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1 big thing: Employers in the dark


Employers are facing stronger legal requirements to ensure they aren't wasting their workers' money on overpriced health insurance, at the growing risk of financial consequences.


  • But employers say secrecy around negotiated health care prices too often prevents them from accessing data that would help them figure out if they're getting a good deal, Tina writes.


Why it matters: Federal rules push employers to serve as responsible stewards — or "fiduciaries" — of their workers' premium dollars.


  • Employers — even the really large ones with sophisticated HR teams — don't always have a good sense of the inner workings of their benefits despite the massive amounts of money they shell out for them.

  • "The core challenge for employers is that they don't have visibility into this information and the vendors that they have relied on to procure health care on their behalf, they don't share it," Elizabeth Mitchell, CEO of the Purchaser Business Group on Health, told Axios.


Driving the news: As of Dec. 31, employers had to attest — at the risk of fines — that their agreements with their third-party administrators, pharmacy benefit managers and other benefit providers contained no "gag clauses" that would block them from data they needed to ensure they were paying fair prices for care.


  • Employer groups tell Axios that requirement has been difficult, if not impossible, to meet in many cases because the administrators of their plans often aren't forthcoming or cooperative.

  • In some cases, employers have identified gag clauses but struggled to get their third-party administrator to remove them, said Chris Deacon, founder of VerSan Consulting, who focuses on policy related to employer health benefits.


The other side: Insurer lobby AHIP didn't immediately provide comment, and it's previously declined to weigh in on employer complaints that they're struggling to get essential data.


What we're watching: Following a playbook used to challenge companies' management of their 401(k) plans, law firms are reportedly lining up potential class action suits against companies over their handling of their health plans, Politico reported recently.




2. Prior authorization fix hailed as first step


New federal rules requiring health insurers to streamline requests to cover treatments are being hailed as a good first step toward addressing a problem that's increasingly aggravated patients and doctors.


  • But it may not be Washington's last word on so-called prior authorization, as lawmakers look to jumpstart legislation that would further limit the practice, Maya writes.


The big picture: Health insurers will have to provide coverage decisions on urgent treatment requests within 72 hours for patients in Medicare Advantage, Medicaid or Affordable Care Act plans under federal rules finalized Wednesday. The deadline is seven days for non-urgent requests.


  • Insurers' requirements for their sign-off on some physician-ordered care is a major tension point with providers.

  • The new protocols largely take effect in 2026. Insurers will also have to publicize prior authorization denial rates and provide more specific justifications for denials.


Yes, but: The new rules don't apply to employer-sponsored insurance plans that cover over 150 million people. Some health care groups still want regulators to adopt faster review standards for prior authorization requests and extend new requirements to drugs, which were largely exempted.


What's next: A bipartisan group of eight lawmakers who brokered prior authorization legislation that passed the House in 2022 on Wednesday said Congress should take up their bill "to cement these gains."


Axios Reporters: Tina Reed, Maya Goldman

1 comment

1 bình luận


A small, but good step at placing another band aid on the gaping wound know as health care where the insurer and its subordinates bleed everyone else dry. A universal policy with restrictions on what insurers could do and mandates on coverage would solve many problems. Add enforcement and stiff fines.

Thích
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