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Welcome to your briefing:

• AI ROUNDUP: What the Biden administration’s artificial intelligence executive order means for radiology

• INDUSTRY ROUNDUP: Kaiser Permanente notifies 13.4 million members of data breach. City of Hope also reported breach

• WELLNESS BYTES: Common blood pressure drug increases lifespan and slows aging in animals

• INSIGHTS CORNER: What are Pharmacy Benefit Managers (PBMs)

• TRIVIA: What is the name of the AI-powered tool that can help doctors diagnose diseases by analyzing medical images, such as X-rays and MRI scans?

AI ROUNDUP

WATCH THIS

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• HHS restores nondiscrimination protections, expands provisions to telehealth, AI (Read More)

• What the Biden administration’s artificial intelligence executive order means for radiology (Read More)

• Apple’s OpenGL and iOS 18: Shaping the future of health care technology (Read More)

• Self-supervised foundation models mitigate bias in histopathology AI (Read More)

• An AI blood test purports to diagnose postpartum depression (Read More)

• Palantir beefs up Healthcare AI work through parexel deal (Read More)

• AI degrades our work, nurses say (Read More)

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INDUSTRY ROUNDUP

• Kaiser Permanente notifies 13.4 million members of data breach. City of Hope also reported breach (Read More)

• Millions were booted from Medicaid. The insurers that run it gained Medicaid revenue anyway. (Read More)

• State health care plans can't exclude gender-affirming surgeries, court rules (Read More)

• Mental health diagnoses jump among seniors (Read More)

• The jump in measles cases in 2023 is very concerning says WHO official (Read More)

WELLNESS BYTES

• The secrets to enhancing memory for everyone (Read More)

• Climbing stairs could help you live longer—and experts say it only takes a few flights a day (Read More)

• Common blood pressure drug increases lifespan and slows aging in animals (Read More)

INSIGHTS CORNER

What Are Pharmacy Benefit Managers (PBMs)?

We all heard of PBM’s, yet do we really know what they do?

Here is a breakdown.

Pharmacy Benefit Managers (PBMs) serve as crucial intermediaries in the healthcare system, managing prescription drug benefits for insurance companies, employers, and other plan sponsors. By negotiating with pharmacies and pharmaceutical manufacturers, PBMs influence drug prices, access, and overall healthcare costs.

The Evolution of PBMs Originating in the late 1950s, PBMs have grown from basic administrative roles to major players in healthcare. They manage complex processes such as formulary management, drug pricing negotiations, and pharmacy network arrangements, significantly impacting drug access and affordability.

Core Functions of PBMs

• Formulary Management: PBMs decide which drugs are covered by health plans and at what cost to patients.

• Utilization Management: Techniques like prior authorization ensure prescribed treatments are necessary and cost-effective.

• Price Negotiation: PBMs negotiate discounts and rebates with drug manufacturers and pharmacies, impacting the final cost to health plans and patients.

• Pharmacy Network Management: By forming networks of pharmacies, PBMs ensure accessible and competitively priced drug dispensing.

• Mail Order Services: PBMs often run or partner with mail-order pharmacies to reduce costs and improve patient convenience.

Criticism and Challenges The PBM industry is often criticized for its opaque pricing structures and limited competition, leading to calls for greater transparency and regulation. Their significant control over drug markets places them at the center of policy debates on healthcare cost management.

Regulatory Focus Both state and federal levels have seen initiatives aimed at reforming PBM practices. These efforts focus on improving transparency, regulating pricing practices, and enhancing competition within the industry. Recent legislative proposals have targeted issues like spread pricing and the need for PBMs to pass rebates directly to plan sponsors and patients.

Emerging Trends and the Path Forward New business models are challenging traditional PBM operations. Innovations in digital health and direct-pay models offer alternatives that could bypass or reformulate the traditional roles of PBMs, potentially improving cost efficiency and patient experiences.

Stakeholders must stay informed about PBM practices and evolving regulations to effectively navigate the complexities of healthcare management. As the industry adapts to increasing demands for transparency and efficiency, understanding the role and impact of PBMs is crucial for all healthcare participants.

Access the full report here

AI TRIVIA

HEALTHCARE CONFERENCES

• May 14-16: IHI Patient Safety Congress (Orlando)

• May 14-15: Fierce Pharma PR & Communications Summit West (Newport Beach, CA)

• May 21-23: Fierce Digital Pharma Innovation Week (virtual)

• May 21-23: WSJ The Future of Everything (New York City)

• May 29-31: thINc360 – The Healthcare Innovation Congress (Washington, D.C.)

• May 31-June 4: American Society of Clinical Oncology Annual Meeting (Chicago)