Phia Group

The First Ten: The Initial Round of Drugs Subject to Medicare Price Negotiations

On August 30, 2023
On August 29, President Biden unveiled the first ten prescription drugs that will be subject to price negotiation with Medicare (Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, Fiasp and NovoLog), representing a watershed moment for Democrats who have spent years clamoring for lower prescription costs.

Wegovy: The Heart of the Matter

On August 18, 2023
Obesity adversely impacts upwards of 100 million adults in the US and accounts for nearly $150 billion in annual health care spending, yet health insurers have been reluctant to cover high-priced weight loss drugs, ones they frequently label as “cosmetic” or “lifestyle” medications. But, given what transpired earlier this month, is it possible that there could be an impending sea change in the medical field’s perception of such treatment?

The Power Dynamics of Gag Clauses

On August 14, 2023
In the already-intricate world of health benefits, Congress passed the Consolidated Appropriations Act, 2021, which is notable to the self-funded industry for three main reasons: it expanded the Mental Health Parity and Addiction Equity Act to require health plans to proactively document their compliance via the nonquantitative treatment limitation (NQTL) analysis; it introduced the No Surprises Act, which fundamentally changed how claims disputes are handled; and it prohibited health plans from entering into contracts containing gag clauses. This particular blog post focuses on gag clauses. The implications of this prohibition on transparency and patient rights are immense, and it’s worth looking into the power dynamics at play since it’s not quite as simple as saying that plans can no longer have these gag clauses.

Diapers & Wipes Reflection

On August 3, 2023
As my family and I look forward to celebrating our daughter Kinsley’s first birthday this Sunday, we have revisited some of our fond memories and challenges in our first year as a family of five. In doing so, we have discussed how helpful Phia’s “Diapers and Wipes” program has been to our family.

Benefest 2023: Talking Costs and Laws with Carriers

On July 31, 2023
By March, amidst the snowbanks contracting and days growing incrementally longer, conference season – at least for the healthcare industry -- is in full bloom. One of the marquee Massachusetts-based healthcare conferences, Benefest 2023, focused on “shaping the future of healthcare” in the commonwealth, was held earlier this summer at Worcester’s Polar Park -- during the peak of conference season.

Merck vs. Biden

On June 23, 2023
The globally recognized, multi-billion-dollar pharmaceutical company Merck & Co. sued the U.S. government on June 6th in an effort to halt the Medicare drug price negotiation program contained in the Inflation Reduction Act. The drug negotiation program aims to form agreements with drugmakers to lower costs on their most expensive drugs, which will save billions of dollars for Americans, particularly those on Medicare, while sapping Big Pharma of billions in potential revenue. In the first attempt by a drugmaker to challenge the law, Merck is pushing to be declared exempt from the drug price negotiation program, which they claim would lower their drug prices by 25 to 60 percent below market value.

What Happens When Auto and Health Insurance Collide?

On June 20, 2023
I remember when I graduated college, I was in the early stages of adulthood and my parents told me that I needed to get my own car insurance. Beyond knowing that my monthly bills were going up, I had little understanding about car insurance other than it was required and it provided protection in the event of an accident. After over a decade of practicing, law I have found that most adults (not just recent college graduates) do not actually know or understand their own auto coverage. Even fewer adults know how auto insurance and health benefits may intersect in the event of an auto collision.

A Weight Off My Chest

On June 6, 2023
Insurance is supposed to be something you purchase to protect yourself against unforeseen – but costly – losses. You don’t “expect” to be involved in a motor-vehicle accident, but you purchase automobile insurance to protect yourself against the costs incurred in an accident. You don’t expect your home to flood or burn down, but you purchase homeowner’s insurance to protect yourself against the costs incurred in such incidents. Automobile insurance does not pay to fill your car’s gas tank or change the oil. These are foreseen, planned costs of automobile ownership and maintenance. Homeowner’s insurance does not pay to replace the filters in your HVAC or power wash mold from the siding. These are foreseen, planned costs of home ownership and maintenance. Why, then, does health insurance pay for foreseen, planned costs of your body’s maintenance? More importantly, how have recent trends taken advantage of our addiction to health insurance, and the expectation that it will pay for everything?

Unwrapping the Benefits to Your Plan

On May 4, 2023
On January 1, 2022, the No Surprises Act (NSA) officially went into effect, affording protection to patients against surprise medical bills on certain types of claims, including out-of-network emergency services, ancillary out-of-network professional services rendered at in-network facilities, and air ambulance services. While the NSA has spared countless patients from potentially devastating balance bills, its complex and ever-evolving dispute resolution process has created headaches for plans and providers alike. Luckily, Phia Unwrapped includes NSA support services during the Open Negotiation period and, if necessary, Independent Dispute Resolution.

Marty Walsh Goes to Bat for NHL Retirees

On April 11, 2023
The National Hockey League’s collective bargaining agreement (“CBA”) is not set to expire until September of 2026, but it was still a hot topic during NHLPA Executive Director Marty Walsh’s introductory media conference last month in Toronto. In particular, there were several questions directed to the erstwhile Boston mayor and US Secretary of Labor about the union’s plans for managing the health benefits of retired players. Judging by his response, he didn’t appear to be blindsided.

Keeping PACE With COVID-19 Developments

On April 5, 2023
On January 30, 2023, the Biden administration announced its plan to terminate the national emergency and public health emergency declarations pertaining to the COVID-19 pandemic. Effective May 11, 2023, the phasing out of the public health emergency will mean a change in coverage requirements (i.e., vaccines administered out-of-network can involve cost sharing, no longer will there be free at-home COVID tests), while the end of the national emergency will affect the tolling of various health benefits related deadlines. The latter issue is one that resonates particularly strongly with The Phia Group’s PACE (“Plan Appointed Claim Evaluator”) service, whereby Phia manages final internal appeals, defends its decisions in the face of external appeal, and oversees the Independent Review Organization (“IRO”) external appeal process.

Jimmy Carter’s Complicated Healthcare Legacy

On March 21, 2023
In the Bicentennial Summer of 1976—during which Jimmy Carter was campaigning for president—there was nonstop pageantry. Patriotism reached fever pitch as parade floats washed in red, white, and blue streamed through smalltown America while Uncle Sam-inspired merchandise flooded the shelves of department stores across the entire union. But overshadowed by the unprecedented amount of hoopla was the sobering reality that the then-two-century-old nation had a broken healthcare system: at this moment in time, 26 million Americans lacked health insurance altogether while another 28 million possessed only minimal coverage. And Carter, who grew up on a backwoods Georgia peanut farm with neither running water nor electricity, sympathized with the plight of the working poor by endorsing the concept that America needed universal healthcare coverage—to the extent that it was economically (and politically) feasible.

Price Transparency: A Chief Concern at SIIA’s Recent Kanas City Forum

On March 9, 2023
KANSAS CITY, MISSOURI – In the opening presentation of the SIIA Price Transparency Forum held at the Kanas City Marriott Downtown last month, SIIA’s Senior Vice President of Government Relations, Ryan Work, made a bold prediction: if healthcare costs remain on this decades-long rising trajectory it could lead to the demise of employer-based healthcare as we know it.

Confusion Over Recent Insulin Cost Capping Discussions

On March 6, 2023
I recently drafted an article regarding legislative proposals to “cap” patient out of pocket costs for insulin. In it, I explained that – while the individual patient’s out of pocket cost may be reduced at the time of purchase – the total cost of the medication is not reduced. Instead, a greater share is shifted onto the health benefit plan or insurance. That payer would then – likely – increase the cost of coverage (premiums, contributions, etc.), resulting in the patient ultimately paying the cost of the drug… simply in a different way. Shifting who pays a designated portion of a price doesn’t reduce the price itself. The only way to reduce the price of something is to reduce the price.

Hospital Prices: Fully Transparent or Still Somewhat Opaque?

On February 23, 2023
In the throes of the first pandemic winter, still months before coronavirus vaccines would roll out in earnest, the Hospital Price Transparency Rule went into effect. It was a promising development in the world of healthcare cost containment—hospitals were now obligated to provide a single, machine-readable digital file containing standard charges for all services and items provided by the facility.