April 11, 2024

New Alzheimer’s Drug Spending Will Leap In Medicare

The Centers for Medicare & Medicaid Services (CMS) says spending on the new Alzheimer’s drug Leqembi will leap well over estimates. CMS estimates that per member per month spending on Leqembi will rise from $1.67 in 2024 to $4.67 in 2025. This will bring spending across all Medicare to $3.5 billion in 2025. This threatens to add demonstrably to Medicare troubles and will hike Part B premiums.



Federal Appeals Court Reinstates Denial Case Against United

A federal appeals court allowed a proposed class action lawsuit to continue. The case alleges that UnitedHealth Group used an algorithm to more stringently review patient claims for substance abuse treatment. Both prior authorization and medical claims denials are being closely scrutinized right now.

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#priorauthorization #claimsdenials


Bipartisan Support For Medicare Doc Fix

Senate Finance Chair Ron Wyden, D-OR, and Ranking Member Mike Crapo, R-ID, displayed rare bipartisanship in their desire to overhaul the Medicare doctor payment system. Although, no one has a concrete plan yet. Support is growing for primary care support. Note to this article has some attacks on Medicare Advantage (MA).

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#providers #physicians #medicare


Provider Megamergers Driving M and A In Q1 2024

Healthcare mergers continued strong in Q1 2024, with a number of megamergers occurring.  The number of Q1 mergers was the highest in four years. Twenty mergers were announced in Q1, up by 5 from a year ago. A series of megamergers drove the results.

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#manda #mergers #acquisitions


MA Plans Scramble To Deal With CMS 2025 Rate Announcement

Medicare Advantage (MA) plans contend that the Centers for Medicare and Medicaid Services’ (CMS) 2025 rate is inadequate and therefore will likely have to rein in benefits. Impacts on large MA insurers may differ based on the percentage of MA revenue against overall income. I think the analysts here are right.

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#medicareadvantage #cms #rates


Optum Already Powerhouse In Physician Ownership, But What About Hospitals

If Optum, United HealthGroup’s services unit, is allowed to buy Steward medical group, its physician footprint will grow even more. Optum would add 3,000 more doctors to its already large 90,000 owned or affiliated providers. Optum is the largest health plan physician owner, with about 10% of the market. Let’s remember that hospitals or private equity own almost 80% of all doctors now.

#providers #hospitals #optum


HLC Says More Needs To Be Done To Drive VBC Payments

The Healthcare Leadership Council issued a four-page briefer that concludes that a faster rollout needs to occur to move from a fee-for-service (FFS) transaction system to a value-based care (VBC) one. This is needed to meet a federal goal of 100% VBC payment penetration by 2030. The group urges strengthening incentives for provider participation, improving data integration and interoperability, and innovation in models.

I am dubious of some of the Medicare FFS recommendations but it is a good paper to read.

Briefing paper here: https://insidehealthpolicy.com/sites/insidehealthpolicy.com/files/documents/2024/apr/he2024_0970.pdf

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#vbc #medicare


Cuban Says He Will Distribute Generics If Feds March In On Expensive Brand Drug On Patents

Mark Cuban upped the ante on march-in rights when he declared that he would agree to distribute any generic if the federal government “marched in” on patent rights to seek to lower prices to the public. There are a few forms of march-in rights, including the federal government obtaining rights to manufacture generics for a drug that is highly priced and had government support. Debate is raging on Capitol Hill due to the high price of many drugs, which are much less expensive in other developed countries.

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#drugpricing #branddrugmakers #cuban


Hospitals Call 2.6% Medicare Rate Hike Wholly Inadequate

Hospitals are calling the proposed 2.6% Medicare pay increase in federal fiscal 2025 wholly inadequate given inflation.

(Article may require a subscription.)

#medicare #hospitals #rates


A Third Of Insured Americans Skip Healthcare Due To Affordability Issues

A study says that more than a third (36%) of insured Americans skipped a healthcare visit in the last year due to financial reasons. The study says that jumps to 83% for uninsured people. It shows the extent of the uninsured and underinsured problem in America. The combined number is 85 million Americans, or a quarter of the population.

#underinsured #uninsured #healthcare #healthcarereform


— Marc S. Ryan

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