The pharmaceutical sector expresses cautious optimism regarding the new administration's policies, particularly in addressing pharmacy benefit managers (PBMs) and revising aspects of the Inflation Reduction Act. Drug manufacturers hope for reforms that could enhance innovation and patient access to treatments while alleviating pressures on pricing.
Potential Reforms Targeting Pharmacy Benefit Managers
The pharmaceutical industry is eager to see changes in how PBMs operate, aiming to improve transparency and ensure savings reach patients. Companies argue that current practices inflate costs and hinder fair distribution of rebates. With bipartisan concerns growing, there is a renewed push for legislative action.
Industry leaders are advocating for three key reforms: decoupling drug prices from PBM compensation, ensuring rebates directly benefit consumers at the pharmacy counter, and increasing transparency in PBM operations. These changes could significantly impact the healthcare supply chain, making it more efficient and cost-effective. For instance, Eli Lilly CEO David Ricks emphasized the need for passing savings directly to consumers, highlighting the opaque nature of PBM business models. While PBMs deny contributing to higher drug prices, placing blame on initial list prices set by manufacturers, calls for reform continue to gain momentum. The previous administration's FTC Chair Lina Khan had initiated investigations into these practices, setting a precedent that the new administration may either build upon or challenge.
Revisiting Medicare Drug Price Negotiations
Drugmakers are also hopeful about potential revisions to the Inflation Reduction Act, specifically targeting Medicare's ability to negotiate drug prices. This provision, though popular among patients, poses challenges for the industry, which argues it could stifle innovation and lead to unintended consequences. The industry seeks legislative or administrative changes to address perceived imbalances in the law.
One major concern is the "pill penalty," which grants biologics longer protection periods compared to small-molecule drugs. This discrepancy could discourage investment in smaller, more affordable medications, potentially reducing the availability of generics. Pharmaceutical Research and Manufacturers of America (PhRMA) CEO Stephen Ubl has highlighted this issue, suggesting that adjustments could be made without congressional approval. Additionally, drug companies are fighting the law through legal challenges, arguing that mandatory price negotiations amount to government-imposed pricing rather than true negotiations. Despite these efforts, health policy experts suggest that significant changes might be difficult due to bipartisan support for lowering drug costs. However, the industry remains committed to finding common ground with the new administration, especially in areas like cancer research and chronic disease management, where collaboration could yield mutual benefits.
Empowering Patients and Payers with Cutting-Edge Solutions
Pioneering Partnerships for Value-Based Care
The healthcare landscape is evolving, and Included Health is at the forefront of this transformation. One of the most significant partnerships announced by the company involves serving the CalPERS employee population of the State of California. This collaboration marks a pivotal moment as Included Health begins providing comprehensive services to over 250,000 members. The partnership with CalPERS underscores Included Health's commitment to driving impactful cost reductions. By aligning with Blue Shield of California, the third-party administrator selected by CalPERS, Included Health aims to achieve a 3% reduction in cost trends within five years. This ambitious goal is supported by a shared savings model, where the company's performance directly influences its financial rewards. Such an arrangement ensures that Included Health remains accountable for delivering high-quality, cost-effective care.Expanding Horizons in Specialty Care
Included Health has always been dedicated to addressing the challenges faced by patients with serious conditions. The company’s recent expansion into specialty care exemplifies this commitment. Starting with cancer, Included Health launched a groundbreaking service on January 1, offering unparalleled access to care within seven days—a milestone in the specialty care sector.Beyond rapid access, the company provides extensive support services to bridge gaps in healthcare delivery. For cancer patients, this includes symptom management and navigation through complex administrative processes. These wraparound services ensure that individuals receive comprehensive care during critical moments in their health journeys. The success of the cancer program will pave the way for future expansions into other specialties, further enhancing Included Health's role in delivering holistic care.Innovative Approaches to Pharmacy and In-Person Care
Included Health is not resting on its laurels. The company is set to introduce several new initiatives in 2025, focusing on pharmacy and in-person care. Historically, Included Health has operated primarily in the virtual space, but the shift towards in-person services represents a strategic move to offer more diverse options for patients.In pharmacy, Included Health plans to roll out innovative solutions aimed at improving medication management and patient outcomes. These efforts will complement the company's existing virtual offerings, ensuring seamless integration across different care modalities. The emphasis on accessibility and quality will continue to guide Included Health's development of new services, reinforcing its position as a leader in personalized healthcare.Advocacy and Support for Patient-Centric Care
At the heart of Included Health's mission is the belief that every individual deserves access to great care. The company's advocacy and support services play a crucial role in achieving this goal. By helping patients navigate the complexities of healthcare, Included Health empowers them to make informed decisions about their treatment options.Financial and administrative assistance are key components of this support. Patients often face overwhelming challenges when dealing with insurance claims, billing issues, and other bureaucratic hurdles. Included Health addresses these concerns head-on, ensuring that individuals can focus on their health without unnecessary stress. This patient-centric approach sets Included Health apart as a trusted partner in the healthcare ecosystem.The state of New Mexico is making significant strides in enhancing rural healthcare services with a substantial financial boost. Governor Michelle Lujan Grisham has announced that 26 additional rural health care providers will receive a combined total of $40.6 million from the Rural Health Care Delivery Fund, part of the $46 million allocated during the 2024 legislative session. This funding aims to address the unique challenges faced by rural areas, including geographic isolation and financial constraints, ensuring more residents can access quality care close to home. The initial allocation of $5.4 million last fall benefited four organizations that demonstrated immediate implementation capabilities. The new funds will support various services such as behavioral health, primary care, maternal and child health care, autism diagnostics, urgent care, mobile crisis response, and diabetes clinics.
Empowering Rural Communities Through Comprehensive Healthcare Services
Rural communities in New Mexico are set to benefit from a wide array of healthcare services supported by this investment. The fund will enhance access to essential medical services across multiple regions, addressing critical needs like autism diagnostics, urgent care, and telehealth services. For instance, Behavior Change Institute plans to open an autism diagnostic clinic in Chaves County and expand telehealth services statewide. Similarly, Roadrunner Home Health will broaden its home health and palliative care services in several counties. These initiatives aim to improve health outcomes and overall well-being for residents in these underserved areas.
In detail, the fund supports projects that tackle specific healthcare gaps. In the northwestern region, Changing Women’s Initiative will establish maternal child health clinics in tribal communities, while Pueblo of Jemez will open a diabetes wound clinic. In the northeastern region, Family Practice Associates of Taos will expand primary care services, and Sunrise Clinics will introduce school behavioral health services. Each project is tailored to meet the unique needs of its community, ensuring comprehensive and timely care. By reducing financial barriers, these investments empower rural providers to deliver high-quality healthcare services that were previously inaccessible.
Addressing Regional Challenges and Expanding Service Offerings
The funding also addresses regional challenges by expanding service offerings in areas most in need. In the southwestern region, Border Area Mental Health Services will extend behavioral health services and begin children and youth programs. Sierra Vista Hospital and Clinics will enhance behavioral health services and create a mobile crisis response team. Vida Midwifery plans to open a birth center offering maternal child health services. These expansions ensure that rural residents have access to vital healthcare resources closer to home, improving their quality of life.
Furthermore, the southeastern region will see improvements in specialized services. Guidance Center of Lea County will expand autism services, Lovelace Regional Hospital will establish women’s health services, and Plains Regional Medical Center will enhance inpatient dialysis services. Quay County will expand dental services, addressing another critical healthcare gap. By focusing on these specific needs, the fund ensures that each region receives targeted support, fostering stronger healthcare infrastructure and better health outcomes for all New Mexicans.