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Full-Text Articles in Insurance

Lowering Out Of Pocket Drug Costs For Consumers, Mylissa K. Price Jan 2019

Lowering Out Of Pocket Drug Costs For Consumers, Mylissa K. Price

Commonwealth Medicine Publications

Prohibiting gag clauses could help lower consumer out-of-pocket pharmacy costs - if Pharmacy Benefits Managers don't raise prices to make-up the difference. Mylissa Price closes our blog series on President Trump's Blueprint to Lower Drug Costs in this final entry.


Deciphering State Medicaid Programs, Rachel Gershon Jan 2019

Deciphering State Medicaid Programs, Rachel Gershon

Commonwealth Medicine Publications

State Medicaid programs vary substantially from one another. For members, researchers, policymakers, and advocates trying to decipher a state’s Medicaid program, this variation can be a source of frustration, because the details of this variation can be hard to locate.


The Implementation Process For Pharmacogenomic Testing For Cancer-Targeted Therapies, Ann Chen Wu, Kathleen M. Mazor, Rachel Ceccarelli, Stephanie Loomer, Christine Y. Lu Dec 2018

The Implementation Process For Pharmacogenomic Testing For Cancer-Targeted Therapies, Ann Chen Wu, Kathleen M. Mazor, Rachel Ceccarelli, Stephanie Loomer, Christine Y. Lu

Kathleen M. Mazor

Recent advances in genomic medicine have led to the availability of genomic tests that have the potential to improve population health, yet the process for obtaining these tests and getting them reimbursed by insurers has not been described. The objective of this study was to describe the process of ordering pharmacogenomic tests by interviewing providers, patients, and laboratories about cancer-related pharmacogenomic tests. We interviewed patients who were prescribed, providers who prescribed medications that should be guided by pharmacogenomic testing, and individuals from diagnostic laboratories. A total of 10 providers, 16 patients, and eight diagnostic laboratories described logistical and insurance issues ...


Will Removing Rebates Really Lower Drug List Prices?, Stephanie Tran Dec 2018

Will Removing Rebates Really Lower Drug List Prices?, Stephanie Tran

Commonwealth Medicine Publications

The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs calls for incentives to lower drug list prices, including removing rebates. Our clinical consultant Stephanie Tran continues our pharmacy blog series with an assessment of this potential change & its impacts.


New Aca Waiver Directives Signal Changes For State Health Insurance Marketplaces, Rachel Gershon, Catherine Torri Dec 2018

New Aca Waiver Directives Signal Changes For State Health Insurance Marketplaces, Rachel Gershon, Catherine Torri

Commonwealth Medicine Publications

New Trump Administrations Section 1332 waiver guidance increases state ACA flexibility. Rachel Gershon & Catie Torri discuss what this could mean for health care policy.


Better Negotiations Between Payers And Manufacturers In An Effort To Reduce Drug Prices, Mckenzie Taylor Nov 2018

Better Negotiations Between Payers And Manufacturers In An Effort To Reduce Drug Prices, Mckenzie Taylor

Commonwealth Medicine Publications

Mckenzie Taylor continues our monthly conversation on the strategies presented in The Trump Administration Blueprint to Low Drug Prices and Reduce Out-of-Pocket Costs, discussing the ways new negotiations between payers and manufacturers are helping to reduce drug prices.


Why Retirement Systems Should Consider Vocational Review, Jody Simpson Nov 2018

Why Retirement Systems Should Consider Vocational Review, Jody Simpson

Commonwealth Medicine Publications

Whether the task is determining if a disability retirement applicant is prevented from performing their past public employment or whether they are able to adjust to other substantial work, administering disability benefit claims is a complex process that requires a sophisticated skill-set to ensure accurate and objective determinations. A critical component of that process is a comprehensive vocational assessment that determines a disability applicants vocational skills and abilities before a final recommendation is rendered.

Discover the value of vocational review and why it can be a critical part of the decision-making process.


How Can Improved Competition Lead To Lower Drug Prices?, Youkavet Samih Oct 2018

How Can Improved Competition Lead To Lower Drug Prices?, Youkavet Samih

Commonwealth Medicine Publications

In this installment of our blog series on "President Trump's Blueprint to Lower Drug Prices and Reduce Out-Of-Pocket Costs," our pharmacy expert Youkavet Samih discusses how creating drug competition drives down prices for consumers.


The Implementation Process For Pharmacogenomic Testing For Cancer-Targeted Therapies, Ann Chen Wu, Kathleen M. Mazor, Rachel Ceccarelli, Stephanie Loomer, Christine Y. Lu Oct 2018

The Implementation Process For Pharmacogenomic Testing For Cancer-Targeted Therapies, Ann Chen Wu, Kathleen M. Mazor, Rachel Ceccarelli, Stephanie Loomer, Christine Y. Lu

Open Access Articles

Recent advances in genomic medicine have led to the availability of genomic tests that have the potential to improve population health, yet the process for obtaining these tests and getting them reimbursed by insurers has not been described. The objective of this study was to describe the process of ordering pharmacogenomic tests by interviewing providers, patients, and laboratories about cancer-related pharmacogenomic tests. We interviewed patients who were prescribed, providers who prescribed medications that should be guided by pharmacogenomic testing, and individuals from diagnostic laboratories. A total of 10 providers, 16 patients, and eight diagnostic laboratories described logistical and insurance issues ...


Insurance Coverage Policies For Pharmacogenomic And Multi-Gene Testing For Cancer, Christine Y. Lu, Stephanie Loomer, Rachel Ceccarelli, Kathleen M. Mazor, James Sabin, Ellen Wright Clayton, Geoffrey S. Ginsburg, Ann Chen Wu Jul 2018

Insurance Coverage Policies For Pharmacogenomic And Multi-Gene Testing For Cancer, Christine Y. Lu, Stephanie Loomer, Rachel Ceccarelli, Kathleen M. Mazor, James Sabin, Ellen Wright Clayton, Geoffrey S. Ginsburg, Ann Chen Wu

Kathleen M. Mazor

Insurance coverage policies are a major determinant of patient access to genomic tests. The objective of this study was to examine differences in coverage policies for guideline-recommended pharmacogenomic tests that inform cancer treatment. We analyzed coverage policies from eight Medicare contractors and 10 private payers for 23 biomarkers (e.g., HER2 and EGFR) and multi-gene tests. We extracted policy coverage and criteria, prior authorization requirements, and an evidence basis for coverage. We reviewed professional society guidelines and their recommendations for use of pharmacogenomic tests. Coverage for KRAS, EGFR, and BRAF tests were common across Medicare contractors and private payers, but ...


The Role Of Clinical Guidelines In A Managed Long Term Services & Supports Framework, Jessica Carpenter, Jill Morrow-Gorton Jun 2018

The Role Of Clinical Guidelines In A Managed Long Term Services & Supports Framework, Jessica Carpenter, Jill Morrow-Gorton

Commonwealth Medicine Publications

This presentation describes the managed long-term services and supports (MLTSS) national landscape since 2012 as well as some LTSS utilization trends. A key part of the presentation is our MLTSS best practice framework and the role of LTSS clinical guidelines in that framework. The presentation includes a case study.

Experts from Disability Community Services and the Office of Clinical affairs gave the presentation during a webinar hosted by the Association for Community Affiliated Plans.


Covering Florida Addendum: Developing Statewide Strategies May 2018

Covering Florida Addendum: Developing Statewide Strategies

Florida Blue Archives Printed Materials

An addendum to Covering Florida, it provides additional perspectives from the Florida Hospital Association. Box 33, Folder 418


The Pricing Impact Of The Decreasing Competitiveness Of The Health Insurance Market, Lauren N. Patterson May 2018

The Pricing Impact Of The Decreasing Competitiveness Of The Health Insurance Market, Lauren N. Patterson

EURēCA: Exhibition of Undergraduate Research and Creative Achievement

The Affordable Care Act created the national insurance exchanges of qualified health plans to encourage a higher insured rate, larger risk pools, and lower prices for quality health coverage. Consolidation of insurers can have opposing effects. The insurers’ risk pools will grow, allowing insurers to better hedge for risk. However, consolidation decreases the prevalence of competition in the market, and past research shows that insurer consolidation decreases market competition and increases prices.

I examine how the number of plans offered in a set market, pricing components, and county health variables impact the monthly premium pricing of plans sold on the ...


Insurance Coverage Policies For Pharmacogenomic And Multi-Gene Testing For Cancer, Christine Y. Lu, Stephanie Loomer, Rachel Ceccarelli, Kathleen M. Mazor, James Sabin, Ellen Wright Clayton, Geoffrey S. Ginsburg, Ann Chen Wu May 2018

Insurance Coverage Policies For Pharmacogenomic And Multi-Gene Testing For Cancer, Christine Y. Lu, Stephanie Loomer, Rachel Ceccarelli, Kathleen M. Mazor, James Sabin, Ellen Wright Clayton, Geoffrey S. Ginsburg, Ann Chen Wu

Open Access Articles

Insurance coverage policies are a major determinant of patient access to genomic tests. The objective of this study was to examine differences in coverage policies for guideline-recommended pharmacogenomic tests that inform cancer treatment. We analyzed coverage policies from eight Medicare contractors and 10 private payers for 23 biomarkers (e.g., HER2 and EGFR) and multi-gene tests. We extracted policy coverage and criteria, prior authorization requirements, and an evidence basis for coverage. We reviewed professional society guidelines and their recommendations for use of pharmacogenomic tests. Coverage for KRAS, EGFR, and BRAF tests were common across Medicare contractors and private payers, but ...


Accounting For Geographic Variation In Social Security Disability Program Participation, John Gettens, Pei-Pei Lei, Alexis D. Henry May 2018

Accounting For Geographic Variation In Social Security Disability Program Participation, John Gettens, Pei-Pei Lei, Alexis D. Henry

Commonwealth Medicine Publications

There is wide geographic variation in Social Security Disability Insurance and Supplementary Security Income participation across the United States. Some policymakers and members of the public may assume that interregional administrative inconsistencies are a major reason for the geographic variation. To test this assumption, and to reveal other potential explanations for the variation, we decompose the total variation into components by examining regional differences in disability prevalence and in program participation among persons with disabilities as well as the correlation between those two factors. We further decompose the variation in participation among persons with disabilities into socioeconomic components. Our findings ...


The Pricing Impact Of Decreasing Competitiveness Of The Health Insurance Market, Lauren N. Patterson May 2018

The Pricing Impact Of Decreasing Competitiveness Of The Health Insurance Market, Lauren N. Patterson

Chancellor’s Honors Program Projects

No abstract provided.


Narrow Networks On The Individual Marketplace In 2017, Daniel Polsky, Janet Weiner, Yuehan Zhang Sep 2017

Narrow Networks On The Individual Marketplace In 2017, Daniel Polsky, Janet Weiner, Yuehan Zhang

Issue Briefs

This Issue Brief describes the breadth of physician networks on the ACA marketplaces in 2017. We find that the overall rate of narrow networks is 21%, which is a decline since 2014 (31%) and 2016 (25%). Narrow networks are concentrated in plans sold on state-based marketplaces, at 42%, compared to 10% of plans on federally-facilitated marketplaces. Issuers that have traditionally offered Medicaid coverage have the highest prevalence of narrow network plans at 36%, with regional/local plans and provider-based plans close behind at 27% and 30%. We also find large differences in narrow networks by state and by plan type.


Stabilizing Individual Health Insurance Markets With Subsidized Reinsurance, Scott E. Harrington Sep 2017

Stabilizing Individual Health Insurance Markets With Subsidized Reinsurance, Scott E. Harrington

Issue Briefs

Subsidized reinsurance represents a potentially important tool to help stabilize individual health insurance markets. This brief describes alternative forms of subsidized reinsurance and the mechanisms by which they spread risk and reduce premiums. It summarizes specific state initiatives and Congressional proposals that include subsidized reinsurance. It compares approaches to each other and to more direct subsidies of individual market enrollment. For a given amount of funding, a particular program’s efficacy will depend on how it affects insurers’ risk and the risk margins built into premiums, incentives for selecting or avoiding risks, incentives for coordinating and managing care, and the ...


The Economic Realities Of Replacing The Affordable Care Act, Hanming Fang Mar 2017

The Economic Realities Of Replacing The Affordable Care Act, Hanming Fang

Penn Wharton Public Policy Initiative

Using simulations based on a new economic model, this brief empirically examines the pivotal mechanisms of the Affordable Care Act, such as the individual mandate, employer mandate, and premium subsidies, to inform the debate over repealing and replacing the Affordable Care Act. The research suggests that the ACA, if left intact, in the long run significantly reduces the uninsured rate. The simulations also suggest that the employer mandate is not a crucial pillar for the success of the ACA. The analysis indicates it is the premium subsidy, rather than the employer mandate or the individual mandate, that is crucial for ...


Health Insurance Co-Ops: Product Availability And Premiums In Rural Counties, Erika C. Ziller Phd, Zach T. Croll Ba, Andrew F. Coburn Phd Oct 2016

Health Insurance Co-Ops: Product Availability And Premiums In Rural Counties, Erika C. Ziller Phd, Zach T. Croll Ba, Andrew F. Coburn Phd

Access / Insurance

Created by the Affordable Care Act (ACA), Consumer Operated and Oriented Plans (CO-OPs) are private, non-profit health insurers that were designed to increase insurance plan choice and lower premiums in the Health Insurance Marketplaces. Early analyses of the ACA suggested that CO-OPs may be particularly beneficial for rural communities, where fewer individual and small group health insurance options have traditionally been available.

This Research and Policy Brief, authored by research staff at the Maine Rural Health Research Center, explores the early availability and role of CO-OPs in rural and urban counties. We describe the regional distribution and market prevalence of ...


Rural Disabled Medicare Beneficiaries Spend More Out-Of-Pocket Than Their Urban Counterparts, Erika C. Ziller Phd, Jennifer D. Lenardson Mhs, Andrew F. Coburn Phd Nov 2015

Rural Disabled Medicare Beneficiaries Spend More Out-Of-Pocket Than Their Urban Counterparts, Erika C. Ziller Phd, Jennifer D. Lenardson Mhs, Andrew F. Coburn Phd

Access / Insurance

The majority of Medicare beneficiaries experience gaps between the care they need and costs covered by Medicare and seek supplemental coverage to meet this gap, including private plans offered by former employers or purchased individually, or public coverage through Medicaid. Since rural beneficiaries are more likely to purchase supplemental indemnity coverage individually, to participate in Medicaid, or to go without supplemental coverage altogether, it is likely that their out-of-pocket spending differs from that of urban residents, although the magnitude and direction of these differences may vary for individual beneficiaries. This study used data from the 2006-2010 Medical Expenditure Panel Survey ...


Disparities In Hospital Services Utilization Among Patients With Mental Health Issues: A Statewide Example Examining Insurance Status And Race Factors From 1999-2010, Viann N. Nguyen-Feng, Hind A. Beydoun, Michael K. Mcshane, James D. Blando Jul 2015

Disparities In Hospital Services Utilization Among Patients With Mental Health Issues: A Statewide Example Examining Insurance Status And Race Factors From 1999-2010, Viann N. Nguyen-Feng, Hind A. Beydoun, Michael K. Mcshane, James D. Blando

Community & Environmental Health Faculty Publications

There exist many disconnects between the mental and general health care sectors. However, a goal of the Affordable Care Act (ACA) of 2010 is to change this by improving insurance access and the intersection of mental and general health care. As insurance status intersects with race, the present study examines how race, insurance status, and hospital mental health services utilization differ across groups within the state of New Jersey. The present study aims to determine trends in hospital mental health care utilization by insurance status and race from 1999 to 2010. The rate of self-pay for mental health disorders in ...


Pharmacy Benefit Management: Are Reporting Requirements Pro- Or Anticompetitive?, Patricia M. Danzon Jun 2015

Pharmacy Benefit Management: Are Reporting Requirements Pro- Or Anticompetitive?, Patricia M. Danzon

Health Care Management Papers

The market-based US health care system relies on pharmacy benefit managers (PBMs) to control pharmaceutical costs, in contrast to most other countries that regulate drug prices and access. Optimal strucuturing and regulation of PBM contracts poses significant agency challenges for private and public payers. However, recent reporting requirements for PBMs may be counterproductive and reflect the interests of competitors rather than customers.


Rural Implications Of Medicaid Expansion Under The Affordable Care Act, Erika C. Ziller Phd, Jennifer D. Lenardson Mhs, Andrew F. Coburn Phd Feb 2015

Rural Implications Of Medicaid Expansion Under The Affordable Care Act, Erika C. Ziller Phd, Jennifer D. Lenardson Mhs, Andrew F. Coburn Phd

Medicaid

In this brief, researchers from the Maine Rural Health Research Center (University of Southern Maine, Muskie School of Public Service) present findings from a SHARE-funded evaluation of the rural implications of Medicaid expansion under the ACA.

The authors examine the following issues:

  • The extent to which prior public health insurance expansions have covered rural populations
  • Whether rural residents who are expected to be newly eligible for Medicaid in 2014 differ from their urban counterparts
  • The extent to which rural individuals might differentially benefit from the ACA Medicaid expansion in light of the expansion becoming optional
  • Whether rural enrollees are likely ...


Workplace Wellness Programs: Are They Part Of The Answer To The U.S.’S Growing Healthcare Crisis?, Maria C. Grillo Dec 2014

Workplace Wellness Programs: Are They Part Of The Answer To The U.S.’S Growing Healthcare Crisis?, Maria C. Grillo

Cornell HR Review

[Excerpt] Of the $2.8 trillion that the United States has spent on healthcare in recent years, the majority of it (75%) is spent treating chronic disease. Chronic disease is “a long-standing condition that can be controlled but not cured… It is the leading cause of death and disability in the U.S., which is 1.7 million lives each year.” To make matters worse, chronic disease indicators in the U.S. have been on the increase recently. And, even though chronic disease is commonly thought to be more prevalent among the elderly, in the past 10 years, it has ...


The Effects Of The Affordable Care Act On Large Employers And The Impact On The Human Resources Function, Maksim Spivak Dec 2014

The Effects Of The Affordable Care Act On Large Employers And The Impact On The Human Resources Function, Maksim Spivak

Cornell HR Review

[Excerpt] The purpose of this paper is to explore how Fortune 500 companies have been affected by the passing of the Affordable Care Act (ACA). More importantly, this paper will explore what strategies companies have adopted, and what the legislation means to the following stakeholders: company boards, executives, managers, employees, the Human Resource function, and the Benefits staff.


Only Too Human: Understanding Health Insurance Markets When Consumers Lack Information, Jonathan T. Kolstad Sep 2014

Only Too Human: Understanding Health Insurance Markets When Consumers Lack Information, Jonathan T. Kolstad

Penn Wharton Public Policy Initiative

When the state and federal health insurance exchanges were introduced in 2013, much attention was paid to the logistics of their launch. Nearly a year later, policymakers should now be looking at a different question: how can we collect and use data from the exchanges to understand how consumers think about insurance choice, so as to make the exchanges function better?


The Effect Of Entry Regulation In The Health Care Sector: The Case Of Home Health, Daniel Polsky, Guy David, Jianing Yang, Bruce Kinosian, Rachel M. Werner Feb 2014

The Effect Of Entry Regulation In The Health Care Sector: The Case Of Home Health, Daniel Polsky, Guy David, Jianing Yang, Bruce Kinosian, Rachel M. Werner

Health Care Management Papers

The consequences of government regulation in the post-acute care sector are not well understood. We examine the effect of entry regulation on quality of care in home health care by analyzing the universe of hospital discharges during 2006 for publicly insured beneficiaries (about 4.5 million) and subsequent home health admissions to determine whether there is a significant difference in home health utilization, hospital readmission rates, and health care expenditures in states with and without Certificate of Need laws (CON) regulating entry. We identify these effects by looking across regulated and nonregulated states within Hospital Referral Regions, which characterize well-defined ...


Navigating The Health Care Labyrinth: Portraits Of The Socioeconomically Disadvantaged, Thomas C. Crawford Phd Jan 2014

Navigating The Health Care Labyrinth: Portraits Of The Socioeconomically Disadvantaged, Thomas C. Crawford Phd

Dissertations & Theses

In 2010, an estimated population of the 311,212,863 Americans generated approximately 1,014,688,290 physician office encounters (Moore, 2010). The frequency and number of professional interactions between caregivers and patients/family members in medical office settings equated to a staggering 1,931 visits per minute. Based on the massive volume of interactions that occurred between patients of different races, ethnicities, genders, sexual orientations, and socioeconomic standings that generated an average household income of $49,445 in 2010 (United States Census Bureau, 2010a) with a physician workforce that the Association of American Medical Colleges (2010) captured as being ...


Can Consumers Make Affordable Care Affordable? The Value Of Choice Architecture, Eric J. Johnson, Ran Hassin, Tom Baker, Allison T. Bajger, Galen Treuer Jul 2013

Can Consumers Make Affordable Care Affordable? The Value Of Choice Architecture, Eric J. Johnson, Ran Hassin, Tom Baker, Allison T. Bajger, Galen Treuer

Faculty Scholarship at Penn Law

Starting this October, tens of millions will be choosing health coverage on a state or federal health insurance exchange as part of the Patient Protection and Affordable Care Act. We examine how well people make these choices, how well they think they do, and what can be done to improve these choices. We conducted 6 experiments asking people to choose the most cost-effective policy using websites modeled on current exchanges. Our results suggest there is significant room for improvement. Without interventions, respondents perform at near chance levels and show a significant bias, overweighting out-of-pocket expenses and deductibles. Financial incentives do ...