Americans are among the least healthy people in the rich world, and among the most likely to die early according to a case made by Nicklas Kristoff in his recent New York Times Opinion piece. It’s true, life expectancy in the United States lags other industrialized nations and the gap seems to be widening. Kristoff offers a schematic comparing individual states with other nations. Missourians live shorter lives on average that residents in 38 states and its life expectancy ranks right above Iran and Morocco. Hawaiians enjoy the longest life expectancy in the U.S. yet, their lifespans still trail those of people in Japan, Australia, South Korea, Spain, Italy, Canada, France, and Taiwan.

The current U.S. average life span is just 76.4 years. Americans have been dying younger for some time, and while the COVID pandemic has factored into recent declines, it is not the only catalyst. Increases in drug overdoses, accidental injury, chronic disease, and suicide rates all contribute to the decline in the U.S. More alarming is that a person’s average “healthspan,” or healthy years not impacted by chronic disease, is only 66.1 years on average for the U.S. population. This ten-year gap between lifespan and healthspan is typically comprised of poor health, resulting in a lower quality of life. Increasingly experts agree that the problem is with the structure of our health system.

Michelle Williams, Dean of the Harvard Chan School of Public Health, finds it shocking that young people in America die at higher rates than their counterparts in other high-income countries, and that the U.S. also has the highest maternal and infant mortality rates among these countries. Her colleague, Dr. Asaf Briton, an internationally recognized health care leader and researcher, notes that while the U.S. has a very good sick care system - its health care system is inadequate in keeping people healthy.

Arianna Huffington agrees in her must read article, Behavior is a Miracle Drug for Our Health. She marvels at new technologies like gene therapy, immunotherapy and neural technology while pointing out the tragedy of modern health care in failing to recognize the miracle drug right in front of us: our behaviors.

BHC’s Board leaders came to a similar conclusion during their August BHC planning session. Employers have an opportunity to define and promote their vision of population health. Promoting healthy lifestyles to prevent disease isn’t just something that employers offer at the worksite. It is what they expect to be the foundation of conversations between patients and their providers and central to therapeutic treatment plans, overseen by health care providers. As the United States population continues to suffer at the hands of a broken medical system, taking charge of what we as employers and individuals can control may be the cure we desperately need.

If you agree it’s time to address this missing piece, please join us for the BHC annual business luncheon for members, October 25^th at the Ritz Carlton. BHC board leaders will be there to share points from BHC’s new strategic plan and begin a discussion on ways to instill employers’ definition of population health into the U.S. health care delivery system. Register for lunch here.

Warm regards,

Louise Y. Probst
BHC Executive Director

If you have been waiting for a break in the heat or rain to get outside, check out the forecast for next week. Tuesday, August 8^th is predicted to be sunny, dry, and mild. A perfect day to reconnect with old friends, meet some new ones, learn new knowledge, and explore opportunities to build and support others in building self-advocacy skills at our BHC Member Luncheon.

The luncheon will cover timely health care topics, presented by leaders from the National Kidney Foundation and a guest appearance from Missouri’s first Chief Medical Officer, Dr. Heidi Miller. As a St. Louis practicing primary care physician, Heidi dedicated her career to improving population health for those facing challenging social disparities. Having accepted the role of Missouri’s first Chief Medical Officer (CMO) only eight months ago, Heidi has a call to action for St. Louis employers. Eager to connect with employers, Heidi will make a guest appearance to share how the Missouri Department of Health and Senior Services is addressing a critical population health concern among its own employees.

Advocacy is a critical life skill, particularly for anyone with a chronic illness. When we don’t feel well because of a chronic condition or other health concerns, we can feel helpless in finding solutions and uncertain about the overall state of our well-being. Having a relationship with a trusted Primary Care Provider is crucial in preventing progression of serious medical conditions, creating space to be heard as a patient, and keeping your personal health within your control. Yet, research demonstrates that when medical guidelines and treatment opportunities advance it can take years, 17 to be exact , for most physicians to become aware of the changes and adapt their medical practice accordingly. Unfortunately, too many people do not receive a medical diagnosis and appropriate treatment until their condition has progressed beyond repair.

This is currently the case with chronic kidney disease. CKD is a growing health concern that currently affects 1 in 7 Americans or an estimated 37 million Americans. It has been deemed a “silent killer” due to the lack of symptoms that manifest in the body until the disease has reached its late stages. Screening protocols, lifestyle interventions, and treatment options have advanced in recent years, but medical practice has not. “Crashing into dialysis” is an expensive and all-too-common occurrence. This event means that patients learn of their kidney failure shortly before facing a dire decision: dialysis or die— yet their kidney function has been diminishing for years, without any action to prevent or slow the damage.

Elizabeth Montgomery, National Vice President, Learning Strategies and Population Health Programs at the National Kidney Foundation, will present on the importance of advocacy in healthcare using kidney disease as an example of necessity for system-wide improvement. To expand your knowledge on this topic and hear what your peers and colleagues are doing to help their employees understand their health care needs and ensure their diagnosis and treatments are timely, please join us for lunch.

Warm regards,

Louise Y. Probst
BHC Executive Director

The high cost of pharmaceuticals and the practices of Pharmacy Benefit Managers (PBMs) continue to attract attention. Congress, federal agencies, and elected officials in state legislatures are exploring actions to reduce drug costs for patients and overall pharmacy spending in the United States. PBMS say their buying power is used to combat high prices set by drug manufacturers and that the rebates and discounts they receive are returned to plan sponsors and ultimately translate into lower premiums. Their critics claim that in addition to being too large, their practices are anticompetitive. The top three PBMs now control 80 percent of the U.S. pharmacy benefit market.

The Federal Trade Commission’s Chair, Lina Khan, announced in June 2022 that the FTC would investigate the practices of the six largest PBMs, under a Section of the FTC Act, which authorizes it to conduct studies without a specific law enforcement purpose. Their investigation will evaluate the impact of PBM practices on competing pharmacies, payers, doctors, and patients. PBMs have been accused of harming patients by extracting rebates, ultimately raising the price that consumers pay for medicines. The more recent vertical integration with the nation’s largest health plans and their wholly owned mail order and specialty pharmacies has attracted the FTC’s attention. Last month the FTC issued additional orders to rebate aggregators, Zinc Health Services, owned by CVS; Ascent Health Services, LLC, owned by Express Scripts; Prime Therapeutics; and other PBMs to provide information. 

Ms. Khan made an interesting observation, highlighting that policy choices have shaped the state of the current PBM industry, allowing for mergers leading to market concentration and vertical integration with insurance companies. Similarly, policy choices have facilitated the acquisition of physician practices by insurance, hospital, and private equity firms. Moreover, it was policy choices that have resulted in Americans paying substantial amounts for prescription drugs whose research were initially funded by taxpayers. It is critical to recognize that these questions of commerce are democratic choices with far-reaching implications. While the FTC plays a significant role, other public entities also have the power to effect change. Advocacy and public engagement are essential to ensure public voices are heard and to uphold accountability.

Congress is weighing in. A May 10th hearing of the U.S. Senate Subcommittee on Health, Education, Labor and Pensions, chaired by Senator Bernie Sanders, brought together the CEOs of four major insulin manufacturers and the three largest PBMs. I appreciated how well-informed our Senate leaders were, the ease with which they called out the wide differences between insulin and other drug prices in the U.S. and the rest of the industrialized world, and doggedly attempted to clarify the flow of money through the PBMs. The high cost of prescription drugs for patients, particularly, the cost before having met their health plan deductible, was a primary concern of Senate leaders who have authored legislation for consideration. 

In the 2020 U.S. Supreme Court (SCOTUS) decision, Rutledge v Pharmaceutical Care Management Association, the court upheld an Arkansas law that required PBMs to pay pharmacies no less than their acquisition costs for prescription drugs. The SCOTUS opinion was that the Arkansas law was not preempted by Employee Retirement Income Security Act (ERISA), a federal law that sets standards for retirement and health benefits, because it regulates PBM payments to retail pharmacies and not employer benefit plan design. 

State legislatures, noting the SCOTUS decision, have not waited to see what actions their federal colleagues might take. A quick look at the National Academy for State Health Policy’s legislative tracker counts 137 PBM regulation bills having been introduced in 43 states. While some states such as Oklahoma and Florida have passed bills that have been into law, it’s a little too soon to fully understand the outcome of the 2023 state assemblies on employer pharmacy benefit offerings. 

The National Community Pharmacy Association, representing independent pharmacies assert that PBMs leverage their size to extract unfair contract terms and have too much influence on their business practices. They have organized an effective campaign to bring their advocacy agenda to the attention of policy makers and the public. Number one on their list is to repeal all exemptions for ERISA plans to make all PBM regulations applicable to all commercial and Medicaid managed care plans. 

ERISA is of critical importance to multi-state employers. Adherence to varying laws in every state where they have employees is an expensive and administrative nightmare. It also greatly impairs their ability to craft plan designs that best meet the needs of their workforce and enable them to manage costs. 

Join the BHC to Expand Your Knowledge
To learn more about this evolving issue, please join the BHC at our June 22nd member meeting as we examine the health policy landscape and its influence on pharmacy benefit plans for multi-state employers. Click here to register for the meeting.

James Klein President American Benefits Council	Jonalan Smith Senior Vice President Lockton Companies

Warm regards,

Louise Y. Probst,
BHC Executive Director

Lung cancer is the leading cause of cancer death in both men and women in the United States, and accounts for over one-fifth of all cancer deaths. According to the CDC, Missouri had the seventh-highest rate of new lung and bronchus cancer diagnoses among states in 2019, and the ninth-highest rate of deaths from lung and bronchus cancer. Although Missouri’s smoking rate has declined over the past decade, at 18% it remains significantly higher than the national rate of 14%. 

Lung cancer screening in Missouri’s commercially insured population was the focus of a recent Midwest Health Initiative report, Lung Cancer Screening: The Missouri Story. While lung cancer screening rates in Missouri doubled between 2018 and 2021 - they remain low at about 6.6% of eligible adults.

Like other cancers, lung cancer survival is greatly improved when the cancer is detected early, as treatment options are less likely to be curative once the cancer has spread. In an effort to reach a broader and more inclusive population of at-risk patients sooner, the U.S. Preventive Services Task Force (USPSTF) changed lung cancer screening guidelines in 2021: low-dose CT screening is now recommended annually for current smokers, or those that quit within the past 15 years, aged 50 to 80, with a history of 20 or more pack-years.

Although early detection of lung cancer is critical, the decision to partake in screening is more complex than it may initially seem. There are potential risks, such as false test results, low doses of radiation exposure, and overdiagnosis. Patients should be counseled on these prior to being screened. Additionally, lung cancer screening is not appropriate for patients who are unwilling or unable, due to other health conditions, to undergo treatment if lung cancer is found. Early detection won’t change the outcome for patients who will not be treated, but screening and diagnosis may cause emotional or physical harm. 

Missouri and other states’ lung cancer statistics can be compared on this American Lung Association interactive website. 

• Overall, patients in Missouri are diagnosed early at a similar rate to patients nationally, except for Latino Americans, who were least likely to be diagnosed early in Missouri.
  
  
• People diagnosed with lung cancer in Missouri are less likely to undergo surgery or other treatment.  
  
  
• Missouri’s five-year survival rate for lung cancer is meaningfully below the national average.

While surgery remains the ideal first-line treatment for patients with early-stage lung cancer, patients who are not healthy enough to undergo the procedure or whose cancer has spread may not be candidates. Other treatments may be recommended, such as chemotherapy, radiation, targeted therapy, or immunotherapy. Recent improvements in survivability are likely due in part to advancements in immunotherapy and targeted treatments informed by biomarker testing.

A new and rapidly evolving field, biomarker testing, enables medical professionals to study tumor cells and characterize their genetic mutations, protein expression, and tissue environment in order to identify treatments that can target the specific molecular pathways of cancer cells. Clinical stage, biomarkers, tumor histology, and several other factors all contribute to the treatment decision. In lung cancer, testing is primarily utilized for late-stage non-small cell lung cancer.

An MHI report coming soon will provide additional insights into targeted therapy and coverage for lung cancer biomarker testing. MHI analysts reviewed clinical guidelines across Missouri’s major health plans and summary plan documents (SPDs) from a handful of self-insured employers and found no barriers to these evolving and game-changing biomarker tests. All Missouri major health plans’ biomarker policies were consistent with national standards. While employer SPDs were generally silent on “biomarker” testing, they explicitly covered medically necessary diagnostic services and genetic testing. Employers may benefit by referencing the National Comprehensive Cancer Network® (NCCN®) in their plan documents. This collaboration of 33 leading cancer treatment centers across the U.S., including Siteman Cancer Center in St. Louis, has established “a comprehensive set of guidelines detailing the sequential management decisions and interventions that currently apply to 97 percent of cancers affecting patients in the United States.” Employers could simply state that their plan provides coverage for biomarker testing consistent with NCCN guidelines, much like the way they state their plan covers preventative screenings recommended by the USPSTF, and rest assured that their coverage will remain consistent with best practices and evolving science overtime.

What else can employers do?  

1. Connect employees with Missouri Department of Health and Senior Services’ free Missouri Tobacco Quit Services. This confidential service is an effective way to help Missourians quit all forms of tobacco, including e-cigarettes and smokeless tobacco. Prevention is always the best policy.
   
   
2. Educate eligible tobacco users and their family members on the importance of annual screenings and early detection, noting the importance among Latino populations and emphasizing the fact that lung cancer screenings have first dollar coverage. 
   
   
3. Educate employees on available support programs, such as those offered through your EAP, which can help with issues like depression and anxiety, coping with emotions, and even managing money issues.
   
   
4. Support employees and their dependents in achieving their best health, and encourage protective factors to boost resilience, such as a nutrient-dense diet, improved physical activity, and healthy sleep habits.
   
   
5. Join BHC members for the April 12th community forum, “Building Immunity: The Science of Healthy Living” for an update on this science. Register here.

Warm regards,

Louist Y. Probst

BHC Executive Director

A national panel of experts took center stage this week to unveil new policy recommendations for putting health care spending in the United States on a sustainable path. The Health Affairs Council on Health Care Spending & Value (the Council) is a nonpartisan, multidisciplinary workgroup tasked with “defining a deliberate approach for moderating health care spending growth while maximizing value” for state and federal policy leaders’ consideration. The recently published road map provides recommendations to public and private stakeholders on how to achieve higher health care value, compatible within various political environments. 

The Process

Throughout the multiyear process, 22 council members reviewed the literature, consulted health care and economic experts, and evaluated the practicality and impact of a wide variety of proposed interventions. The Road Map for Action clarifies that the Council’s analysis considered several drivers of health care cost: administrative waste, excess prices, clinical waste, regulatory burden, supply chain profits, clinician earnings, and fraud and abuse. 

The publication also notes that the growth in U.S. health care spending relative to Gross Domestic Product (increasing from 6.9% in 1970 to 17.7% in 2019) seriously crowds out the ability of government and families to afford other necessary services. Council leaders urged that the extent of the U.S. health care spending problem must not lead to inaction. To show the magnitude of opportunity and the risk of doing nothing, research by Dartmouth health economist Jonathan Skinner and colleagues was referenced. It estimated that if health care’s share of GDP could be stabilized to the 2019 level of growth and remain there until 2031 (rather than following its rising trajectory since 1980) then health care spending would be $3 trillion dollars less.

The Recommendations

In addition to stating the Council’s objectives, the road map also makes clear what is not a focus of its work: social determinants of health, low-value care, and pharmaceutical pricing and spending. The rationale for intentionally excluding these areas is not a lack of concern for these issues, rather a clarity of focus and knowledge of efforts underway elsewhere. There is also a detailed discussion of the roles of federal and state government, with a seeming preference for state action with federal alignment and support. The road map includes a ranking of policy recommendations, which fall into four areas: 

1. Administrative streamlining
   
   
2. Price regulations and supports for competition
   
   
3. Spending growth targets
   
   
4. Value-based payments 

Why It Matters
In reading this work, I celebrated the alignment between the national experts’ deliberations and the conversations that have evolved during a similar local, multi-stakeholder effort over the last two years. Published last month, the Midwest Health Initiative’s new report Realizing Effective and Affordable Change in Health Care details the process of achieving shared commitments to health care spending growth targets in St. Louis for the 2023, 2024, and 2025 years. Resulting from a partnership of nearly 30 public and private employers, labor unions, health plans, health systems, and medical groups, the REACH workgroup will guide regional efforts to mitigate rising health care costs, while also monitoring advancements in primary care.  

National-Local Alignment
Both the Council’s and REACH’s efforts are intentional and centrally focused on bending the health care cost curve. Although the road map calls for statewide, mandated strategies, REACH is unique in its voluntary, regional approach. Yet, there are other important parallels to point out:

• The national road map suggests “collective action” has been a missing ingredient from U.S. actions to stem spending and calls for multi-stakeholder governance. At the outset, the REACH workgroup acknowledged the importance of an “all-in” approach, seeking commitments from every major St. Louis medical group and health system to align actions in flattening spending growth.
  
  
• The road map emphasizes that data for target setting must be readily available so that spending growth can be calibrated below key economic indicators, such as gross state product, household income, wages, or Consumer Price Index. REACH participants evaluated the same list of economic indicators and selected state domestic product as the preferred metric to provide a context for understanding regional health care spending growth.
  
  
• The road map notes that centralized data collection is essential and also recommends that states analyze (transparently) areas of high spending, spending variation, and spending growth rates to determine potential drivers, such as outlier prices, practice patterns, population characteristics, or other factors. REACH partners have agreed upon measures and methodologies to assess cost and quality performance among St. Louis medical groups, which will be published in future public reports. 

As a next step for REACH, a series of meetings to support stakeholders in realizing these shared goals will begin next month. Participation is open to interested BHC employer members. Please contact me or Allison Ball to get involved in this important work.

Warm Regards,

Louise Y. Probst

BHC Executive Director