Biosimilars: Payer Decision Making
Once the first Humira biosimilar, Amjevita, launched in the United States in January, payers needed to begin making decisions about coverage not only for Amjevita but for all the other Humira...
Health Insurer Capital: How Much Surplus Should a US Health Insurer Hold?
Health insurers are required to hold minimum levels of surplus each year. However, the exact amount a health insurer chooses to hold can vary significantly from one insurer to the next...
The Financial Impact of Biosimilars
There is a coming wave of changes arriving soon to the pharmacy market in the form of biosimilars. And that coming wave has a big event in 2023: the launch of Humira biosimilars, which...
Provider Contracting Trends – Déjà vu All Over Again
About 30 years ago I met with my then-business partner to think into the future and try to anticipate what we might see in terms of changes in the healthcare system. The results of this challenging process were...
The Big Event: Humira Biosimilar Launches
Today is the day! The Big Event of 2023 is the launch of multiple Humira biosimilars which begins today with the arrival of Amgen’s Amjevita on the market. The launch of Amjevita is the first step in the Big Event...
Intelligent Capitation Rates – Strategically Aligning Risk Adjustment with Costs
Aligning capitation rates with the line of business and risk selection of attributed members is an important component of provider contracting. Furthermore, doing so can illuminate hidden dynamics in financial...
Utilization Profiling for Care Management (and Profitability!)
Although there are many variables influencing healthcare costs, the most important are unit cost and utilization. Unit cost is subject to many constraints in relation to both healthcare and the broader...
Pharmacy Provisions of the Inflation Reduction Act
I read the 725-page draft of the Deficit Reduction Act[1] so you don’t have to. Well, I skimmed 427 pages of it while focusing on the 164 pages which make significant changes to prescription drugs. This article outlines...
Mother May I? Interpreting ACA Pricing Allowances
“Mother-May-I” is a classic kids’ game that teaches little ones to honor their mother by having players request to take steps towards their mother but only taking steps if their mother allows it! While it would be strange...
3rd Annual ACA Consumer Value State Rankings
The story of consumer value in the Affordable Care Act (ACA) individual marketplaces echoes one of the great epochs of our nation’s history where a sense of manifest destiny culminated in a quest to unite the coasts...