Pricey weight-loss drugs? Connecticut has a plan

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Nov 15, 2023 View in browser   By Ben Leonard and Chelsea Cirruzzo Presented by With Kelly Hooper  Driving the Day States are looking for ways to stem the high price of covering weight-loss drugs like Ozempic in their health plans. | David J. Phillip/AP Photo BLOCKBUSTER DRUGS — Connecticut’s state employee health plan was on course to spend $30 million this year on a class of diabetes drugs exploding in popularity as an effective way to lose weight. State Comptroller Sean Scanlon, who runs the plan, decided it was untenable. But instead of scrapping coverage of the drugs like some other large employers have, the state — which covers 265,000 employees, including teachers, police officers and firefighters — is trying something different, Kelly reports. Since July, state health plan members who seek popular drugs like Ozempic and Wegovy for weight loss must first enroll in a clinical lifestyle management program called Flyte, which offers online weight-management tools. Participants can meet with providers and receive personalized care plans. The providers might prescribe one of the medications, which the state health plan would then cover, or recommend a different course of treatment. “I never considered getting rid of the drugs, but I also knew that the status quo was not going to work, and we had to look at other options,” Scanlon told POLITICO. If successful, the unique plan out of Connecticut might offer a roadmap for public and private organizations, which see their finances hamstrung by the costly, yet effective, treatment. Why it matters: Connecticut’s experiment, which shows early promise, comes at a crucial moment for state and federal officials contending with the costs of the blockbuster treatments. Approval of such therapies could upend treatment for millions of Americans and become some of the best-selling drugs of all time. Even so: The drugs are expensive, and patients may need to stay on them indefinitely. State Medicaid directors, public universities and state officials are just beginning to wrap their heads around who will pay for them. The University of Texas system, one of the largest employers in the state with more than 116,000 workers, dropped weight-loss drug coverage in September because of rising costs. The University of Michigan, which covers about 120,000 people, is increasing co-pays to help cover the drugs’ costs. In North Carolina, the treasurer’s office estimated that spending on this class of drugs within its state employee health plan — covering 750,000 people — could jump to more than $1 billion over the next six years. To control costs, the state health plan will no longer cover them for new members effective Jan.1. WELCOME TO WEDNESDAY PULSE. Is there something you’d like to get into the final spending deal? Let us know. Reach us at bleonard@politico.com or ccirruzzo@politico.com. We can keep you anonymous. Follow along @_BenLeonard_ and @ChelseaCirruzzo. TODAY ON OUR PULSE CHECK PODCAST, host Lauren Gardner talks with POLITICO health care reporter Kelly Hooper, who further explains Connecticut's approach to covering pricey weight-loss drugs in its employee health plans by tying coverage to lifestyle programs. Listen to today’s Pulse Check podcast   A message from PhRMA: The most profitable 340B hospitals provide the least amount of charity care. A new report shows the top performing 340B hospitals collected nearly $10 in profit for every $1 invested in charity care in 2021. 340B program discounts are meant to help hospitals care for their most vulnerable patients. Instead, 340B hospitals are making record profits while free and discounted care remains low. It's time to reset the balance with 340B.    In Congress House Speaker Mike Johnson got the support he needed — from 209 Democrats and 127 Republicans — to avert a government shutdown Tuesday. | Francis Chung/POLITICO ON TRACK FOR A DEAL — With much less drama than earlier this year, the government is set to be funded on autopilot into early 2024. The White House and Senate Majority Leader Chuck Schumer threw their support behind a stopgap continuing resolution to fund the government on an interim basis with two separate deadlines — one on Jan. 19 and another on Feb. 2, which would include the HHS funding bill. A total of 209 House Democrats joined 127 Republicans in supporting the continuing resolution, sending it to the Senate. House Democratic leaders noted that the package has no spending cuts or “poison-pill” add-ons. The move will keep government agencies open but doesn’t avert a 1 percent cut to federal spending negotiated in the debt ceiling deal that will take effect in April if a long-term deal isn’t reached. CMS is concerned that a continuing resolution could impact agency operations, and the agency has implemented a partial hiring freeze. The health care angle: Health industry groups say the patch could deprive them of an opportunity to attach policy riders, like efforts to avoid doctor pay cuts taking effect next year, POLITICO’s Robert King reports. “Omnibuses happen for a reason,” Susan Dentzer, president and CEO of America’s Physician Groups, said in an interview with POLITICO. “It is not like they haven’t served an important purpose for many years.” Some groups representing doctors tried but failed to stop a looming 3.4 percent cut to Medicare payments in the continuing resolution, according to four people familiar with the lobbying effort. Lawmakers, including Rep. Larry Bucshon (R-Ind.), told POLITICO the lack of an omnibus could impact doctor pay efforts. But Bucshon said lawmakers could still reauthorize the SUPPORT Act, which tackles the opioid epidemic. BIPARTISAN BULLISHNESS ON PSYCHEDELICS — The top lawmakers on both sides of the House Veterans’ Affairs Committee’s health subcommittee want more research into psychedelics’ potential to treat veterans’ mental health issues. Subcommittee chair Mariannette Miller-Meeks (R-Iowa) said psychedelics could transform care but urged caution, adding, “We are not advocating for the legalization or casual use.” Democrats and Republicans said they want to ensure no misuse occurs. “In a time when much of Congress is polarized and partisan, this is one area where many of us … agree that more should be done,” said subcommittee ranking member Julia Brownley (D-Calif.). Studies on psychedelics funded by outside groups are being conducted at VA facilities. Dr. Carolyn Clancy, assistant undersecretary for health, told the committee no statutory barriers bar the VA from funding its own psychedelics’ research, but layers of regulatory barriers discourage research. She said the agency will fund studies in the future, though. It’s not yet clear whether the treatments will be curative, Clancy said, or used for ongoing maintenance. A timeline for more widespread use is also unclear, she said. Clancy also touted the agency’s pilot at 60 sites employing virtual reality to reduce suicides tied to pain, testing the use of positive environments to help build coping mechanisms.   GET A BACKSTAGE PASS TO COP28 WITH GLOBAL PLAYBOOK: Get insider access to the conference that sets the tone of the global climate agenda with POLITICO's Global Playbook newsletter. Authored by Suzanne Lynch, Global Playbook delivers exclusive, daily insights and comprehensive coverage that will keep you informed about the most crucial climate summit of the year. Dive deep into the critical discussions and developments at COP28 from Nov. 30 to Dec. 12. SUBSCRIBE NOW.     Drug Pricing WARNOCK INSULIN VOTE TARGET — Sen. Raphael Warnock (D-Ga.) is targeting a vote by the end of the year on his bill to limit the out-of-pocket cost of insulin to $35 a month in the private insurance market and for the uninsured, he told reporters Tuesday.   Warnock said Senate Majority Leader Chuck Schumer is “focused” on the legislation, though he didn't discuss how the bill could move. He added he’s waiting on a Congressional Budget Office score for the bill’s uninsured portion to look for potential pay-fors, which he said he worked with Schumer on to expedite. In a report released Tuesday, Warnock and Sen. John Kennedy (R-La.) said the $629 million, 10-year CBO cost estimate for the private insurance portion pales in comparison to the cost of diabetes annually at more than $410 billion. Warnock said his and Kennedy’s offices have been working with staff members of Sens. Jeanne Shaheen (D-N.H.) and Susan Collins (R-Maine) on a separate proposal to cap insulin costs. The Collins-Shaheen bill would limit monthly cost-sharing for at least one insulin type and dosage to $35 or 25 percent of the list price, whichever is lower, and has additional requirements for pharmacy benefit managers. Insulin prices figure to be a top priority in this session of Congress, impacting tens of millions of Americans with diabetes. Schumer has long been crafting a drug pricing package, but details remain unclear.   A message from PhRMA:   Around the Agencies MORE POSTPARTUM COVERAGE — The Centers for Medicare and Medicaid Services on Tuesday approved Missouri’s plan to offer a full year of Medicaid coverage after pregnancy, making it the 40th state to offer such coverage. The measure, which Missouri moved to expand this summer, would mean 18,000 additional people would be eligible for Medicaid. Alaska, Mississippi, Nebraska, Nevada and Texas plan a year extension, and Utah and Wisconsin have proposed a more limited coverage extension, according to KFF. Arkansas, Idaho and Iowa haven’t moved to do so. The option has been available since last April as an initial temporary option, but Congress has made it permanent. Lawmakers hope to improve U.S. maternal mortality rates — which lag behind other peer nations — and other maternal health outcomes.   A NEW POLITICO PODCAST: POLITICO Tech is an authoritative insider briefing on the politics and policy of technology. From crypto and the metaverse to cybersecurity and AI, we explore the who, what and how of policy shaping future industries. We’re kicking off with a series exploring darknet marketplaces, the virtual platforms that enable actors from all corners of the online world to traffic illicit goods. As malware and cybercrime attacks become increasingly frequent, regulators and law enforcement agencies work different angles to shut these platforms down, but new, often more unassailable marketplaces pop up. SUBSCRIBE AND START LISTENING TODAY.     WHAT WE'RE READING The New York Times reports on the impact of the rising costs of care for older adults. Healthcare Dive reports on the American Medical Association’s new policies on obesity drugs and treatment for opioid use disorder. POLITICO’s Josh Sisco reports on a House hearing showing GOP support for antitrust.   A message from PhRMA: 340B hospitals charge patients more. The average costs per prescription for a patient was more than 150% greater at a 340B hospital. 340B program discounts are meant to help hospitals care for their most vulnerable patients. Instead, 340B hospitals make record profits while patients often pay more. It's time to reset the balance with 340B.     Follow us on Twitter Dan Goldberg @dancgoldberg Chelsea Cirruzzo @chelseacirruzzo Katherine Ellen Foley @katherineefoley Lauren Gardner @Gardner_LM Kelly Hooper @kelhoops Robert King @rking_19 Ben Leonard @_BenLeonard_ David Lim @davidalim Megan Messerly @meganmesserly Alice Miranda Ollstein @aliceollstein Carmen Paun @carmenpaun Daniel Payne @_daniel_payne Evan Peng @thepngfile Ruth Reader @RuthReader Erin Schumaker @erinlschumaker Megan R. Wilson @misswilson   Follow us

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