Medicare Math. Medicare Part B premiums will go up about 6% next year, Social Security cost of living adjustment will be 3.2%.

Really Stupid Vaccine Policies. Sometimes a story hits just right like this Washington Post opinion piece on RSV vaccines for adults and how the access is harmed by coverage policies. This year two RSV vaccines were approved for RSV in older adults, but coverage is under Medicare Part D (prescription drug benefit.) This is fantastic news. But reimbursement issues are marring the rollout.

COVID, pneumonia and flu vaccines are all covered under Medicare Part B so physicians and pharmacists can administer them and get reimbursed. The RSV vaccines are covered under Part D with shared clinical decision making. Theoretically all Part D plans are supposed to cover them without cost-sharing but there is a spider web of problems getting coverage and access.  First you have the delay in plans adding them to formulary. You also have physicians not offering them in office because physicians aren’t routinely reimbursed by Part D. And then you have the variation in state laws surrounding pharmacists and their ability to conduct the shared decision making required for the vaccine and the administration. And sometimes pharmacy chains within a state have different interpretations of what is permitted. The comments section of the Washington Post piece illustrates the chaos perfectly with a back and forth of beneficiaries who had no problem getting the vaccine and others saying it wasn’t covered – sometimes by the same insurer. At some point I’ll write a longer piece about this but for now I’ll just say that I really wish we’d just move all vaccines to Part B and make this easier and more equitable all around.

Updating an update. This week the Center for Medicare and Medicaid Innovation (CMMI) posted an update to the report issued in response to the Executive Order issued last October calling for lowering prescription drug prices. CMMI is looking at 3 different models -a $2 Medicare drug lists, cell and gene therapy access and accelerating clinical evidence. A few bits of new information were included on each model –

$2 Medicare drug lists: CMMI will focus on about 150 generic drugs in lower cost tiers; they are thinking through how to share this information with beneficiaries. (Hello patient groups and coalitions like MAPRx).

Cell and gene therapy access: CMMI is looking to establish multi-state outcomes-based agreements with manufacturers. There is expressed interest by states (and a sense of urgency) so CMMI is attempting to move the timeline up to a rolling start in 2025 (rather than 2026).

Accelerating clinical evidence: As CMMI works with the Food and Drug Administration it looks like the problem they were trying to solve is sort of solving itself? They will continue to look at ways to encourage the completion of confirmatory trials. However, there feels like there is a but…. in the update. Like maybe there is little to solve for.

COVID Hits, They Just Keep on Coming. This week there was some news that just reiterated that the COVID era is as bad as we thought it was and, beyond the recent surge, the impacts are still there. First up, liver disease went up and the need for transplants. And research came out this week that suggests that 20% of teens had major depression in 2021 and less than half got treated. And there were inequities in who got treated. 20% is a LOT. Stop and think about the trickle-down impact of that on classmates, teachers, and families and what the long-term impacts must be.

Spending more than our neighbors. The Commonwealth Fund did a study on U.S. spending on healthcare. We spend twice as much per person compared to peer countries due to higher prices (including salaries (15% of the excess spending), prescription drug costs (10% of excess spending) but the big driver was administrative costs. Our administrative costs drove 30% of the excess spending.

I want it, I get it. Best Buy is jumping into the consumer-demand/prescription space. Customers can get a prescription for a glucose monitor from a third-party company, Wheel, and then have the glucose monitor (and refills) sent directly to them.  Best Buy will not be accepting insurance.