Latest news with #AmericanJournalofHealth-SystemPharmacy
NBC News
4 days ago
- Health
- NBC News
Medicare Part D premiums are likely to go up next year. Here's why.
Medicare enrollees who buy the optional Part D drug benefit may see substantial premium price hikes — potentially up to $50 a month — when they shop for next year's coverage. Such drug plans are used by millions of people who enroll in what is called original Medicare, the classic federal government program that began in 1965 and added a drug benefit only in 2006. The drug plans are offered through private insurers, and enrollees must pay monthly premiums. It's not known whether insurers will pursue the maximum increase allowed, as premium prices for next year won't be revealed until closer to open enrollment, which starts Oct. 15. Increases are expected to mainly affect stand-alone Part D plans, not the drug coverage offered as part of Medicare Advantage, the private sector alternative to original Medicare. More on that later. Policy experts say premiums are likely to go up for several reasons, including increased use of some higher-cost prescription drugs; a law that capped out-of-pocket spending for enrollees; and changes in a program aimed at stabilizing price increases that the Trump administration has continued but made less generous. One thing is surer than ever, say many policy experts: Beneficiaries should not simply roll over their existing stand-alone Medicare drug plans. 'Everyone should shop plans in open enrollment,' said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center. Here are three reasons prices would rise. 1. It's the spending! Every year, insurers keep an eye on what they're spending on drugs so they can build that into their premium estimates. Spending covers both the prices charged by drugmakers and volume, meaning how many people take the medications and how often. And it's up. Spending by insurers and government programs for prescription drugs in 2024 across the market grew more than 10%, which is slightly greater than in recent years, according to a research report published last month in the American Journal of Health-System Pharmacy. Estimates are not yet available for this year's trends. Still, in 2024, researchers found that drug prices overall decreased slightly. Spending rose because of drugs coming on the market and increased utilization, especially for pricey weight loss drugs and another category of medications that treat various autoimmune conditions, such as rheumatoid arthritis. Such increased use is evident in Medicare. Many beneficiaries, for example, are treated for autoimmune conditions. And even though Medicare doesn't cover treatment for weight loss, many members have diabetes or other conditions that the new weight loss drugs can treat. The Trump administration, according to The Washington Post, is considering a five-year pilot program in which Medicare Part D plans could voluntarily expand access to the drugs, which can cost more than $1,000 a month without insurance. Details have not yet been provided, but the pilot program would not begin in Medicare until 2027. Another wild card for insurers is the Trump administration's tariffs on businesses that purchase products made overseas, which could boost drug prices because the U.S. imports a lot of its pharmaceuticals. Much, however, remains unknown about whether drugmakers will pass along any additional tariff costs to consumers. So, while rising spending is one factor, it isn't the only reason next year's premium prices are expected to go up. 2. New out-of-pocket caps for consumers Changes made to Medicare aimed at helping people with high out-of-pocket costs for expensive medications may be a bigger factor. Here's why: Starting this year, Medicare enrollees have a limit on how much they must pay out-of-pocket for prescription drugs. It's capped at $2,000, a threshold that will rise each year to cover inflation. Lawmakers in Congress set those changes in the Inflation Reduction Act under President Joe Biden. The law also shifted a larger share of the cost of drugs used by Medicare beneficiaries from the federal program to insurers. That $2,000 cap is a big change from previous years, when people taking expensive drugs had a higher threshold to meet annually and were on the hook to pay 5% of the drug's cost even after meeting that amount. Those additional 5% payments ended last year under the provisions of the IRA. Before that law passed, 'people would spend $10,000 or $15,000 out-of-pocket each year just for a single drug,' Dusetzina said. 'The Inflation Reduction Act was necessary to make Part D proper health insurance, but there's a cost to do so.' While the cap is a big help for affected consumers, the reduced amounts paid by some beneficiaries — coupled with the cost shift to insurers — could lead plans to spread their increased expenses across all policyholders through higher premiums. A growing number of health plans have also begun to require enrollees to pay a percentage of a drug's cost, rather than a flat-dollar copay, which can lead to larger-than-expected costs at the pharmacy counter, Dusetzina said. While consumers not currently taking high-cost specialty drugs may not see a benefit in the $2,000 cap initially, they might one day, say policy experts, who note that drugmaker prices continue to rise and that enrollees could fall ill with a condition like cancer or multiple sclerosis for which they need a very high-priced drug. 'It's important to think not just in context of those groups who hit the cap every year, but also people are paying more in premiums to protect their future selves as well,' said Casey Schwarz, the senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group. The new prescription drug cap and other changes apply to both the stand-alone Part D drug plans and Medicare Advantage plans. But those Medicare Advantage plans are not expected to increase the drug portion of their premiums, partly because the private sector plans are paid more per member than what it costs taxpayers for the traditional program. That means Advantage plans have far more money to add benefits, such as vision and dental coverage, which traditional Medicare does not include, or to use them to cushion the impact of rising spending on drug costs, thus limiting premium increases. Those additional benefits are advertised to attract customers to Medicare Advantage, which also sometimes offers plans with minimal or no monthly premium costs. There are other differences between traditional Medicare and private sector plans. For example, Advantage members must stick to doctors and hospitals in the plan's networks, and they may face more prior authorization or other hurdles than in the traditional program. The growing difference between premiums — fueled by the extra rebates flowing to the private sector plans — 'is increasingly tilting coverage toward Medicare Advantage and making traditional Medicare plus a stand-alone PDP [prescription drug plan] unaffordable for many enrollees,' said Juliette Cubanski, deputy director of the program on Medicare policy at KFF, a health information nonprofit that includes KFF Health News. 3. Trump administration reduced funding meant to slow premium growth The final factor in the premium increase equation is a program set up to slow the rise of premiums in stand-alone Part D plans. It began under the Biden administration to offset premium increases tied to changes in the Inflation Reduction Act by temporarily injecting additional federal dollars to help insurers adjust to the new rules. That plan sent just over $6 billion this year to Part D insurers. And it had an effect. The average monthly premium for a stand-alone Part D drug plan dropped 9%, from $43 last year to $39 this year, according to KFF, even when factoring in that some plans raised prices by up to $35 a month, the maximum increase allowed under the stabilization plan for this year. In a memo released in late July, the Trump administration said it would continue the program for next year, while shaving about 40% of the funding. A government official told The Wall Street Journal that the administration felt that keeping the full funding would have mainly benefited the insurers and cost taxpayers an 'enormous, excess amount.' The stabilization effort next year will send $10 a month per enrollee to Part D insurers to help keep premiums in check, down from $15 this year. Among other changes, it allows insurers to raise premiums by as much as $50 a month, up from the $35 allowed this year. That would be a substantial increase, Cubanski noted, although it is not clear just how many insurers would pursue the full amount. 'We did see some plans this year were taking premium increases of that $35 amount in 2025, and I fully expect we will see some plans with increases up to $50 a month' next year, she said. Another reason to take a close look at all the options once open enrollment begins.
Los Angeles Times
19-05-2025
- Health
- Los Angeles Times
Chronic Disease Care Gets a Digital Makeover with Virtual Consultations
For people living with chronic conditions like diabetes, hypertension, heart failure, routine care means regular appointments, lab work, medication changes, lifestyle counseling. It's a lot, but technology is helping to shift the load. A 2023 meta-analysis showed that digital health interventions improved physical activity and daily function in patients with chronic conditions by 0.29 and 0.36 respectively [1]. That may not seem like a lot but in public health terms it's big. When patients can stay active and functional they're less likely to end up in the ER or hospitalized. Through telehealth platforms clinicians can review vitals, trend them, adjust treatment plans, offer lifestyle coaching—all remotely. It's personalized care without the waiting room. Telehealth's value is in its flexibility. It doesn't replace in-person visits but instead complements them by: Booking a virtual consultation is easy and convenient often with same or next day availability. And insurance coverage can significantly impact the cost and accessibility of virtual consultations with many plans accepted to reduce or eliminate out of pocket expenses. Take hypertension for example. A patient tracking blood pressure from home might text in their readings to their provider. Based on the numbers a doctor might bump up their lisinopril from 10mg to 20mg—no office visit required. It's simple, safe and efficient. Virtual consultations also reduce wait times compared to in-person visits eliminating the need to wait in crowded waiting rooms. Remote Patient Monitoring (RPM) is one of the most impactful offshoots of virtual care. Whether through wearable tech like smartwatches or connected devices like glucometers and blood pressure cuffs, RPM allows providers to track patient data continuously and act fast if things start to go sideways. Benefits of RPM include: RPM can also help manage chronic conditions by allowing patients to get certain prescriptions through telehealth platforms. While most of the data is around chronic conditions, experts say RPM's potential for post-surgical recovery or high-risk pregnancies is underutilized. Another innovation making waves? Virtual Group Visits (VGVs). These are scheduled sessions where multiple patients with similar conditions (like prediabetes or asthma) join a provider online to get education, ask questions and support each other. VGVs can also provide mental health support for patients with conditions like anxiety and depression. Research in the American Journal of Health-System Pharmacy shows VGVs as a powerful tool in improving chronic disease outcomes while scaling access [4]. They address medical needs but also provide a sense of community—something many patients crave when managing lifelong illnesses. Healthcare access and convenience have improved a lot with virtual care. Patients can now schedule visits with their primary care provider or specialist from the comfort of their own home, no need to go to a medical office. Virtual care visits can be used for many medical conditions including common conditions like sinus infections, ear pain and pink eye. Patients can also use virtual care for preventive care like checking blood pressure and getting advice on over-the-counter medications. Virtual care can also be used for mental health care where patients can get support and treatment from a mental health professional. With virtual care patients can get high quality care anytime, anywhere using a mobile device or computer and even access their patient portal to view test results, schedule visits and communicate with their provider. Many healthcare providers including board certified doctors and nurse practitioners offer virtual care services and some even accept insurance making it a convenient and affordable option for patients. Despite its success, virtual care isn't perfect. Some of the challenges flagged in recent studies include: This highlights the need for tailored implementation strategies. It's not enough to offer virtual care, it needs to be usable and useful for everyone. Health insurance can play a big role in making virtual care accessible and affordable for more patients. Thanks to virtual consultations patients have more options than ever before. Platforms now support secure messaging with care teams, asynchronous updates and even prescription refills—all without stepping foot in a clinic. The American Telemedicine Association sets standards for telehealth services to ensure the credibility and quality of care provided through virtual consultations. Organizations like the American Heart Association support these changes. Their guidelines recommend using telehealth for post-stroke care, cardiovascular monitoring and long term management of conditions like atrial fibrillation [2], [3]. In diabetes care for example controlling hypertension is a top priority. According to the Annals of Internal Medicine blood pressure targets should be below 80 mm Hg and medications like thiazides, ACE inhibitors or angiotensin receptor blockers are first line options [8]. All of this can be monitored remotely through virtual check-ins and RPM tools. Virtual consultations aren't a pandemic workaround—they're here to stay. For people with chronic conditions they offer something precious: consistency. Virtual care reduces barriers, improves monitoring and keeps patients at the center of their health journey. In a world where managing health used to mean juggling appointments and waiting rooms, virtual consultations are creating space—for rest, autonomy and better outcomes. They are a convenient alternative to going to a doctor's office, reducing the need for in-person visits and wait times. [1] Zangger, G., Bricca, A., Liaghat, B., Juhl, C. B., Mortensen, S. R., Andersen, R. M., Damsted, C., Hamborg, T. G., Ried-Larsen, M., Tang, L. H., Thygesen, L. C., & Skou, S. T. (2023). Benefits and Harms of Digital Health Interventions Promoting Physical Activity in People With Chronic Conditions: Systematic Review and Meta-Analysis. Journal of medical Internet research, 25, e46439. [2] Schwamm, L. H., Chumbler, N., Brown, E., Fonarow, G. C., Berube, D., Nystrom, K., Suter, R., Zavala, M., Polsky, D., Radhakrishnan, K., Lacktman, N., Horton, K., Malcarney, M. B., Halamka, J., Tiner, A. C., & American Heart Association Advocacy Coordinating Committee (2017). Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association. Circulation, 135(7), e24–e44. [3] Kernan, W. N., Viera, A. J., Billinger, S. A., Bravata, D. M., Stark, S. L., Kasner, S. E., Kuritzky, L., Towfighi, A., & American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; and Council on Peripheral Vascular Disease (2021). Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke, 52(9), e558–e571. [4] Mirsky, J. B., & Thorndike, A. N. (2021). Virtual Group Visits: Hope for Improving Chronic Disease Management in Primary Care During and After the COVID-19 Pandemic. American journal of health promotion : AJHP, 35(7), 904–907. [5] Lewinski, A. A., Walsh, C., Rushton, S., Soliman, D., Carlson, S. M., Luedke, M. W., Halpern, D. J., Crowley, M. J., Shaw, R. J., Sharpe, J. A., Alexopoulos, A. S., Tabriz, A. A., Dietch, J. R., Uthappa, D. M., Hwang, S., Ball Ricks, K. A., Cantrell, S., Kosinski, A. S., Ear, B., Gordon, A. M., … Goldstein, K. M. (2022). Telehealth for the Longitudinal Management of Chronic Conditions: Systematic Review. Journal of medical Internet research, 24(8), e37100. [6] Campbell, K., Greenfield, G., Li, E., O'Brien, N., Hayhoe, B., Beaney, T., Majeed, A., & Neves, A. L. (2023). The Impact of Virtual Consultations on the Quality of Primary Care: Systematic Review. Journal of medical Internet research, 25, e48920. [7] Farias, F. A. C., Dagostini, C. M., Bicca, Y. A., Falavigna, V. F., & Falavigna, A. (2020). Remote Patient Monitoring: A Systematic Review. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 26(5), 576–583. [8] Vijan, S., & Hayward, R. A. (2003). Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Annals of internal medicine, 138(7), 593–602.
