A Guide To Navigating Health Plans and Fixing American Health Insurance with Mark Ryan
02/22/25 • 29 min
In this episode, Our guest is MARC RYAN, who has extensive leadership experience across the healthcare industry. Most recently, he was a founding executive and President of MedHOK (MHK, acquired by Hearst Health). He has launched and operated multiple health plans. Marc served in senior policy roles in state and federal government, including as state management secretary of Connecticut and helping build Medicare Part D’s relationship with state drug assistance programs in 2006. He created Connecticut’s Medicaid and children’s health managed care programs and its long-term care continuum. Marc is the author of The Healthcare Labyrinth: A Guide To Navigating Health Plans and Fixing American Health Insurance and the host of the Healthcare Labyrinth Podcast.
Topics covered:
(1) What are the trends in drug spending and the impact on all types of insurance products -- Medicare, Medicaid, commercial/employer -- cost trends for medical and retail
(2) What is driving the major increases in drug costs/spending?
(3) How are GLP-1s treated across various products? And will coverage change?
(4) American drug prices compared with others? Can you discuss how we compare vs. other developed countries and why (more than twice -- in many cases 3, 4, and 5 times more -- impacts on employer, Medicare, etc. -- rising percentage of healthcare as well as employer)
(5) Medicare drug price negotiations -- what it is and what has happened so far? where do you stand?
(6) A lot is occurring in plans on PA, formularies, benefit design, PBM reform -- a very hot topic -can you tell us more about this and what you predict? (7) Can you explain the traditional PBMs vs. transparent ones? FTC lawsuit against PBMs and drug supply channel issues
(8) There have been major changes to Part D and it is impacting Medicare Advantage and Part D -- what is happening for 2025 benefits as well as can you tell us a little on a study that questioned the value of Part D?
(9a) Medication Adherence in the Star program for MA and Part D plans -- key. Can you tell us more here? 9(b) How could pharmacists in the community support medication adherence etc -- Will discuss trends from health plans about recognizing the best way to ensure medication reconciliation and adherence is teaming up with pharmacists.
Guest - Marc Ryan
Host - Hillary Blackburn, PharmD, MBA
- https://www.linkedin.com/in/hillary-blackburn-67a92421/
- @talktoyourpharmacist for Instagram and Facebook
In this episode, Our guest is MARC RYAN, who has extensive leadership experience across the healthcare industry. Most recently, he was a founding executive and President of MedHOK (MHK, acquired by Hearst Health). He has launched and operated multiple health plans. Marc served in senior policy roles in state and federal government, including as state management secretary of Connecticut and helping build Medicare Part D’s relationship with state drug assistance programs in 2006. He created Connecticut’s Medicaid and children’s health managed care programs and its long-term care continuum. Marc is the author of The Healthcare Labyrinth: A Guide To Navigating Health Plans and Fixing American Health Insurance and the host of the Healthcare Labyrinth Podcast.
Topics covered:
(1) What are the trends in drug spending and the impact on all types of insurance products -- Medicare, Medicaid, commercial/employer -- cost trends for medical and retail
(2) What is driving the major increases in drug costs/spending?
(3) How are GLP-1s treated across various products? And will coverage change?
(4) American drug prices compared with others? Can you discuss how we compare vs. other developed countries and why (more than twice -- in many cases 3, 4, and 5 times more -- impacts on employer, Medicare, etc. -- rising percentage of healthcare as well as employer)
(5) Medicare drug price negotiations -- what it is and what has happened so far? where do you stand?
(6) A lot is occurring in plans on PA, formularies, benefit design, PBM reform -- a very hot topic -can you tell us more about this and what you predict? (7) Can you explain the traditional PBMs vs. transparent ones? FTC lawsuit against PBMs and drug supply channel issues
(8) There have been major changes to Part D and it is impacting Medicare Advantage and Part D -- what is happening for 2025 benefits as well as can you tell us a little on a study that questioned the value of Part D?
(9a) Medication Adherence in the Star program for MA and Part D plans -- key. Can you tell us more here? 9(b) How could pharmacists in the community support medication adherence etc -- Will discuss trends from health plans about recognizing the best way to ensure medication reconciliation and adherence is teaming up with pharmacists.
Guest - Marc Ryan
Host - Hillary Blackburn, PharmD, MBA
- https://www.linkedin.com/in/hillary-blackburn-67a92421/
- @talktoyourpharmacist for Instagram and Facebook
Previous Episode
Empowering Pharmacy Leaders: Practical Steps for Enhancing Team Performance with Laurie Lee Smith
In this episode, our guest is Laurie Lee Smith, who is the CEO of Laurie Lee Leadership and a seasoned executive coach with over three
decades of healthcare expertise, certified by the International Coaching Federation (ICF). Laurie’s international coaching and leadership engagements have spanned continents, including North America, the Middle East, Europe, and Asia, with a focus on enhancing the influence of healthcare leadership on a global scale. Her coaching philosophy is anchored in the cultivation of high-trust leaders who support teams capable of achieving peak interdependence. Laurie holds a Master of Science in Nursing Administration from the University of Mary and a Bachelor’s degree in Nursing from the University of Alaska, Anchorage. She also holds a Green Belt certification in LEAN Six Sigma, a certificate in Brain-Based Coaching, and Board Certification through the ANCC in advanced Nursing Administration. Laurie received her formal training in executive coaching at the Hudson Institute of Coaching and is currently working toward a PhD in Industrial/Organizational Psychology.
Main points:
- Uncovering blind spots as a leader
- Why we are resistant to change
- How to improve social and emotional intelligence
- How coaching can support growth as a leader
Guest - Laurie Lee Smith
LinkedIn: linkedin.com/in/laurie-lee-smith
Website: www.laurieleeleadership.com
Host - Hillary Blackburn, PharmD, MBA
- https://www.linkedin.com/in/hillary-blackburn-67a92421/
- @talktoyourpharmacist for Instagram and Facebook
Next Episode
Telehealth: A Comprehensive Guide for Pharmacies with Arielle Miliambro
In this episode, our guest is Arielle Miliambro, a Partner specializing in regulatory and transactional law within the Healthcare & Life Sciences departments. She assists clients with legal issues related to telehealth, data privacy, value-based care, and fraud compliance. She offers counsel on regulations like the Anti-Kickback Statute and prepares requests for OIG Advisory Opinions.
Arielle also guides stakeholders in telehealth and digital health models on fraud, corporate practice, and virtual care requirements. Additionally, she advises clients on data security and privacy issues, including HIPAA compliance and data breach response. She works with providers to develop value-based care and alternative payment models.
Her expertise extends to pharmacy clients, whom she advises on remote prescription processing, compliance, and licensing board matters. She also assists practitioners with in-office dispensing and scope of practice concerns. Furthermore, Arielle supports clients with corporate transactional matters, drafting various legal agreements and documents.
Telehealth Topics for Podcast
- What is the difference between telehealth and telepharmacy
- Pharmacy role in bigger picture of telehealth models
- Considerations for kickbacks/fee splitting in telehealth models depending on pharmacy’s reimbursement
- Pharmacists duty to validate script prior to dispensing
- Telehealth “red flags”
- Where does the line get drawn as to pharmacist’s obligations with respect to the actual patient encounter between prescriber/patient
- Covid changes
- State
- Licensing flexibility for prescribers
- Scope of practice of pharmacists
- Federal
- Telehealth reimbursement
- DEA prescribing
- History / status of new rules related to CDS prescribing
- State
- Telehealth vs Telepharmacy Differences
- Brief overview distinguishing the definitions of each:
- Telehealth: Remote provision of clinical care
- Telepharmacy: Remote provision of pharmacy services (e.g., offsite pharmacist doing DUR, offering patient counseling)
- Brief overview distinguishing the definitions of each:
- Changes in Telehealth During Covid
- Federal and State Waivers
- DEA waivers (current through 2025)
- Physician licensing waivers by state (expired)
- Modality flexibilities (mostly expired; some extended/made permanent depending on payor)
- Federal and State Waivers
- Pharmacist Obligations in Validating Telehealth Prescriptions
- Pharmacist obligations/duties
- BOP audits/investigations originating from BME
- Maintaining Out-of-State Licenses for Telehealth Patients
- DEA Updates with Proposed/New Final Rules
Guest - Arielle Miliambro
LinkedIn: Frier Levitt | LinkedIn
Instagram: N/A
Website: Frier Levitt | LinkedIn
YouTube: Frier Levitt - YouTube
Twitter/X: (2) Frier Levitt (@FrierLevitt) / X (twitter.com)
Host - Hillary Blackburn, PharmD, MBA
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