Discussions
Improving Prior Authorization Processes: An Obstinate Goal for an Essential Payer Tool
For decades, the stated purpose of prior authorization (PA) for managed health care plans has been as follows: to ensure the appropriateness of a specific drug for any specific patient. The Academy of Managed Care Pharmacy states, “[PA] is an essential tool that is...
Prescription Digital Therapies: The Big Disconnect Between Manufacturers and Payers
Prescription digital therapies (PDTs) are apps that persons with disorders can only download to their smartphone with a doctor’s prescription. They are generally meant to be used as an adjunct to drug therapy and/or live counseling, depending on the indication. For...
The Employer Is a Fiduciary for Its Employees Under ERISA, not an ATM for Its PBM
A lawsuit filed by Johnson & Johnson employees against the drug manufacturer’s employee benefits operation on February 6 spotlights the potential, substantial liability for self-insured employers not adequately managing their pharmacy benefits. At issue is the...
Will PBMs Survive the Rush of Legislative Proposals to Restrict Their Practices?
Surely, these can be trying times for pharmacy benefit manager (PBM) C-suite executives. They have been through a revolving door of Congressional hearings, and their responses have resulted in a constant shower of legislative proposals to deprive them of the shield of...
Drug Manufacturers’ Suits Against Medicare Price Negotiations Ring Hollow
With the announcement of the first drugs subject to the IRA in 2026, the drug industry filed lawsuits to prevent CMS from implementing the program. Their only true motivation is to forestall loss of revenue on lucrative products, not preventing future innovation.
The Value of Denying Valid Medical Claims
I’ve written about aspects of the patient journey in the past, and one thorny difficulty is the problem of inappropriate claim denials. Note, I used the word “difficulty” here, not “challenge” because there is no need for diplomacy here. When someone is seriously ill...
The Drug Industry Rightly Fears Judicial Overreach
I am appalled that this subject needs to be addressed. The US Food and Drug Administration (FDA) isn’t perfect, but it is still the global gold standard for evaluating medicines for safety and effectiveness. The FDA, though not quite recovered from the self-inflicted...
From Wellness Apps to Prescription Digital Therapeutics
Throughout its development, the US healthcare system has been attracted to new and shiny technologies like bees to honey. This is a significant reason why the cost of healthcare rises over time. It is also one reason why value-based care initiatives show smaller...
Federal Trade Commission to Investigate PBM Practices
Scrutiny on pharmacy benefit managers (PBMs) has just been ratcheted up considerably. The Federal Trade Commission (FTC) announced on June 7 the launch of its investigation into PBM practices, targeting the largest players. This investigation comes at an extremely...
FDA Taking a Big Gamble on Alzheimer’s Drug; Expect Payers to be Wary [at Best]
It is difficult to speculate on what FDA’s motivation might be to overrule the recommendation of its Advisory Committee and approve Biogen’s aducanumab for the treatment of mild Alzheimer’s disease. Relatively few providers are convinced of the value of this agent...
Does Meeting an Unmet Need Justify a Premium Drug Price?
The pharmaceutical industry sometimes forgets how payers calculate the value of their products. Payers do not view value solely through the lenses of clinical efficacy, safety, and utility. The case for the value of a COVID-19 vaccine to prevent disease or an...
A Simple Plan: Universal Catastrophic Care
In our previous post, we documented the difficulties and challenges in considering a “Medicare-for-all” scenario to extend coverage to virtually everyone. We also discussed the potential for implementation of a “public option,” which was first proposed with the...
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