Tag: 2020 News

A little over two years after its $753 million acquisition of the prescription medicine delivery service Pillpack, Amazon has finally launched Amazon Pharmacy, its online and mobile prescription medication ordering and fulfillment service.

The launch of the new Pharmacy service within Amazon is a blow to other discount prescription services like the publicly traded GoodRx and companies like RxSaver and delivery services like ExactCare Pharmacy.

The competition from Amazon was likely one reason why GoodRx began offering telemedicine services as a point of differentiation and to move up the value chain. It will be interesting to see if Amazon will also move to providing virtual care for more than its employees.

Last year, the company rolled out Amazon Care for its workers in Seattle as part of a pilot service that provided both in-person and telemedicine services.

Using a secure pharmacy profile, Amazon customers can add their insurance information, manage prescriptions and choose payment options all through Amazon’s service. And in another small push towards wider healthcare services, and not just selling items, users are provided with “self-service help” tools on Amazon’s portal, and they also have the option to speak to pharmacists either via over the phone, for advice: “Friendly and knowledgeable pharmacists are available 24/7 to answer questions about medications.”

After launching its own line of over-the-counter drugs in 2019, this is arguably Amazon’s broadest push into the healthcare business to-date, one that could open up very large, new revenue opportunities for the company, especially as the ongoing COVID-19 pandemic pushes consumers both toward more remote care, and using online channels for all their shopping needs.

While Amazon Pharmacy looks to be a US-only launch for now, it’s a global opportunity. Online pharmacy services are projected to hit revenues of $131 billion by 2025 worldwide. Prescription drugs, meanwhile, have been estimated to be a $904 billion industry this year, growing to nearly $1.3 trillion by 2025.

Amazon is also letting customers compare prices with their insurance co-pay, without insurance or with the savings available through the Prime prescription savings plan to choose the lowest option. Amazon is also staffing a pharmacy service accessible at all hours so that customers can answer questions about their medications.

In August, Amazon launched its fitness tracker, Halo. The personal health and wellness monitoring and advice service includes a $64.99 wrist tracker and an application suite for monitoring health.

This year, CMS has been quite active announcing several updates to its Medicare Secondary Payer Recovery Portal and holding a recent webinar on redetermination requests. CMS trends regarding post-settlement Total Payment Obligation to Claimant (TPOC) beneficiary recovery have been causing some challenges for workers’ compensation carriers from another angle. CMS will also be holding a webinar on the NGHP Beneficiary Recovery Process on December 9th.

In September, CMS and the Commercial Repayment Center (CRC) held a webinar session to address “redetermination” requests as part of the administrative appeals process regarding conditional payment disputes of non-group health plans (NGHP). CMS reviewed the five levels of the administrative appeals process before the CRC discussed the various appeals available to primary payers in the administrative appeals process.

The CRC outlined the specific arguments it will accept as part of a redetermination request as follows:

— Termination of Ongoing Responsibility for Medicals (ORM) due to benefits exhaustion;
— Termination of ORM due to settlement or other claim resolution;
— Benefits denied/revoked by applicable plan;
— Non-covered services;
— Unrelated services; and
— Duplicative primary payment.

As part of this session, the CRC emphasized adherence to established appeal timelines and other related requirements is critical. On this point, the CRC advised redeterminations must be received within 120 days from the date a Medicare demand letter is received by the named debtor, which CRC noted is presumed to be five days after the date of demand.

CMS’s trend of having the BCRC pursue the claimant post-settlement is currently causing some challenges and frustration particularly in workers’ compensation settlements.

Specifically, the BCRC is increasingly opening conditional payment recovery cases upon receipt of TPOC information and issuing final demands with the claimant named the debtor. This occurs even in situations where the parties have previously worked with the CRC to resolve conditional payment cases related to ORM.

When this happens, the carrier cannot interact with the BCRC on the claim without having a separate Proof of Representation (POR) executed by the claimant. This, in turn, complicates the workers’ compensation carrier’s ability to ensure that Medicare’s recovery is resolved if they cannot secure a POR from the claimant post-settlement.

To prevent this, workers’ compensation carriers wishing to ensure conditional payment exposure is fully resolved may need to consider securing a POR from the claimant as part of the settlement process to avoid having to chase the claimant post-settlement for this required authorization.

CMS has recently announced that it is holding a Non-Group Health Plan (NGHP) Beneficiary Recovery Process Webinar on December 9, 2020, at 1:00 p.m. ET. CMS indicates that its primary intended audience is “attorneys who represent beneficiaries and other beneficiary representatives.”

Indivior Solutions was sentenced to pay $289 million in criminal penalties in connection with a previous guilty plea related to the marketing of the opioid-addiction-treatment drug Suboxone. The sentence was pursuant to a plea agreement.

In total, the payments made by Indivior Solutions and its parent companies, Indivior Inc. and Indivior plc, along with payments made under a 2019 resolution with Indivior’s former parent, Reckitt Benckiser Group plc, and criminal penalties paid pursuant to plea agreements with two former Indivior executives will exceed $2 billion.

That amount represents the second-largest monetary resolution obtained by the Department of Justice in a case involving an opioid drug.

Suboxone, which contains the powerful opioid buprenorphine, is a drug product approved for use by recovering opioid addicts to avoid or reduce withdrawal symptoms while they undergo treatment for opioid-use disorder.

In connection with its guilty plea, Indivior Solutions admitted to making false statements to the Massachusetts Medicaid program (MassHealth) related to the relative safety of Suboxone Film, a version of Suboxone, around children.

Indivior Solutions pleaded guilty on July 24, 2020, to a one-count felony criminal information charging false statements relating to health care matters.

Last June, Indivior’s former CEO, Shaun Thaxter, pleaded guilty to a one-count misdemeanor information related to Indivior’s false and misleading representations to MassHealth. He was sentenced to a six-month term of incarceration and $600,000 in criminal fines and forfeiture.

Last August. Indivior’s former medical director, Tim Baxter, pleaded guilty to a one-count misdemeanor information related to Indivior’s false and misleading representations to MassHealth. His sentencing is scheduled for Dec. 17.

Indivior Solutions that in October 2012 it sought to convince MassHealth to expand Medicaid coverage of Suboxone Film in Massachusetts and sent MassHealth a misleading chart and false data indicating that Suboxone Film had the lowest rate of accidental pediatric exposure (i.e., children taking medication by accident) of all buprenorphine drugs in Massachusetts, when in fact it did not.

Indivior Solutions further admitted that sending the false and misleading information occurred in the context of marketing and promotional efforts directed at MassHealth, which were overseen by top executives.

MassHealth announced it would provide access to Suboxone Film for patients with children under the age of six shortly after Indivior provided the false and misleading information to agency officials.

Many recent studies show stunning public mistrust in vaccines. And mistrust could push levels that potential COVID-19 vaccines are taken in the United States below the rates needed to protect communities against the disease.

One new prepublication study of 8,000 people in the U.S. and Britain found that fewer people would “definitely” take a COVID-19 vaccine than the 55% of the population scientists estimate is needed to provide so-called “herd immunity”.

The study comes as one of the major vaccine efforts showed promising results. Pfizer said on Monday its experimental COVID-19 vaccine is more than 90% effective based on interim data from late stage trials. The data were seen as a crucial step in the battle to contain a pandemic that has killed more than a million people.

— People without a college degree, those in low-income groups and non-whites are more likely to reject a COVID-19 vaccine, the study found.

— Women were more likely than men to refuse a COVID-19 vaccine, but more respondents in both countries said they would accept a vaccine if it meant protecting family, friends, or at-risk groups.

In the United States alone, another study by the Pew Research Center found, the share of adult Americans who say they would “definitely” or “probably” get a Covid-19 vaccine fell from 72 percent in May to 51 percent in September.

An October Harris poll showed that 78% of Americans think that the speedy approval process of a coronavirus vaccine is driven by politics – not by proof that shots work. About 83% said they would worry about a safe a coronavirus vaccine is if it was approved quickly.

And recent Axios-Ipsos polls confirms that vaccine resistance is growing. The percentage of people who say they are likely to get the first generation COVID-19 vaccine as soon as it is available fell from about 47% in August, to 39% at the end of September.

Heidi Larson, a professor at the London School of Hygiene & Tropical Medicine, who co-led the newest study said “This threatens to undermine the levels of COVID-19 vaccine acceptance.” She is also director of the international Vaccine Confidence Project.

A new study from the California Workers’ Compensation Institute shows the steep drop in the number of inpatient hospitalizations involving California injured workers over the past decade was largely due to the ongoing decline in spinal fusions and a more recent decline in lower extremity joint surgeries.

The study reviews discharge data compiled by the state Office of Statewide Health Planning and Development (OSHPD) on 35.9 million inpatient hospital stays from 2010 through 2019 paid by workers’ compensation, Medicare, Medi-Cal and private insurance, in order to identify workers’ compensation inpatient trends and to compare the volume and types of California inpatient hospitalizations covered by workers’ compensation to those covered by the three other systems.

Workers’ comp is by far the smallest of the medical delivery systems reviewed, accounting for just 0.4 percent of all inpatient stays in 2019, which is not surprising given that it has only accounted for between 1.4 percent and 1.6 percent of California healthcare costs over the past decade.

However, over the same 10-year span the study found that the number of workers’ comp inpatient hospitalizations declined 36.2 percent, more than twice the 15.9 percent decline noted for private coverage, and in sharp contrast to the 4.0 percent increase in Medicare and the 14.5 percent increase in Medi-Cal hospitalizations.

The study found that a key factor leading to the reduction of workers’ comp inpatient stays was the sharp decline in the number of injured workers receiving spinal fusions, which fell 53.1 percent between 2010 and 2019, a decline that was spurred by multiple factors including the adoption of utilization review and independent medical review programs requiring that treatment meet evidence-based medicine standards, the elimination of duplicate payments for implantable devices used in spinal surgeries, and fraud convictions that led to the sale of hospitals that had a high volume of workers’ comp back surgeries.

At the same time the overall number of work injury claims declined and there were technological and procedural advances that allowed more services to be provided in outpatient settings, prompting the growth of ambulatory surgery centers and an expansion of services at those facilities.

The study notes that spinal fusions were not the only type of workers’ compensation inpatient hospitalizations that saw a significant decline, as the number of workers’ comp discharges associated with lower extremity joint replacements has gradually declined in each of the past five years, falling from 2,727 workers’ comp discharges in 2014 to 2,140 in 2019, a net decrease of 21.5 percent.

In addition to tracking inpatient trends for California workers’ compensation, Medicare, Medi-Cal and private plans over the 10-year study period, the study also provides detailed data showing the breakdown of workers’ comp inpatient stays among the top 5 Major Diagnostic Categories (MDCs); the proportion of surgical vs. “medical” (non-surgical) hospitalizations in each of the 4 payer groups; the top 5 workers’ comp surgical and medical inpatient discharges by diagnostic-related group (MS-DRG) in 2019; the breakdown of the top 10 workers’ comp MS-DRGs across payer groups in 2019; the volume and prevalence of spinal fusion surgeries by payer group from 2010 through 2019; and the top 10 hospitals for workers’ comp inpatient care as well as the 10 hospitals with the highest ratio of workers’ compensation inpatients to total inpatients.

CWCI members and subscribers can access the report in the Research section and others can purchase it for $14 from the online Store. CWCI members may also log in to the Research section to access an updated version of CWCI’s Inpatient Hospitalization Claim Interactive Tool.