Josette Gbemudu

Lots of news and opinion pieces out there this week about the Medicare IRA price negotiations for the first 10 identified products. These new prices will go into effect in 2026, with some drugs discounted as much as 79% from 2023 prices (see the table in the attached Fact Sheet). It will be interesting to watch this evolve and see how it ultimately trickles down to patient out of pocket cost, impacts on patient access to therapy and on innovation for new product development.

27

2 Comments

Social determinants of health (SDOH) are becoming increasingly crucial in our already complex healthcare environment from a data collection, reporting, and action perspective. This week I’m sharing a link to a white paper I wrote about how patient service programs can incorporate actionable, tactical, and scalable solutions to help address SDOH challenges, advance health equity, and achieve better health outcomes for patients. Let’s connect if you’d like to discuss more… https://lnkd.in/ect4H9N3

32

As the dust settles on election results, #Avalere is helping clients game out scenarios for the future of #IRA negotiations and other drug pricing policies under the new #Congress and #WhiteHouse. If you need materials with robust policy nuance to help your forecasting and internal prioritization, please consider Avalere your partner in sorting through the uncertainty. #Medicare #DrugPricing

36

All pharma CEOs need to understand that they have a responsibility beyond that to their shareholders. Maximizing profits for shareholders beyond what is needed to earn a return on R&D investment—at the expense of people who cannot afford their pharmaceuticals—is unethical. Business ethics should be taught not only in MBA school, but in all undergraduate and graduate programs.

5

2 Comments

Great 18 minute podcast using layman terms to discuss some complex topics in the dynamic healthcare ecosystem. Take a listen and consider subscribing. I’m interested in the next episode on the topic of reimbursement vs. coverage. Thanks for sharing this Michael Navin. #marketaccess #healthcare #pbms #pharmaceuticals

12

1 Comment

🎧 #ICYMI: When Lorece Shaw, PharmD (Director, Prior Authorization) joined us for episode 17 of Astonishing Healthcare, she shared a personal story about a situation where she was prescribed twice the recommended dose of a #medication. Thankfully, she was able to catch the mistake due to her experience and speak with the dispensing #pharmacist, but we all know that the healthcare system can be challenging to navigate, even for experienced consumers. In cases like these, #priorauthorization can help as well! You can listen to the entire episode here: https://okt.to/JhISkm

9

When I speak with people about their concerns about the health care system, one theme often comes up: The need to hold middlemen accountable. That’s why the results of our latest Patient Experience Survey with Ipsos don’t come as a surprise to me. Our team surveyed 2400 insured Americans, and the data show the hurdles insurers and middlemen force patients to jump through to access medicines they need. 1. Four in 10 (41%) insured Americans taking a prescription medicine have experienced insurer- and PBM-imposed barriers to care in the past year, such as prior authorization or step therapy. 2. A third of insured Americans (33%) say their out-of-pocket costs for health care services have increased over the past year. 3. Most insured Americans (90%) support cracking down on abusive insurer and PBM practices that limit patient access to medicines. Policymakers can address these insurer- and PBM-imposed hurdles impacting patients’ access to medicines by passing reforms that ensure savings to directly to patients and middlemen don’t profit off the price of medicines. Learn more: https://lnkd.in/erfrJeaY

81

5 Comments

As noted in Pharmacy Times, Medicare is about to experience one of its most significant transformations in decades, bringing big changes that will affect millions of beneficiaries. As we approach 2025, the landscape for Medicare plans is shifting dramatically, and more people than ever will need to re-evaluate their options during this year’s Annual Enrollment Period (AEP). While traditionally, only around 10% of Medicare beneficiaries switch plans each year, the new policies are likely to drive a much higher rate of plan changes as individuals seek the best fit for their healthcare needs. For pharmacies, this period of uncertainty presents a unique opportunity to step up as trusted advisors. By guiding patients through these changes, pharmacies can not only help patients make informed decisions but also strengthen long-term relationships and become essential partners in navigating the evolving Medicare landscape. How are you preparing to support patients during this transformative time? #MedicareChanges #HealthcareSupport #PharmacyLeadership #Rxspeaks https://ow.ly/75fh50TKr5e

1

Read this in the WSJ - in today’s political environment, it’s clear that the biopharma industry can't focus solely on innovation within the lab and communicate in ways that regular people either don't understand or feel is condescending. To safeguard the progress of science, we need to move beyond Beltway conversations and connect with real voices across America. Authentic, emotionally-resonant engagement can bridge the gap between complex research and public understanding. By highlighting the human impact of our work, we can foster trust and underscore the value of innovation in every community. Its real work that will ensure companies are properly positioned for the next administration.

8

It's a positioning thing. Where Walgreens is flailing to find strategic fit with primary care (via its $6 billion write-down of VillageMD), Elevance Health plans to build a $4 billion business unit focused on chronic care management. Per company CEO Gail K. Boudreaux: “This will help us continue through having a focus on advanced primary care; it’s still very much focused on our chronic patients and complex patients. We are still building specialty care enablement. In time, Elevance Health will have full ownership of what we expect will be a leading platform for value-based care delivery and physician enablement at scale.” It's a competition thing. "The new partnership with Clayton Dubilier & Rice is “a necessary move as Elevance looks to hold its own [against] mega brands like CVS Health and UnitedHealth Group, which have entered the delivery space in a more aggressive manner,” Forrester analyst Arielle Trzcinski writes here in emailed comments. Elevance said its partnership with CD&R aims to create a new advanced primary care offering supported by care coordination, referral management and health coaching." And it's a thing still locked in the conceptual past. The next cycle of evolution in the business and economics of healthcare *works* with a more original narrative, a different screenplay altogether, a new genre, something that creates space to expand what Stacey Chang (via Kent Lawson) calls the 'impact horizon'. There's a difference between "primary care" and 'continuous health engagement' as ideas for big innovation. The former is an obsolete framing, with almost no kinetic energy to power anything other than a margin squeeze. The latter is a new economic concept, a foundation upon which to shift the center-of-gravity for the American Way of Healthcare. From "Hospitals Declare War on Corporate Insurance", by Paul Keckley: To industry watchers, the war is no surprise. It’s been simmering for years but most recently inflamed as operating margins for most hospitals eroded while profits among corporate insurers led by Big 6 (UnitedHealth, Humana, Aetna, a CVS Health Company, Elevance, Cigna Healthcare, Centene Corporation) swelled at double-digit rates. To outsiders, it’s not quite so clear. Corporatization seems embedded in the business models for both. And both appear complicit in well-documented beliefs that the health system is failing as unnecessary higher costs make it less accessible, affordable and effective. As the War intensifies, each combatant is inclined to make their cases aggressively contrasting “us” against “them.” ********* Market innovation is really about management innovation. And the process starts by positioning strategy at a system level. The goal isn't to "fix" a broken engine, but to enable 'gravitational pull' into a new orbit for competition and collaboration. To Engage: [email protected] To Meet Next Week: @ #asembia24 To Explore #ModernStrategy: Blue Spoon Consulting

21

5 Comments

📈 New data is now available from CMS, sharing insights through June 2024. Here are some key stats that are featured: - 67.5M Total Medicare Enrollment - 50.5% Enrolled in MA & Other Health Plans - 89.5% Age 65 and Over - 80.4% With Medicare Part D Coverage What will this mean for the next open enrollment period? It will be interesting to see as the year wraps up. #Payers #Medicare #Medicaid #CMS

13

2 Comments

Check out my BCG colleagues recent report that focuses on improving #healthequity with patient analytics. The research unveils significant disparities in the treatment of Heart Failure with Reduced Ejection Fraction (HFrEF) across the United States. Focusing on areas with notably low engagement, particularly in under-served urban areas. Explore the findings and actionable strategies here: https://lnkd.in/gbMpC9d8

9

#CMS has proposed exciting refinements to the Outpatient Prospective Payment System (OPPS) that promise significant benefits for healthcare and the nuclear medicine industry. Currently, the diagnostic agent costs are packaged with nuclear medicine tests, but the update suggests separate payments for qualifying agents. Several new radiopharmaceuticals will qualify. This change will enhance payment accuracy and expand patient access to essential diagnostic tools, reflecting a strong commitment to superior patient care. Furthermore, it will drive innovation in the development of new #radiopharmaceutical diagnostics by ensuring fair reimbursement for high-cost agents. #HealthcareInnovation #NuclearMedicine #CMSUpdates

3

This interesting perspective is worth a quick read and some consideration. There is a reshuffling of who profits the most, but unfortunately, patients won't see any relief in prices. Please see the following quote from the article. "During this period of volatility, the core business model of the Big Three public pharmaceutical distribution companies—Cardinal Health, Cencora, and McKesson—remains intact. Put simply: Buy low, sell high, collect early, and pay late. But as I explain below, wholesalers continue to position themselves as essential intermediaries by expanding their industry position and strengthening their economic fundamentals." Adam FeinStacey RichterGe BaiChris DeaconScott Conard, MDShawn GremmingerLarry BeckerRob Marty, DBA, MHAAl Lewis 🇺🇦Stacy MaysAnn M. Richardson, MBA https://lnkd.in/gJR4yvar

7

1 Comment

🧐 PBM executives are under scrutiny again! Chairman Comer is calling them out to correct their hearing testimony—another wake-up call for transparency and accountability in the PBM industry. It's a reminder that when it comes to pharmacy benefits, fiduciary duty should always come first. We need to stay vigilant and ensure that actions align with words. 💡#TransparencyMatters #PBMs #Accountability #FiduciaryDuty

3

1 Comment

Scrolling through the ISPOR attendees list makes me very happy 😍 - we are quite a community! Derek Xu and I are also pretty excited about the findings of our health equity poster:🌟 "Health Equity and HTAs: Agencies are asking for equity data - but are they using it?". 🌟 We were positively surprised! Would love to book a chat if you are interested in health equity in relation to value strategy or HTA, or if you'd like to discuss your value strategy and communication needs more broadly. The link to book a chat and enter our 'win a bike' competition is in the comments.

31

1 Comment

First panel of the 🍂🍁fall, and I’m energized for the conversation ahead! I’m thrilled to join some visionary minds for the panel “Making Healthcare Fairer & More Equitable Across the Nation” on Thursday, September 12. I’ll be alongside Michael Pace of PalmHealthCo🌴, Arianne Kidder of Seae Ventures, Willie T. Reaves Jr. Of Cellino, and our moderator, Keely Benson of the Massachusetts eHealth Institute. Together, we’ll dive into: 🔷 The promise of healthtech to advance health equity and improve access to care. 🔷 The technology needed to bridge the gap in communities across the nation. 🔷 Whether commercial scalability is catching up with equitable innovations. 🔷 Identifying the missing tools in the health equity toolkit. 🔷 Strategies to move beyond politics and turn health equity into reality. 📅 If you’re passionate about making digital health equitable for Everyone, join us at the LSX USA Congress on September 11-12. Learn more and register here: www.lsxleaders.com/USA #LSXUSA #Healthtech #Biotech #AI #MachineLearning #HealthEquity #DigitalHealth

72

8 Comments

You bettah ask somebody! Venture capitalists, if you are not investing in Philly life sciences companies, you may want to pay attention here. Because to know us, is to be in the know! Listen to Ajay Raju, only our ecosystem can make this man age backwards. Why!? Because he knows we cure and treat disease whilst multiplying the $$$. #peaceofmindinvestments #lifescience #lifesciences #americanbazaaronline

39

The conversation around consolidation in healthcare is overwhelmingly focused on providers, while payors have been gobbling up entities under the guise of vertical integration for years. PBMs are just one example -- and probably the most egregious -- of how payors are profiteering off the backs of sick Americans. The FTC's latest report shows PBMs have significant power over prescription drug prices and control over access, too. And as the FTC says in its report, all for the explicit purpose of boosting their profits. Meanwhile, providers continue to catch most of the blame for rising healthcare costs. Providers facing challenging contract negotiations would do well to start unpacking these types of inequities for their stakeholders and winning back the narrative on cost. And doing so well in advance of a contract negotiation. Shifting this narrative will take years. Providers must play the long game. https://lnkd.in/eGfDxNXw

10

2 Comments