Spotlight on Market Access
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MMIT Payer Portrait: Priority Health
Priority Health is the health insurance arm of Corewell Health, the Grand Rapids, Mich.-based nonprofit health system of 22 hospitals formed by the merger of Spectrum Health and Beaumont Health. It is the second-largest health insurer in Michigan, behind Blue Cross Blue Shield of Michigan, serving members across the spectrum of insurance products, including Michigan’s managed Medicaid program and the Affordable Care Act exchanges. Priority Health will expand its reach to Indiana and Ohio with its planned acquisition of Physicians Health Plan of Northern Indiana, a small nonprofit insurer serving the employer group markets.
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MMIT Payer Portrait: Point32Health
Canton, Mass.-based Point32Health was established Jan. 1, 2021, following the successful merger of Harvard Pilgrim Health Care and Tufts Health Plan, two major players in the New England health insurance markets. With more than 1.5 million members, Point32Health is one of the largest insurers in New England, serving members across the spectrum of insurance products. The org’s top state market is Massachusetts, where it is the second-largest insurer overall, behind UnitedHealthcare. The insurer in February 2024 unveiled plans to acquire Baystate Health's insurance subsidiary, Health New England. The deal would grow Point32Health’s membership by 11%, to more than 1.7 million lives, according to AIS's Directory of Health Plans.
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MMIT Payer Portrait: Highmark Health
Highmark Health is a privately owned not-for-profit subsidiary of Highmark, Inc. and a Blue Cross and Blue Shield licensee for its insurance offerings in Delaware, Pennsylvania, New York and West Virginia. With its history as a hospital system dating back to the 1840s, Highmark is now the largest insurer in Delaware and Pennsylvania. The company also operates Allegheny Health Network, a Western Pennsylvania-based health system of 14 hospitals and more than 300 sites of care. This makes Highmark one of the largest integrated delivery networks in the U.S. Highmark expanded to New York with its 2021 acquisition of the payer HealthNow New York Inc. and its two regional Blues brands.
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More States Eye Drug Affordability Boards, PBM Regulations
PBM and drug pricing regulation will continue to be hot topics at the state level after several years of busy lawmaking, experts predict, even as PBM reforms are diluted and stalled in Congress. They predict that more states than ever will continue to embrace or pursue policies like drug affordability review boards.
“I do think the momentum is still strong, because states have the ability to do a lot more,” Kate Sikora, associate principal at Avalere Health, tells AIS Health, a division of MMIT. “Federal bills typically get a little bit watered down by the time they actually pass. So some of these state laws are a little bit heartier — a little bit more robust — in terms of what they attempt to do.”
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What Should Pharma Manufacturers Know Before Launching DTC Programs?
While plenty of telehealth and online drug dispensing companies have rolled out direct-to-consumer (DTC) offerings, two pharma manufacturers have unveiled their own digital platforms this year in a bid to streamline and simplify consumers’ experience with the U.S. health care system. Other drugmakers are likely to launch similar offerings, say industry experts, as they offer benefits to various stakeholders. Still, certain challenges exist for those stakeholders, and manufacturers will need to ensure that they take certain steps — both pre- and post-launch — to set themselves up for success while remaining compliant with various regulations.
On Aug. 27, Pfizer Inc. launched PfizerForAll, a “user-friendly digital platform designed to make access to healthcare and managing health and wellness more seamless for people across the U.S.” It is aimed at Americans with migraine, COVID-19 or flu and offers adult vaccinations for conditions such as COVID-19, flu, respiratory syncytial virus (RSV) and pneumococcal pneumonia.
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