Quarterly analytic spotlight

The current administration's policies surrounding healthcare affordability will play a pivotal role in shaping the future landscape of health insurance. With uncertainties looming over the enhanced premium subsidies that could expire in 2025, vulnerable populations stand to be significantly affected. A projected loss of coverage for around 7 million individuals could lead to increased healthcare spending for those who remain insured, compounding existing affordability issues. Considering these implications, health policy analysts are called upon to assess the broader impact of policy changes, not just for insurance coverage but for healthcare spending overall. The potential reintroduction of short-term limited-duration plans may further erode traditional health coverage, necessitating diligent monitoring and strategic advocacy efforts.

As we look ahead to 2025 and beyond, pricing strategies will be essential. The predicted increase in employer-sponsored coverage costs emphasizes the importance of developing pricing frameworks informed by comprehensive data analytics, transparency benchmarks, and effective negotiation strategies. With a focus on sustainable strategies, health policy analysts must engage stakeholders across the healthcare spectrum to foster collaborative solutions that prioritize affordability and access.

Achieving healthcare affordability in the U.S. is inherently tied to the issue of price transparency. Regulatory updates have begun to reshape how healthcare services are priced, requiring providers to disclose pricing information that patients can access before receiving care. The impact of such regulations is anticipated to influence both healthcare costs and consumer protection measures significantly.

The recent regulations around surprise billing protections and the need for better data transmission for prior authorization processes are prime examples of how lawmakers are working to shield consumers from unexpected medical costs. Payers must closely monitor these developments as they underscore the complex interplay between regulations and cost implications for both payers and providers.

Three years into the No Surprises Act: Are you compliant with federal regulations? Read blog

Moreover, the anticipation of changes to enhanced premium subsidies under the new administration adds another layer of complexity. If these subsidies are allowed to expire at the end of 2025, millions may lose insurance coverage, significantly affecting enrollment rates and consequently impacting overall healthcare affordability. Analysts should emphasize the need for continued advocacy around regulation that promotes transparency and affordability in healthcare.

The landscape of diabetes and obesity treatment is witnessing a seismic shift, primarily driven by the adoption of GLP-1 medications. From a mere 4.8 patients per 1,000 in 2013 to a staggering 54.6 per 1,000 by 2024, the utilization of GLP-1s has surged, with associated costs escalating from $13 per month to $342. This dramatic rise suggests that GLP-1s are increasingly becoming the cornerstone of diabetes management, second only to metformin, and are now playing a critical role in treating obesity.

However, recent trends indicate a potential plateau in GLP-1 utilization in 2024, influenced by new payer utilization management strategies. Another significant factor contributing to this slowdown is the limited new branded drug approvals, with only a generic version of Victoza entering the market recently. Such dynamics may signal a critical moment for benefits professionals to assess not only the financial implications of GLP-1 therapy on healthcare affordability, but also the barriers to utilization patients face under varying coverage policies.

At the end of 2024, Truven conducted a survey to better understand how payers are currently covering GLP-1s and what strategies they plan to deploy in the future. We found that 100% of healthcare payers covered diabetes-specific GLP-1s, whereas only 65% provided coverage for obesity-specific versions. Coverage tiers also varied across GLP-1 products with 62% of diabetes-specific products covered as ‘Preferred’ compared to only 41% of obesity-specific products. This disparity in coverage significantly impacts utilization rates (especially for obesity specific products) and highlights an urgent need for tailored support strategies that cater to both diabetes and obesity patients. Furthermore, the data revealed that 94% of health plans employ utilization management for diabetes medications, which in turn appears to affect patient adherence. In contrast, payers without stringent criteria showcased higher adherence rates, indicating that payers need to consider how utilization management criteria could be impeding clinical goals and advocate for more inclusive and accessible treatment options.

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Watch the full webinar to see how different utilization strategies impact downstream utilization and adherence.

The rising mental health crisis underscores the need for comprehensive strategies to address mental health service availability. Recent data indicates that around 18% of health plan members filed a mental health claim in the past year, signifying the urgent demand for services that effectively support mental well-being.
Challenges persist, particularly in socioeconomic contexts where individuals in high-poverty areas experience significant barriers to accessing mental health care. Stigma, financial barriers, and limited community support continue to hinder treatment. Addressing these disparities is pivotal for employers and health plans who aim to create frameworks that promote mental health accessibility.

Employers are taking actionable steps to combat these challenges by fostering mental health awareness in the workplace. Initiatives, including inviting health professionals to engage employees in discussions about mental wellness and providing access to counseling services, can significantly improve outcomes. Policy analysts should encourage employers to analyze demographic data and community factors, identifying gaps in service utilization to tailor interventions effectively.

As the landscape shifts, understanding the diverse needs of populations can help enhance the delivery of mental health services. Integrating cultural competence into health and benefits strategies is crucial to eradicate the stigma surrounding mental health treatment and improve overall healthcare affordability.
Watch the full webinar to see an example of how SDoH data can help you dig into mental health trends in your population.

As healthcare costs continue to rise, innovative pricing strategies will be crucial in addressing affordability for consumers and employers alike. Insights from data analytics, particularly from resources such as MarketScan, a Truven data solution, highlight trends in reimbursement across different service lines and the impact of various diagnosis-related groups [DRGs] on inpatient payments.

The top DRGs alone account for over 30% of inpatient payments, revealing critical areas where healthcare providers should concentrate their negotiation efforts. Integrating multiple data sources, such as Medicare rates and machine-readable files, into pricing strategies enables providers to achieve a more comprehensive market overview, identify potential savings opportunities, and align rates with market medians.

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Furthermore, it remains essential for ongoing monitoring of reimbursement trends in conjunction with regulatory changes. Analysts should advocate for transparency and strategic pricing that reflects the true cost of coverage while ensuring access to necessary services for diverse populations.

In conclusion, addressing healthcare affordability requires a multifaceted approach that encompasses clinical outcomes, regulatory compliance, mental health considerations, and innovative pricing strategies. As we navigate the complexities of healthcare policy in the coming years, the commitment to affordable and accessible healthcare for all individuals must remain at the forefront of our efforts.

Upcoming events:

• Are you going to The Conference Board’s Employee Health Care Conference on April 8? Please stop by the Truven booth and say hello!
• Healthcare decisions are only as good as the data behind them—yet too often, claims and EHR data remain siloed, leaving an incomplete picture of the patient journey. Join our webinar with Veradigm to discover how our Linked EHR and Claims Database is revolutionizing healthcare research.
  

Fresh insights:

• Marcy Tatsch, Truven Executive Vice President and General Manager, published a blog reflecting on 2024 and sharing a preview of the promising path ahead.
• Morgan Health announced its investment in Truven as part of its mission to help employers improve the quality, affordability, and equity of healthcare by improving access to data.
• Healthcare cost increases show no sign of stopping, begging the question: “How can employers lower costs and improve employee health?” Read our blog on how