries to invade our lives. Which is why every American knows that when sick happens, we reach for Mucinex.”

– Elyse Altabet, Marketing Director for Mucinex at RB

For all of us getting ready for “back to school” and all the germs that come with the season, we thought a Friday laugh was in order. In a survey by Crestline Promotional Products, the slimy, green Mucinex mascot, Mr. Mucus, came in dead last out of 82 mascots for being the most creepy, least likable, least personable (HA!), and least trustworthy.

Source: “No love for Mr. Mucus: RB’s Mucinex character ranks as least likable among mascots,” FiercePharma, August 15


$7,726 in 2018 vs $4,617 in 2008


A family of 4 with employer coverage spent $7,726 out of pocket on healthcare costs in 2018: $4,706 for premiums and $3,020 on deductibles, copays, and coinsurance. Compare that to 2008, when that family spent $4,617: $2,838 for premiums and $1,779 in cost-sharing.

In just 10 years, healthcare costs for families jumped to triple the rate of inflation, while deductibles catapulted to 10 times that of inflation. Employers also had to deal with skyrocketing expenses during that same time period, with average costs to cover workers’ families increasing 51% from $10,008 to $15,159.

Source: Matthew Rae, “Tracking the Rise in Premium Contributions and Cost-Sharing for Families With Large Employer Coverage,” Kaiser Family Foundation, August 14


Live Webinar: Achieve Better Patient Outcomes With Clinically Supported, Tech-Enabled Adherence Programs

Thursday, August 29 | 11:00 AM–12:00 PM ET
Join Lash Group leadership—Michael A. Craig, Vice President, Market Development and Strategy, and Dale Hanna, Product Director, Adherence Services—to discuss why clinical expertise and teams trained in empathy are critical components of tech-enabled support solutions—and how this combination can transform outcomes. Register today


Live AMCP Webinar
Pre-Approval Dossiers: A 360-Degree View for Payers and Manufacturers

Tuesday, September 10 | 2:00–3:00 PM ET
Join Evelyn Sarnes, PharmD, MPH, Vice President of Medical Communications at Xcenda, for a live webinar that aims to provide insights around the evolution of the pre-approval information exchange between manufacturers and payers, as it relates currently to the development and consumption of a pre-approval dossier. There will be diverse perspectives as well as insights collected via the FormularyDecisions.com community—home of the AMCP eDossier System. Learn more


AMCP Nexus 2019

October 29November 1 | National Harbor, MD
Xcenda and Dymaxium are proud to join managed care colleagues in National Harbor, MD for 4 days that spotlight the innovative practices currently impacting the managed care and healthcare community. Join us a booths #311 and #313. Learn more


Count on Health Policy Weekly for an at-a-glance view of legislative and regulatory developments and news that impacts the healthcare industry.


Jennifer Snow
Vice President,
Reimbursement and
Policy Insights,

Scott Shields
Associate Director,
Health Policy



Doug Cook
President | Commercialization Services & Animal Health

Kristine Flemister, PharmD
President | Xcenda

Tommy Bramley, PhD, RPh
President | Lash Group

Stacie Heller
Vice President | Government Policy | AmerisourceBergen Corporation

Rita Norton
Senior Vice President | Government and Public Policy | AmerisourceBergen Corporation

Ana Stojanovska
Vice President | Commercial Consulting | Xcenda


Jenna Kappel | Stew Kaufman | Reeya Patel | Scott Shields | Linnea Tennant | Kyler Tormey


Laurie Kozbelt | Ellen Olson


Aug. 16, 2019


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