Phia Group

Healthcare and Politics… Ugh. Old News!

On September 27, 2024
Donald Trump recently stated that while he will never give up on repealing the ACA, he also said that he was not running on terminating the ACA. This is likely a smart decision, given that a recent Kaiser Family Foundation (KFF) poll revealed that for Republican voters, repealing Obamacare was an important issue for a very small percent of respondents. Is this demonstrative of a more widespread loss of interest in health care as a political talking point?

The First Ten: Medicare Unveils Inaugural List of Negotiated Drug Prices

On September 16, 2024
Last month, while many of us were busy vacationing or doing last-minute back-to-school shopping, the Biden administration announced that it had reached an agreement with the titans of the pharma industry to lower prices on the 10 costliest prescription drugs under Medicare, thus bringing to fruition Democrats' decades-long push to allow the government to negotiate directly with pharmaceutical manufacturers. While individual plans had previously been able to haggle over prices with Big Pharma, this development marks a seminal moment as it is the first time that Medicare used its clout to be able to negotiate for the program as a whole.

Section 1557 Final Rule: Where Do We Stand?

On August 30, 2024
The implications of the Section 1557 Final Rule are currently in flux since the Final Rule was issued on April 26, 2024. The purpose of the Final Rule was to extend the protections against discrimination in healthcare, with a particular emphasis on gender identity. The inclusion of gender-affirming care within the protection against sex discrimination was a huge step forward in strengthening the scope of Section 1557 beyond what was originally afforded when the rule first passed.

What the Overturning of Chevron Means for Healthcare

On July 19, 2024
For the past forty years, federal agencies have had considerable latitude to interpret and enforce regulations and subsequently advance regulatory initiatives. Per the precedent established in the Supreme Court’s 1984 decision in Chevron U.S.A., Inc. v. Natural Resources Defense Council, courts have had to defer to federal agencies regarding legal challenges over ambiguously written laws passed by Congress. The rationale was as follows: The public servants employed by the federal agencies, whether they be scientists, engineers, law enforcement officials, economists, or experts in another field, have more specialized expertise in the given matter – even more so than Supreme Court justices -- and should thus be accountable for implementing the law. But effective late last month, the High Court, believing that unelected government officials should not wield such tremendous influence, overturned that precedent, thus yielding unprecedented power to the courts to use their own discretion in interpreting laws – many of which pertain to the country’s healthcare ecosystem.

The Supreme Court and State Bans on Gender-Affirming Care for Minors: What’s Next?

On June 26, 2024
Samantha and Brian Williams of Nashville are no different from any other parents in that they want what’s best for their 15-year-old daughter. The Williams’ situation, however, is different from that of many parents as their child identifies as transgender while residing in a state that restricts access to puberty blockers, hormone therapies, and surgeries for minors undergoing gender transitioning. Per the American Civil Liberties Union, the Williams’ daughter is one of approximately 3,000 transgender adolescents in Tennessee where, by law, medical providers cannot perform procedures that “enable a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex” or “treat purported discomfort or distress from a discordance between the minor’s sex and asserted identity.”

Direct Contracting and Occam’s Razor

On June 21, 2024
Maybe I should be, but I’m not ashamed to admit that when I first heard of Occam’s Razor, I assumed it had something to do with shaving. Whatever the context, many know Occam’s Razor as a principle of decision-making holding that “the simplest explanation is the best one”. Although the real idea is similar, William of Ockham’s logic is a bit more formulaic than that. To paraphrase, Occam’s Razor suggests that when choosing between multiple options, the best choice is the one that requires the fewest assumptions to reach. Put another way, the best option is the one that has the highest likelihood of actually being the case, by requiring the fewest assumptions to achieve it.

Implications of the Section 1557 Final Rule

On June 17, 2024
The non-discrimination protections of Section 1557 of the Affordable Care Act are not new, as the Affordable Care Act was originally enacted in 2010. However, the recent Final Rule published on May 5, 2024, provided clarification and additional requirements as they relate to strengthening civil rights protections for individuals.

2024 Benefest: Not Just Massachusetts in Focus

On June 14, 2024
Earlier this month, 2024 Benefest, hosted by the Massachusetts Chapter of the National Association of Benefits and Insurance Professionals (NABIP), took place at the DoubleTree by Hilton Hotel Boston-Westborough. While the conference largely focused on the Massachusetts healthcare ecosystem – panel discussions of which reached the general consensus that, from an affordability and access perspective, these are incredibly challenging times due to unprecedented staffing shortages reducing providers’ daily bandwidth – there was considerable time spent examining federal healthcare developments, including how November’s election will impact employer-sponsored benefit plans.

The Price is Wrong, Y’all

On June 4, 2024
National spending on healthcare was approximately $74 billion in 1970. Fast-forward to 2022, the growth alone on healthcare spending from 2021 was $175 billion, topping out around $4.5 trillion total spending for that year. It’s a well-worn saying in the healthcare industry but it still rings true: “It’s the prices, stupid.” Every ounce of work and creativity that we at The Phia Group, and many of our colleagues in the industry, pour into trying to reduce healthcare costs may ultimately be for naught if the prices continue to rise indefinitely. One of the driving factors behind those ever-increasing costs: consolidation.

The End of a (Brief) Era

On May 2, 2024
Five years ago, Walmart, the multi-billion-dollar retail behemoth, opened its first-ever health clinic in Georgia. Soon, dozens more Walmart-sponsored clinics started opening their doors across not just Georgia, but also Arkansas, Florida, Illinois, Missouri, and Texas. Most of these pop-up clinics operated in rural communities where chronic diseases were rampant and (affordable) primary care options were scarce. Irrespective of the pandemic soon unfolding, they served their purpose: customers shopping for microwaveable dinners and bath supplies could stop by for a doctor’s appointment, get stitched up, take a flu test, or even get X-rays done, all for a very reasonable fee. As many of these shoppers/patients either lacked health insurance or had high deductible plans with imposing out-of-pocket costs, these clinics represented their only viable option for obtaining any semblance of proper healthcare. Surely, some had not been to a doctor of any type for years.

IDR: The Confusion Never Ends!

On April 8, 2024
It seems like every day that The Phia Group's consulting team is presented with an IDR-related issue brought up by either a provider in an appeal or simply a TPA trying to iron out or streamline its processes. Sometimes the question centers around the specifics of the IDR process, but sometimes the question instead focuses on the very concept of IDR itself and when it becomes applicable to begin with.

Reimbursing . . . Medicaid?

On April 3, 2024
Imagine that you have recently lost a loved one, are still in the midst of grieving, feeling sleep deprived, dealing with a bevy of uncomfortable logistical issues, and then told . . . that you may have to forfeit your house.

Lenmeldy: The World’s New Most Expensive Drug

On April 1, 2024
The U.S. Food and Drug Administration (FDA) stoked the fire that is the ever-present discussion surrounding gene therapy when it approved Lenmeldy on March 18, 2024. Lenmeldy is the first FDA- approved gene therapy to treat metachromatic leukodystrophy (MLD), a rare disease that affects the brains and nervous systems of children in their late infantile and early juvenile years.

Wegovy: Not Just a Weight Loss Drug

On March 20, 2024
Earlier this month, the wildly popular weight loss medication was approved in the US to help prevent life-jeopardizing cardiovascular events in people who are overweight, obese, and/or have a history of cardiovascular disease. The FDA’s stamp of approval for drugmaker Novo Nordisk to include cardiovascular benefits to Wegovy’s label meant it was the first weight loss drug to market itself in this manner. Now the million-dollar question (no pun, intended) becomes, will this label expansion make insurers feel more inclined to provide coverage? For good measure, will Medicare, currently barred by law from covering drugs for weight loss alone, be compelled to include Wegovy under its umbrella?

The Indirect (But Significant) Impact of a Recent Massive Healthcare Breach on Benefit Plans

On March 11, 2024
It’s not often we see a healthcare/health benefit story so big that it crosses into the mainstream. The recent cyberattack in the healthcare industry is just that type of story, however, and the American Hospital Association has already called it “the most significant cyberattack on the U.S. health care system in American history.”