Phia Group

Cobenfy: A Potential Game-Changer for Schizophrenia Patients – But at What Price?

On October 9, 2024
As you’re reading this blog, millions worldwide are suffering from the horrors of schizophrenia, one of the most complex, debilitating, and stigmatized mental disorders inflicted on humanity, the symptoms of which typically manifest themselves in early adulthood, though they are not always so easy to detect. Those afflicted by this condition are desperately trying to manage an array of frightening symptoms (hearing voices, delusions, memory lapses to name a few) while carrying on with their lives. In this country alone there are approximately 2.8 million Americans living with schizophrenia; tragically, many of those 2.8 million Americans won’t be living much longer as there is a particularly acute rate of suicide among people battling schizophrenia. Meanwhile, so many others suffering often experience prolonged bouts of homelessness and/or run afoul of the law. And for decades, pharmacological innovation has moved at such a glacial pace that treatment has largely yielded inadequate improvement in symptoms and/or intolerable side effects during therapy that many have felt inclined to discontinue usage.

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.

Health Over Wealth

On August 5, 2024
In 2017, New York Times medical journalist Dr. Elisabeth Rosenthal published “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.” It quickly became one of this century’s most influential healthcare books, enlightening the masses about the corporate greed embedded in a trillion-dollar industry, one that is ostensibly grounded in altruistic endeavors.

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.

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 Stewardship of Hospitals

On May 16, 2024
Hospitals, ambulatory surgery centers, long-term care facilities, primary care physician practices, nursing homes, hospice care. They are the most indispensable institutions of any functioning society, but unlike a Fortune 500 company or professional sports franchise, the identity of their respective owners often remains an afterthought. That is, unless you work for or are served by a financially distressed health care system, such as for example Steward Health Care, the massive private-for-profit healthcare conglomerate that recently filed for Chapter 11 bankruptcy protection.

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.

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?

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